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Original Research Articles: Original Clinical Research Report

One Size Does Not Fit All: A Perspective on the American Society of Anesthesiologists Physical Status Classification for Pediatric Patients

Ferrari, Lynne R. MD*; Leahy, Izabela MS*; Staffa, Steven J. MS*; Johnson, Connor BS*; Crofton, Charis BA; Methot, Craig BS*; Berry, Jay G. MD

Author Information
doi: 10.1213/ANE.0000000000004277
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Abstract

KEY POINTS

  • Question: Are the current American Society of Anesthesiologists physical status (ASA-PS) criteria appropriate for pediatric patients?
  • Findings: There was good interrater reliability among clinical anesthesiologists with regard to assigning ASA-PS to pediatric patients using the proposed pediatric-targeted criteria.
  • Meaning: A pediatric-focused ASA-PS stratification would be of clinical value.

For >50 years, anesthesiologists have used the American Society of Anesthesiologists physical status (ASA-PS) classification system to stratify a patient’s preoperative comorbid conditions.1–3 The original physical status grading system was commissioned by the ASA in 1941 and modified in 1962; the current version represents a further revision.2,4,5 Originally created as a tool to collect statistical data related to anesthesia care, the preoperative assignment of ASA-PS has become a surrogate for perioperative risk.

Despite the fact that it was never designed for this purpose, health care groups, hospitals, law firms, insurance companies, and others now use it to predict perioperative risk.2,5–13

The ASA-PS scoring system has been criticized for its simplicity, subjectivity, and lack of specificity in both adults and pediatric patients.14–17 Despite this, the ASA-PS classification system is simple to use, easy to remember, rapid to perform, and does not require diagnostic tests or inclusion of sophisticated data. It is a subjective scale, and the lack of precise definitions for each category often results in poor agreement among both anesthesiologists and nonanesthesia providers contributing to low-to-moderate interrater reliability.7,16–23 The incongruences in chronic disease burden and ASA-PS classification have been specifically observed in pediatric practice. As a result, a more specific and concise physical status grading system with definitions specifically for use in the pediatric population including acute illness, congenital malformations, and syndromes has been suggested.24,25 The purpose of this study was to define a pediatric ASA-PS based on previously reported suggestions and to assess the interrater reliability and agreement of more specific and concise pediatric ASA-PS scores in pediatric anesthesia practice. We hypothesized that, based on the objective characteristics included in the proposed definitions, the pediatric ASA-PS score would represent better reproducibility and increased interrater reliability.

METHODS

Study Design

Table 1. - Demographic and Clinical Characteristics of the Study Population
Characteristic Full Cohort Original ASA Score
I II III IV
n (%) n (%) n (%) n (%) n (%)
Age (y)
 <1 10 (8) 0 (0.0) 4 (13.3) 3 (10.0) 3 (10.0)
 1–4 36 (30) 5 (16.7) 14 (46.7) 8 (26.7) 9 (30.0)
 5–9 28 (23) 5 (16.7) 3 (10.0) 8 (26.7) 12 (40.0)
 10–14 19 (16) 9 (30.0) 4 (13.3) 6 (20.0) 0 (0.0)
 15–18 16 (13) 6 (20.0) 3 (10.0) 2 (6.7) 5 (16.7)
 ≥19 11 (9) 5 (16.7) 2 (6.7) 3 (10.0) 1 (3.3)
No. of organ systems affected by chronic conditions
 0 22 (18) 15 (50.0) 6 (20.0) 1 (3.3) 0 (0.0)
 1 18 (15) 5 (16.7) 13 (43.3) 0 (0.0) 0 (0.0)
 2–3 29 (24) 8 (26.7) 7 (23.3) 10 (33.3) 4 (13.3)
 4–6 25 (21) 1 (3.3) 2 (6.7) 9 (30.0) 13 (43.3)
 >6 26 (22) 1 (3.3) 2 (6.7) 10 (33.3) 13 (43.3)
Complex chronic conditions
 Any 91 (76) 14 (46.7) 18 (60.0) 29 (96.7) 30 (100.0)
 None 29 (24) 16 (53.3) 12 (40.0) 1 (3.3) 0 (0.0)
 Technology 25 (21) 0 (0.0) 3 (10.0) 10 (33.3) 12 (40.0)
 Cardiovascular 49 (41) 3 (10.0) 4 (13.3) 18 (60.0) 24 (80.0)
 GI 36 (30) 1 (3.3) 2 (6.7) 16 (53.3) 17 (56.7)
 Neuromuscular 34 (28) 1 (3.3) 5 (16.7) 12 (40.0) 16 (53.3)
 Renal 31 (26) 3 (10.0) 5 (16.7) 14 (46.7) 9 (30.0)
 Metabolic 20 (17) 2 (6.7) 3 (10.0) 8 (26.7) 7 (23.3)
 Respiratory 27 (23) 2 (6.7) 3 (10.0) 10 (33.3) 12 (40.0)
 Malignancy 16 (13) 1 (3.3) 0 (0.0) 8 (26.7) 7 (23.3)
 Hematological/immunological 17 14) 1 (3.3) 1 (3.3) 8 (26.7) 7 (23.3)
Total 120 (100) 30 (25) 30 (25) 30 (25) 30 (25)
Abbreviations: ASA, American Society of Anesthesiologists; GI, gastrointestinal.

Table 2. - Elective Procedures of the Study Population
Procedure Type Full Cohort Original ASA Score
I II III IV
n (%) n (%) n (%) n (%)% n (%)
Orthopedic 32 (26.7) 14 (46.7) 3 (10.0) 6 (20.0) 9 (30.0)
ORL 28 (23.3) 9 (30.0) 13 (43.3) 2 (6.7) 4 (13.3)
General surgery 14 (11.7) 1 (3.3) 1 (3.3) 7 (23.3) 5 (16.7)
GU 13 (10.8) 1 (3.3) 6 (20.0) 6 (20.0) 0 (0.0)
Plastic surgery 9 (7.5) 4 (13.3) 4 (13.3) 1 (3.3) 0 (0.0)
GI 7 (5.8) 0 (0.0) 0 (0.0) 3 (10.0) 4 (13.3)
Dental 4 (3.3) 0 (0.0) 1 (3.3) 0 (0.0) 3 (10.0)
Neurosurgery 3 (2.5) 0 (0.0) 1 (3.3) 2 (6.7) 0 (0.0)
GYN 1 (0.8) 1 (3.3) 0 (0.0) 0 (0.0) 0 (0.0)
Pain 1 (0.8) 0 (0.0) 0 (0.0) 0 (0.0) 1 (3.3)
Cardiac surgery 4 (3.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (13.3)
Radiology 4 (3.3) 0 (0.0) 1 (3.3) 3 (10.0) 0 (0.0)
Abbreviations: ASA, American Society of Anesthesiologists; GI, gastrointestinal; GU, genitourinary; GYN, gynecology; ORL, otorhinolaryngology.

This is a prospective analysis of reclassification of ASA-PS in 120 patients selected from a population of 3295 cases who underwent elective surgical procedures between May 1, 2017 and December 31, 2017 at a freestanding children’s hospital. Data collected include age, surgical procedure, history of complex chronic conditions, and the original ASA-PS assignment (Tables 1 and 2). This study was approved for human subject research by the Boston Children’s Hospital Institutional Review Board (IRB), and the requirement for written informed consent was waived.

Randomization and ASA-PS Reclassification

To provide representation across all ASA-PS categories, stratified random sampling was implemented to select 30 patients from each of 4 ASA-PS categories (I, II, III, and IV). Each case within a discreet ASA-PS category was assigned a random number between 0 and 1. The cases were sorted by the assigned random number, and the first 30 cases were selected in the sample. This process was repeated for each of the 4 ASA-PS categories. Patients with an ASA-PS of V were excluded.

Each case was reviewed by 3 independent reviewers from a group of 15 experienced clinical anesthesiologists. A total of 360 ASA reclassifications were collected (120 cases each given 3 reclassifications). For each case, the reviewer was provided a printed copy of the preanesthetic evaluation documentation form as well as the proposed pediatric ASA-PS category descriptions and was asked to assign an ASA-PS25 (Table 3). The proposed pediatric ASA-PS category descriptions, developed in previous work, extend beyond the original, adult-based ASA-PS descriptions by providing pediatric-relevant examples of chronic conditions (eg, ASA IV includes symptomatic congenital cardiac abnormalities as well as dependence on home mechanical ventilation). In the previous work, the pediatric-relevant examples for each ASA-PS description were informed by chronic condition data assessed with the Agency for Healthcare Research and Quality (AHRQ) chronic condition indicator (CCI) system. The AHRQ CCI system is an open-source, publicly available diagnosis classification scheme that classifies approximately 14,000 (International Classification of Diseases [ICD]) diagnosis codes as chronic or not.26–28 Using the AHRQ system with a cohort of pediatric perioperative patients, the sentinel pediatric conditions associated with each ASA-PS classification were identified and used for the proposed pediatric examples.

Table 3. - Revised ASA Physical Status for Pediatric Patients
ASA Physical Status Definition Examples, Including but Not Limited to
I A normal “healthy” patient Healthy, normal BMI for age with no chronic disease
II A patient with a “mild” systemic or acute disease; no functional limitations Corrected congenital cardiac abnormality; well-controlled dysrhythmias, asthma without exacerbation, seizures, non–insulin-dependent diabetes mellitus; abnormal BMI for age
III A patient with a “severe” systemic or acute disease that is not life threatening; some functional limitation Uncorrected congenital cardiac abnormalities, chronic heart disease, chronic renal failure, epilepsy, muscular dystrophy, cystic fibrosis, asthma not well controlled, chronic respiratory disease, history of organ transplantation, brain and spinal cord malformation, malnutrition, insulin-dependent diabetes mellitus, premature infant PCA <6060 wk
IV A patient with a severe systemic or acute disease that is a “constant threat to life”; functional limitation from severe, life-threatening disease Symptomatic congenital cardiac abnormalities, cerebral hemorrhage at birth, active sequelae of prematurity, hypoxic–ischemic encephalopathy, implanted devices, morbid obesity for age, hydrocephalus, ventilator dependence, gastrostomy, endocrinopathies, and metabolic diseases
V A “moribund” patient who is not expected to survive beyond the next 24 h without surgery Massive trauma, intracranial hemorrhage with mass effect, patients on ECMO, respiratory failure or arrest, malignant hypertension, congestive heart failure, hepatic encephalopathy, disseminating intravascular coagulation
VI A “brain-dead” patient whose organs are being removed with the intention of transplanting them into another patient
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; ECMO, extracorporeal membrane oxygenation; PCA, patient controlled analgesia.

A sample of 4564 pediatric patients undergoing general anesthesia was grouped according to their original ASA-PS classification, and the most frequent AHRQ CCIs within each group were used to derive the examples for the proposed pediatric ASA-PS category descriptions.

Statistical Analysis

Qualitative Analysis.

To gain understanding and insight into the rationale used by the pediatric anesthesiologist reviewers to assign ASA-PS classification, a qualitative research approach was applied using selected cases and focus groups. A modified Delphi method was used and included a review of 1 patient case from each ASA-PS category. The Delphi method is a structured communication technique or method, originally developed as a systematic, interactive forecasting method that relies on a panel of experts.29 Twelve senior anesthesiologists were selected to participate in the focus groups. During each focus group meeting, 4 cases were discussed, one from each ASA-PS category as originally assigned. The medical history, current state of health, and comorbid conditions of each patient were discussed to determine if reclassification into a different ASA-PS category was warranted. The focus group discussions were audio recorded and transcribed verbatim. Transcripts were reviewed and coded based on the research question. Next, data were categorized and properties and patterns were assigned. An inductive method was utilized to analyze and code for potential themes. Overall, themes related to pediatric ASA-PS definitions and examples were identified and appropriately grouped into thematic categories. Data collection and analysis occurred simultaneously and stopped once data saturation was achieved. Several steps were taken to assure the validly of the data. Robust data were collected using word-for-word transcription of the audio recording. This step assured accurate documentation and descriptive validity of the data collected during the focused group discussion. Validity of common expert opinions was obtained during group discussions, and to facilitate the validation of the data, a triangulation method was used by establishing a link to the pediatric ASA-PS definitions, examples, and transcribed documents during focus groups. At the end of each session, a final vote was tallied as to whether the ASA-PS assignment for each case was accurate or necessitated reclassification into a different ASA-PS category.

Quantitative Analysis.

Demographic and clinical characteristics of the study sample are presented as frequencies and percentages within the full cohort and stratified by original ASA-PS. The summary of ASA-PS reclassifications is presented within each original ASA assignment category using frequencies and percentages as well. Because 3 independent reviewers provided a new ASA-PS for each of 120 patients, we present the complete data on all 360 reclassified ASA scores.

To evaluate the interrater agreement of the ordinal ASA-PS reclassifications among the multiple expert reviewers, intraclass correlation (ICC) and the corresponding 95% confidence interval (CI) were obtained from a 1-way random-effects regression model with a random effect for reviewer. The ICC was obtained from 1-way random effects, and regression modeling was chosen to obtain an estimate of interrater patients in each ASA-PS reclassification category.30 The absolute agreement across all 3 reviewers, partial agreement, and complete disagreement within each of the original ASA-PS categories is reported as percentages. Fleiss κ statistic was calculated within each ASA-PS category as a measure of interrater agreement beyond chance.

All statistical analyses were performed using Stata version 15.0 (StataCorp, College Station, TX). A 2-sided α level of .05 was used to determine statistical significance.

Power and Sample Size Considerations

We elected to randomly select 30 cases from each of 4 ASA-PS categories for reassignment by 3 independent reviewers in a stratified random sampling procedure. A group of 15 raters provided precision for the ICC estimate using a 95% CI with a margin of error of 0.065 around the expected ICC value of 0.75 (ie, 95% CI, 0.685–0.815). Sample size and precision calculations were performed using nQuery Advisor (version 8.0; Statistical Solutions Ltd, Cork, Ireland).

RESULTS

Patients Originally Assigned ASA-PS I

Table 4. - Inter-Reviewer Agreement in ASA-PS Reclassification
Original ASA Full Cohort Reviewer Agreement
All 3 Agreed 2 of 3 Agreed No One Agreed
n (%) n (%) n (%) n (%)
I 30 (25) 15 (50) 13 (43) 2 (7)
II 30 (25) 9 (30) 21 (70) 0 (0)
III 30 (25) 9 30) 18 (60) 3 (10)
IV 30 (25) 13 (43) 17 (57) 0 (0)
Abbreviation: ASA-PS, American Society of Anesthesiologists physical status.

Figure.
Figure.:
Results of ASA-PS reclassification. Total responses are used (n = 360, 3 responses per patient). Bars represent frequency of reclassifications within each original ASA-PS classification (I–IV). ASA-PS indicates American Society of Anesthesiologists physical status.

The median age of the randomly selected sample of 30 (n = 30) patients originally assigned an ASA-PS score of I was 13 years (interquartile range [IQR], 8.3–16.0). Fifty percent had 1 or more chronic conditions, and 46.7% had at least 1 complex chronic condition (Table 1). The most common procedure types were orthopedic surgery (46.7%, n = 14), otorhinolaryngology (30.0%, n = 9), and plastic surgery (13.3%, n = 4) (Table 2). On case review, 42.2% (n = 38) of reclassifications resulted in an upgrade to ASA-PS II and 5.6% (n = 5) ASA-PS III. Fifty-two percent of reclassifications kept the original designation of ASA-PS I (Figure). For ASA-PS I, the κ statistic was 0.61. In 50% of cases, all 3 reviewers agreed on the new ASA-PS score, while in 43.3% of cases, 2 of the 3 reviewers agreed. In a small number of cases (6.6%, n = 2), all 3 reviewers disagreed (Table 4).

Patients Originally Assigned ASA-PS II

The median age of the randomly selected sample of 30 (n = 30) patients originally assigned an ASA-PS score of II was 3 years (IQR, 1–11.5). Eighty percent had 1 or more chronic conditions, and 60.0% had at least 1 complex chronic condition (Table 1). The most common surgical procedure types were otorhinolaryngology (43.3%, n = 13), genitourinary (20.0%, n = 6), and plastic surgery (13.3%, n = 4) (Table 2). On case review, 36.7% (n = 33) of reclassifications resulted in an ASA-PS III and 3.3% (n = 3) ASA-PS IV. Fifty-one percent of reclassifications kept the original designation of ASA-PS II, and a small number (8.9%, n = 8) of reclassifications resulted in a decreased ASA-PS of I (Figure). For ASA-PS II, the κ statistic was 0.41. In 30% of cases, all 3 reviewers agreed on the new ASA-PS score, while in 70.0% of cases, 2 of the 3 reviewers agreed on the new ASA-PS score. No cases resulted in complete disagreement (Table 4).

Patients Originally Assigned ASA-PS III

The median age of the randomly selected sample of 30 (n = 30) patients originally assigned an ASA-PS score of III was 7 years (IQR, 3–14). Ninety-six percent had 1 or more chronic conditions, and 96.7% had at least 1 complex chronic condition (Table 1). The most common surgical procedure types were general surgery (23.3%, n = 7), genitourinary (20.0%, n = 6), and orthopedics (20.0%, n = 6) (Table 2). On case review, 28.9% (n = 26) of reclassifications resulted in an ASA-PS IV. Sixty-three percent of reclassifications kept the original designation of ASA-PS III, and a small number (7.8%, n = 7) resulted in a decreased ASA-PS of II (Figure). For ASA-PS III, the κ statistic was 0.30. In 30% of cases, all 3 reviewers agreed on the new ASA-PS score, while in 60% of cases, 2 of the 3 reviewers agreed. However, in some cases (10%, n = 3), all 3 reviewers disagreed (Table 4).

Patients Originally Assigned ASA-PS IV

The median age of the randomly selected sample of 30 (n = 30) patients originally assigned an ASA-PS score of IV was 5 years (IQR, 2–8.75). All patients had 2 or more chronic conditions, and 100% had at least 1 complex chronic condition (Table 1). The most common surgical procedure types were orthopedic surgery (30.0%, n = 9), general surgery (16.7%, n = 5), with an even division across plastic surgery, gastroenterology, and cardiac surgery (13%, n = 4 for all) (Table 2). On case review, 24.4% (n = 22) of reclassifications resulted in a decreased ASA-PS of III. Seventy-four percent (n = 67) of reclassifications kept the original designation of ASA-PS IV. One (n = 1) reclassification resulted in ASA-PS V (Figure). For ASA-PS IV, the κ statistic was 0.47. In 50.0% of cases, all 3 reviewers agreed on the new ASA-PS score, while in 50.0% of cases, 2 of the 3 reviewers agreed. No cases resulted in complete disagreement (Table 4).

Agreement Analysis

The ICC as a measure of agreement among the reviewers across the reclassified ASA-PS categories on the patient case level was 0.77 (95% CI, 0.71–0.83; P < .001). This demonstrates strong overall agreement of the reclassified ASA-PS scores.

Focus Groups

Of the 4 anesthesia cases discussed, consensus on the reclassified ASA-PS score based on the proposed pediatric-specific definitions was reached for 2 cases (50%). The group unanimously (n = 12) voted to reclassify the patient originally assigned an ASA-PS I–II due to the presence of exercise-induced asthma. The focus group was split on the ASA-PS assignment for the patient originally assigned an ASA-PS II, with 8 (66.6%) anesthesiologists reporting that the patient should remain ASA-PS II, and 4 (33.3%) reporting that the patient should be upgraded to ASA-PS III. Themes that arose in the discussion of ASA-PS for this patient were active sequelae of the comorbid disease. Comments during the discussion included “The disease is active requiring medications,” “Asthma well controlled could be a II but not controlled or persistent could be a III,” and “change to III for coughing choking aspirating.”

The group unanimously (n = 12) agreed that the ASA-PS III patient had the correct original assignment but was split regarding the correct ASA-PS designation for the patient originally assigned an ASA-PS IV. Eight (66.6%) anesthesiologists reported that the patient should remain ASA-PS IV, and 4 (33.3%) reported that the patient should be downgraded to ASA-PS III. Relevant discussion included “…normal echocardiogram with concern for narrowing of trachea without limitations. Functioning well at home; labs look good, nothing urgent or emergent, no constant threat to life that would make the patient an ASA IV.”

DISCUSSION

The main findings from the current study suggest that adding pediatric-specific examples to ASA-PS categories resulted in a high prevalence of ASA-PS reclassification of existing cases by senior, pediatric anesthesiologists. There was high interrater reliability and strong consistency for the reclassified ASA-PS designations among the anesthesiologists. Reliability was higher for reassignment of ASA-PS I and IV designations than to ASA-PS II and III designations. This may suggest that the midlevel “gray zone” of ASA-PS II and III categories needs further clarification. For instance, the example of a patient with mild asthma that is well controlled with daily bronchodilator therapy without acute exacerbations might be an ASA-PS II, but if that patient was not well controlled on multiple medical therapies and had baseline wheezing with frequent exacerbations, that might be rated as an ASA-PS III. The focus group discussions identified additional considerations for further ASA-PS definition refinement, including active sequelae of disease, active versus well-controlled comorbidities, and functional limitations. These findings may be used to help optimize the use and value of ASA-PS in pediatric perioperative care.

To explore the current practice regarding the assignment of ASA-PS across the entire range of acuity in pediatric patients, this study using actual patient profiles rather than hypothetical scenarios was undertaken. If the criticism of the current adult-focused ASA-PS definitions is that they are vague, the proposed pediatric-specific examples may also be considered to be vague and not inclusive of all possible disease categories. Acknowledging this, the specific pediatric examples were chosen to represent the disease categories and organ systems that are commonly assessed in children undergoing surgical or interventional procedures and include common chronic conditions of any complexity distinguished using the AHRQ chronic conditions system. Rather than to choose arbitrary conditions, the CCI designation was derived as a well-documented validated set of conditions that may be referenced when communicating with other professionals and considering outcomes. The definition of a chronic condition is one that lasts 12 months or longer and has one or both of the following effects: (1) it places limitations on self-care, independent living, and social interactions and (2) it results in the need for ongoing intervention with medical products, services, and special equipment.25 Considering a more granular description of function and comorbidity might provide a less subjective assessment of patients which is crucial to the accuracy of other measures of risk that included the ASA-PS assignment such as the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk calculator, the ACS Children’s Surgery Verification assessment, the Pediatric Risk Assessment (PRAm) tool, and the Task Force for Children’s Surgical Care.31–34

To further investigate the critical thinking applied in the ASA-PS reassignments, a quantitative method of data collection was utilized. During several focus groups, different perspectives were elicited from the participants, and the proposed pediatric ASA-PS definitions and examples were evaluated and discussed. The analysis of the focus groups confirmed that anesthesiologists disagreed on the reclassification of ASA-PS II or III and struggled with definitions and examples. Recurring themes among anesthesiologists were the need for more clarity regarding patients’ functional limitations, prematurity, obesity, acuity, and cardiac anomalies. The Appendix presents an overview of quotations from the focus groups, related to ASA-PS definitions and examples. Guided by this observation with the intent to minimize subjective scoring, the ASA II definition was modified to include “no functional limitation,” whereas ASA III patients have “some functional limitations.” Other suggestions included clarifying examples for patients with congenital cardiac abnormalities. The definition was also modified and now includes “corrected congenital cardiac abnormality” for ASA II, “uncorrected congenital cardiac abnormalities” for ASA III, and “symptomatic congenital cardiac abnormalities” for ASA IV. Additional investigation is warranted to assess how existing clinical classifications of severity in pediatric chronic disease could integrate with ASA-PS scoring. For example, the Risk Adjustment in Congenital Heart Surgery (RACHS)-1 method could be used to categorize congenital heart anomalies by severity into ASA scores (eg, single ventricle physiology = ASA III).35 A similar approach could be used with the American Academy of Pediatrics–endorsed severity of asthma symptomatology (eg, severe, persistent asthma = ASA III).36

There has been little written since the 2006 suggestion that the current ASA-PS classification system be enhanced to include pediatric-specific definitions.23 It has been suggested that a grading system developed specifically for use in pediatrics may reduce subjectivity and inconsistency.4 The limitations of the current system for effective use in pediatrics include the absence of timing and severity of acute self-limiting illness, the omission of congenital abnormalities and syndromes, and the definition of functional limitation in pediatric populations including infants and neonates. In the purest sense, it is the organ system compromise as a result of congenital abnormality or functional limitation that should be assessed when assigning the ASA-PS; however, because this is not addressed by the current ASA-PS definition, it is left up to the subjective opinion of the practitioner. It is possible that some providers, who are constantly exposed to high-acuity patients, apply a skewed view that minimizes the complexity and the severity of systemic disease.

Although the ASA-PS system was designed to be a simple means of assessing preoperative health, it is not sufficiently granular or comprehensive to be applicable to all patient populations. For over a decade, there have been suggestions made in the literature that a revision aimed at providing guidance for assessing pediatric patients would be valuable. We have attempted to provide and test a pediatric-specific version in a single free-standing pediatric institution. Future directions for this work would include exploring this proposed version in other pediatric institutions and refining the pediatric-focused ASA-PS II and III criteria.

ACKNOWLEDGMENTS

The authors would like to acknowledge the contributions made by Drs Alrayashi, Brustowicz, E. Brusseau, R. Bruseau, Bulich, Chacko, Hickey, Mizrahi, Nargozian, Nasr, Redd, Rockoff, Tung, and Vlassakova to the Delphi Method.

DISCLOSURES

Name: Lynne R. Ferrari, MD.

Contribution: This author helped design the study/generate the idea, manage and analyze the data, review the literature, and compose and edit the manuscript.

Name: Izabela Leahy, MS.

Contribution: This author helped design the study/generate the idea, manage and analyze the data, review the literature, and compose and edit the manuscript.

Name: Steven J. Staffa, MS.

Contribution: This author helped design the study/generate the idea, manage and analyze the data, and compose and edit the manuscript.

Name: Connor Johnson, BS.

Contribution: This author helped manage and analyze the data, and compose and edit the manuscript.

Name: Charis Crofton, BA.

Contribution: This author helped manage and analyze the data, and compose and edit the manuscript.

Name: Craig Methot, BS.

Contribution: This author helped manage and analyze the data, and compose and edit the manuscript.

Name: Jay G. Berry, MD.

Contribution: This author helped design the study/generate the idea, manage and analyze the data, review the literature, and compose and edit the manuscript.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

APPENDIX. - Quotations From Focus Group Discussions
Patient Factors
“When you talk about organ system like say oncologic is not that disease in and of itself that predicts your physical status it is the organ system derangement or the physiologic abnormality as a result of that is what you are scoring.”
“Insulin-dependent diabetic might be an ASA III whereas a non–insulin-dependent might be an ASA II but there should be some agreement on terms.”
“End-stage renal disease or an oncology patient with cancer would be considered an ASA III. The justification is a severe systemic disease and functional limitation; if currently in treatment.”
Prematurity
“Prematurity or age does not affect the ASA score, but it is the functional limitations of organ system dysfunctions as a result of this that would be considered.”
“ASA IV extreme prematurity should be changed to comorbidities related to prematurity since if they were premature but come as a healthy child at two years of age, it would not be a risk factor.”
“Premature infants’ physical status by their very nature has impairment of normal function compared to the rest of the population, they have immature lungs and hearts and the data reflect increased mortality risk for any patient under a year.”
Obesity
“Patient with obesity and asthma would not qualify as an ASA I.”
Acuity
“If a patient has renal failure, pulmonary involvement, has had a transplant, active malnutrition as a result of disease, you would have severe systemic disease that is not life threatening at the moment, but if admitted with sepsis it could become an ASA IV due to the constant threat to life.”
“Asthma well controlled could be an ASA II where as asthma not well controlled or persistent should be a ASA III.”
“A 1-year-old boy undergoing direct laryngoscopy/bronchoscopy with mild systemic disease; no functional limitations. If he came in sick with mucus then he would be considered an ASA III but since his baseline is manageable he would be an ASA II.”
“The difference between an ASA II and ASA III is that the disease is active.”
“The acuity of patients has gotten so much worse over the years that complex patients can seem healthy to us.”
Cardiac Anomalies
“There are conditions that the comorbidity causes severe systemic disease and therefore would be considered life-threatening or constant threat to life.”
Abbreviation: ASA, American Society of Anesthesiologists.

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