Surgical grade
Definition
Example
1
Minor
Excision of skin lesion; drainage of breast abscess
2
Intermediate
Primary repair of inguinal hernia; excision of varicose vein(s) of leg; tonsillectomy/adenotonsillectomy; knee arthroscopy
3
Major
Total abdominal hysterectomy; endoscopic resection of prostate; lumbar discectomy; thyroidectomy
4
Major +
Total joint replacement; lung operations; colonic resection; radical neck dissection
Neurosurgery
–
–
Cardiovascular surgery
–
–
American Society of Anaesthesiologists (ASA) Grading
ASA grading is based upon the ability of the patient to tolerate anaesthesia according to the extent of their disease (Table 5.2). In addition, it provides an indication of the mortality risk associated with each level [1].
Table 5.2
ASA grading
ASA grade | Definition | Example | Typical mortality (%) |
|---|---|---|---|
I | “Normal healthy patient” (Without any clinically important comorbidity and without clinically significant past/present medical history) | 0.05 | |
II | “A patient with mild systemic disease” | Occasional use of GTN spray for stable angina (2–3 times per month) Well controlled diabetes with no obvious complications | 0.4 |
III | “A patient with severe systemic disease” Note: Disease is not a constant threat to life. | Regular use of GTN spray (2–3 times per week) for unstable angina) Poorly controlled diabetes, diabetic complications (e.g. claudication, impaired renal function) | 0.45 |
IV | “A patient with severe systemic disease that is a constant threat to life” | 25 | |
V | “Not expected to survive 24 h with or without surgery” | 50 |
Fifty percent of surgery is carried out on patients from Grade I. As grading increases, so too do associated comorbidities, thus increasing the risk of post-operative morbidity and mortality.
Key Points
A more thorough investigation of a patient’s history reduces the likelihood of unanticipated complications arising at any stage of the patient’s journey.
Careful consideration of pre-operative investigations is beneficial to patients and hospital spending.
Capacity and Consent
What?
In twenty-first century healthcare in the UK, patients choose their pathway of care. This relies on two elements: capacity and consent.
“Capacity” refers to the ability “to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment” [3]. This relies upon the provision of information, risks, benefits and alternatives by a doctor. To have capacity, a patient must be able to satisfy the following conditions:
Understand and retain information regarding the treatment
Evaluate the risks and benefits of treatment
Reach a decision regarding their course of treatment
Communicate their decision to the clinician
At all stages, doctors and surgeons must act to facilitate the capacity of patients. This involves presenting information in a way that the individual can understand, and using several means of communication where necessary. Capacity is dependent on the situation and may change according to the setting. For example, a deaf patient may lack capacity to choose treatment for their inguinal hernia when a surgeon talks to him/her, but may be able to do so when presented with the information in written form.
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