Use of the ASA Physical Status Grading System in pediatric practice

BACKGROUND: The American Society of Anesthesiologists (ASA) Grading System is widely used to describe preoperative physical status. Inconsistency of grading between anesthetists has been demonstrated in studies using hypothetical adult patient scenarios. We aimed to investigate the use and interrater reliability of the ASA Grading System in pediatric anesthesia practice. METHODS: A two-part questionnaire was mailed to all 176 current members of the Society of Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The first part of the questionnaire obtained information regarding type of practice, use of the ASA Grading System, opinions regarding grading systems in general and opinions as to the limitations of the ASA System. In Part II, respondents were presented with 15 hypothetical patient scenarios and asked to grade them using the ASA System. The scenarios were designed to cover a range of ages and conditions common in pediatric practice. RESULTS: There were 130 replies (73.9%) after two mailings. The majority of respondents had been in predominantly pediatric practice for >5 years, had read the ASA Grading System within the last 2 years, and used it regularly. However, 30% modified the grading system for use in pediatrics. Many limitations of the ASA System in pediatric practice were identified. There was considerable lack of consistency in the grading of the hypothetical patient scenarios, with each scenario receiving at least three different ASA gradings. Case scenarios involving trauma or airway compromise were associated with greater inconsistency. There was no demonstrable correlation between grading consistency and patient age, familiarity with the ASA Grading System or experience of the anesthetist. CONCLUSIONS: The ASA Grading System shows poor interrater reliability in pediatric practice, as it does in adults. This should be borne in mind when using the ASA System for clinical or scientific work in pediatrics. A physical status grading system developed specifically for use in pediatrics may reduce inconsistency.