Introduction: The ASA score presents the disadvantage of being subjective and its inter-individual concordance rate is criticized by several authors. This study aims at assessing the concordance between ABCK score and ASA score.

 Methods: It is a descriptive study conducted from 1st December 2013 to 30th August 2014 in 3 hospitals of Kinshasa city: Hôpital de l’amitié sinocongolaise, Hôpital Saint Joseph and Hôpital Marie Biamba Mutombo. All patients admitted for pre-anaesthesia consultation during the period of the study were assessed using ASA score and ABCK score. Were excluded from the study all pregnant women and children.

Informed consent was obtained from all participants. The conformity of the new score with the ASA score was assessed using the kappa of Cohen test.

Results: 768 patients out of them 449 women and 319 men were examined. The sex ratio was 1.4 in favour of women. The average age was 39.4 ± 16.8 years. Low blood pressure and anaemia were the main complications during and post surgery operations and were mostly found in stages 3 and 4 for the 2 scores.

Blood transfusion was frequent in stages 3 and 4 for the 2 scores. Mortality tends to increase with the patient’ stage in the 2 groups (ASA: X2 = 25.98; p < 0.001 and ABCK: X2 = 29.70; p < 0.001). The risk of death was not related to the score used (p = 0.31 as per Fisher for class 3 and X2 = 0.52; p = 0.24 for class 4). And, there was an excellent concordance with a Kappa at 0.86 between ABCK and ASA (p < 0.001).

Conclusion: This study revealed the existence of an excellent concordance between the 2 scores.

• Concordance: ASA-ABCK

The ASA score set up by the American Society of Anaesthetists (ASA) [1] is one of the classifications frequently used in anaesthesia [2,3]. Designed in 1941 [1], it is still considered to be the gold standard. The ASA score is a combination of all pre surgery examination results, expressed by a numerical value which is based on a fundamentally subjective estimation, independent of the patient’s age and of the type of surgery to be performed on the patient. It ranges patients into 6 stages of increasing gravity: ASA 1: Normal patient, ASA 2: Patient with moderate systemic abnormality, ASA 3: Patient with severe systemic abnormality, ASA 4: Patient with severe systemic abnormality which represents a constant life threat, ASA 5: a moribund patient whose survival is improbable without performing the surgery and ASA 6: Patient declared as in brain death status from whom organs are extracted for transplantation.

Even though it is considered to be a good predictive indicator of the per operative surgery mortality [2,4], the ASA classification opens ways to diverse interpretations of the terms that define its different stages [5,6]. This makes some authors to consider it as vague and subjective [7].

From its introduction, several studies have shown evidence of disagreements and inconsistencies on the ASA score rating [5,8,9]. Local diseases, even though they can alter the physical status, do not influence the ASA classification. The word “systemic” brings more confusion in this classification: the myocardial infarction, for example, although a severe disease, is a “local” condition and should not be considered as a “systemic” disease in this classification; despite the low rates of post-surgery recovery that is observed among this kind of patients [10].

In the same way, conditions like cirrhosis of the liver, perirenal abscess, infected wounds, intestinal perforation, skull fracture, although they all greatly affect the physical status of the patient, cannot be labelled as “systemic disease”, which means a generalized disorder affecting the whole body just like high blood pressure or diabetes [10].

These discrepancies made some medical facilities to establish their own assessment methods [11,12]. To mention some, the Acute Physiology And Chronic Health Evaluation (APACHE) [11], the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (Possum) [13] and more others. However, none of these existing pre-surgery assessment systems could reach the same level of use like the ASA [14].

In sub-Saharan Africa including in D.R.Congo, the anaesthesia is most of the time performed by a less qualified personnel [15,16]. Some authors have shown that insufficiency of material means and lack of qualified personnel is common in performing the anaesthesia act in developing countries [17,18]; this exposes the ASA classification to a more important risk of subjectivity.

To overcome this difficulty, this study is aiming at proposing a simpler and less subjective score, presented in clearer terms, concise and accurate, the ABCK, which could be utilized besides the ASA or replace it.

It is a descriptive multicentric study carried out from 1st December 2013 to 30th September 2014 in three hospitals of Kinshasa city: Hôpital de l’amitié sino-congolaise, Hôpital Saint Joseph and Hôpital Marie Biamba Mutombo. All patients admitted for pre anaesthesia consultation during the period of the study were assessed using both scores: ASA and ABCK scores. ASA and ABCK scores were independently applied to each patient enrolled in the study. The new classification is named after the use of a mnemotechnic means in the first three letters of the alphabet. Elements that were assessed include for letter A the presence or the absence of the alteration of the general status of the patient, for letter B, the presence or the absence of a respiratory condition et for letter C, the presence or the absence of a cardio-circulatory condition. The letter K in this classification represented a constant (Table 1).

Because of the disagreements in the interpretation of the ASA score in paediatric surgery and in pregnant women [9,19], patients from these 2 categories were excluded from this study. The pre-test was carried at the Hospital of Ndjili. Data collection was performed using a data collection sheet.

Analyzed data were presented in percentages and comparison between ABCK score and ASA score was done using the Cohen test. The Epi Info software program, version 3.5.3 was used and Fisher’s exact test and the Chi-square test were applied in the statistical analyses. Results with p-values < 0, 05 were considered statistically significant.

Informed consent was obtained from all participants. Patients in ASA 4 and 5 stages were unable to provide their informed consent; this was obtained from a legal guardian of the patient and in his/her absence, from a family member designated by other family members.

768 patients out of them 449 women and 319 men were examined. The sex ratio was 1.4 in favour of women. The average age was 39.37 ± 16.79 years (Tables 2-6).

This study has revealed an excellent matching between the ABCK score and the ASA score (kappa = 0.86; p value <0.001). It is known that ASA score is a subjective estimation and its matching rate has been criticized by several authors [5,20,21,22]. This is a reason for searching a new score. That is why the ABCK score has this advantage to only consider the presence or the absence 

Table 1: ABCK score of Kinshasa.

The patient stage was obtained from the sum of the scores A+B+C+K. The K letter in the calculation was considered as a constant which value remains equal to 1. This figure 1 was added to the sum of rankings to avoid having a value equal to zero, since there is no zero risk in statistics. The patient stage was then equal to A+B+C+1. Scores ABCK 5 (moribund) and 6 (decerebrated) were decided on clinical observation basis.

Table 2: Distribution of patients by type of surgery.

Table 3: Distribution of patients by ASA and ABCK score concordance

Table 4: Distribution of patients by type of complications observed.

This table shows that low blood pressure and anaemia were the most commonly observed complications.

Table 5: Distribution of patients who received blood transfusion by their ASA and ABCK stages.

In the two groups, blood transfusion tends to increase with the patient’s stage, and blood needs were greater in stages 3 and 4.

Table 6: Distribution of patients’ mortality by their ASA and ABCK stages

Mortality tends to increase with the patient’s stage in the two groups (ASA: X2 of tendency = 25.98; p < 0.001 and ABCK: X2 of tendency = 29.70; p < 0.001). The death risk for patients in stage 3 was not dependent of the score used (p = 0.31 according to Fisher). In the same way, the risk of death for stage 4 was not dependent of the type of score used, ABCK or ASA (X2 = 0.52; p = 0.24).

of a systemic pathology, which makes its use simpler and less subjective.

The ASA classification is based on the presence or the absence of the diagnosis of a systemic disease and on the estimation of its stage of severity; this is expressed in terms which can explain the lack of inter-individual matching [21]. This is another reason which limits the use of ASA in developing countries where performing anaesthesia is mostly faced with the issue of lack of qualified personnel. In some regions of Africa, 80% of anaesthesia acts are performed by anaesthesia technicians [23,24].

Therefore, because of the simplicity of its usage, its strong matching with the ASA and its low subjectivity, the ABCK could be an alternative method to the ASA score.

Searching for a score which combines a good prediction and a good matching in predicting the post-surgery outcome of patients, Malviya and co. [25] designed a classification, the NARCO-SS score (Neurological, Airway, Respiratory, Cardiovascular and Other) which allows to assess the outcome of patients who underwent paediatric surgery. These authors showed the existence of a strong correlation between the NARCO-SS and the ASA-PS.

his classification presents a similarity with the ABCK, especially for the components of the respiratory function (R) and the cardio-vascular function (C). The ABCK differs from the NARCO-SS by the following components: the different significance of the letter A, alteration of the general status for ABCK and Airway for NARCO, and the absence of the search for neurological details in the ABCK and “others” which are present in the NARCO-SS. However, because the present study excluded children, who are the main topic of the NARCO-SS study, there was no possibility for comparison between the two scores.

There is a link between ASA stages and complications and post surgery morbidity and mortality. Post surgery morbidity increased from 0.41‰ for ASA stage I to 9.6‰ for ASA stages IV and V. In addition, patients in ASA stage III and above present a high risk of death than those in lower stages [7,26,27]. In this study, no death was observed in patients in stages below stage 3 in both scores. The risk of death was not related to the type of score used.

Furthermore, ASA stages are correlated to the peri operative haemorrhage. And, particularly, ASA III is a predictive factor of the peri operative haemorrhage, and by this fact, blood need is more important for patients in ASA III or above, comparatively to lower stages [28]. In this study, considering the intra-stage percentage, blood transfusion was mainly given to patients in ASA and ABCK stages 3 and 4.

Strengths and weaknesses of the studY

This study has several limitations which need to be taken into account in interpreting the results. The main limitation is that this is a descriptive study. As such, it is vulnerable for its internal validity as well as its external validity. Its main interest is to propose a simple score which is less subjective and its correlation to ASA for the pre surgery assessment of patients

There is a strong concordance between the ASA classification and the ABCK. By its simplicity, its user-friendliness despite the level of the hospital, the qualification or the experience, the ABCK could be used to replace the ASA, particularly by the service provider whom qualification cannot allow the use of the ASA.

Even though there is a correlation between ABCK and ASA, for the purpose of generalization of the results of this new score, it will be of great interest to conduct a study with a larger sample including patients from obstetrics and from paediatric surgery who were not included in this study.

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