ASA or CFS for ICU Prediction in Geriatric Hip Fracture

Study Title Comparative analysis of American Society of Anesthesiologists (ASA) physical status classification and Clinical Frailty Scale (CFS) in predicting postoperative intensive care unit (ICU) admission in geriatric hip fracture surgery Introduction With the rapid increase in the elderly population worldwide, geriatric hip fracture cases have become one of the most critical health issues in anesthesia and surgical practice. This patient group is characterized not only by surgical trauma but also by reduced physiological reserve, multiple chronic diseases, and high frailty levels. Major complications following hip fracture surgery extend hospital stays, increase healthcare costs, and lead to high mortality rates. Therefore, predicting which patients will require intensive care unit (ICU) support in the preoperative period is vital for both patient safety and efficient hospital resource management.

The American Society of Anesthesiologists (ASA) physical status classification, widely used in traditional anesthesia practice, successfully defines a patient's systemic disease burden but does not fully reflect the biological resistance and functional capacity of an elderly individual against surgical stress. It is reported in the literature that patients with the same ASA score can have significantly different clinical outcomes; even with similar chronic disease burdens, patients defined as "frail" face worse postoperative results. The Clinical Frailty Scale (CFS), developed by Kenneth Rockwood, measures "biological aging" based on a patient's mobility level and independence in activities of daily living, revealing the "reserve depletion" that traditional scoring systems overlook.

The primary rationale for this study is to directly compare the success of the ASA score and the CFS in predicting the need for postoperative ICU admission in a geriatric hip fracture population. While both scores are known to have predictive value, their superiority over each other and their combined use in clinical decision-making remain controversial in acute trauma groups like hip fractures. This research will provide a scientific basis for anesthesiologists to use more sensitive tools in preoperative risk assessment and to develop appropriate triage strategies for patients in the "hidden risk" group (low ASA but high CFS scores).

Materials and Methods This study is a retrospective cohort study examining the data of patients aged 65 and older who underwent surgery for a hip fracture (femur neck, intertrochanteric, or subtrochanteric fracture) between November 2023 and December 2025. Approval was obtained from the relevant ethics committee, and the data of 243 patients with complete operative records were evaluated. Cases transferred to another center before surgery, those with inaccessible surgical data, or those followed conservatively were excluded. Demographic information such as age and gender, as well as comorbidities (hypertension, diabetes, coronary artery disease, dementia), preoperative laboratory values (hemoglobin, albumin, creatinine), and echocardiography findings, were obtained through the hospital information management system.

Among the parameters used for risk assessment, ASA scores were recorded directly from preoperative anesthesia forms. Clinical Frailty Scale (CFS) scores were retrospectively calculated based on the Rockwood scale by scoring functional data such as mobility levels, domestic independence, and history of assistive device use found in nursing follow-up notes. Intraoperative variables, including anesthesia technique (general or spinal), surgical duration, and the requirement for vasoactive drugs, were also included. The primary endpoint of the study is the requirement for postoperative ICU admission, while secondary endpoints include total ICU stay, development of delirium in the first 48 hours, myocardial injury after non-cardiac surgery (MINS), acute kidney injury (AKI), and in-hospital mortality.

Inclusion and Exclusion Criteria

Inclusion criteria

Age: Patients aged 65 years and older.

Diagnosis: Acute traumatic hip fracture (femoral neck, intertrochanteric, or subtrochanteric).

Surgical Intervention: Patients scheduled for and undergoing surgery (arthroplasty, osteosynthesis, etc.) for a hip fracture.

Data Integrity: Complete records of preoperative ASA score, laboratory findings, and postoperative follow-up notes.

Functional Information: Sufficient clinical notes to allow for retrospective CFS scoring.

Exclusion criteria

Pathological and Periprosthetic Fractures: Fractures due to bone metastasis/tumors or fractures occurring around an existing prosthesis.

Multi-trauma: Presence of other major organ injuries or additional extremity fractures.

Conservative Follow-up: Patients not undergoing surgery due to medical contraindications or preference.

Missing Data: Patients with incomplete records or those transferred to another center immediately post-op.

Inclusion criteria

Age: Patients aged 65 years and older.

Diagnosis: Patients diagnosed with acute traumatic hip fracture, including femoral neck, intertrochanteric, or subtrochanteric fractures.

Surgical Intervention: Patients who have undergone or are scheduled for surgical treatment (e.g., arthroplasty, internal fixation/osteosynthesis) for hip fracture.

Data Integrity: Availability of complete electronic health records, including preoperative anesthesia evaluation forms and ASA physical status scores.

Functional Assessment: Presence of sufficient clinical and nursing documentation to retrospectively determine the Clinical Frailty Scale (CFS) score based on preoperative functional status.

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Exclusion criteria

Pathological and Periprosthetic Fractures: Fractures resulting from bone metastases or those occurring around an existing prosthesis.

Multiple Trauma: Patients with concomitant major organ injuries or additional limb fractures that could impact clinical outcomes.

Conservative Management: Patients who did not undergo surgical intervention and were managed non-surgically.

Incomplete Data: Cases with missing ASA scores, laboratory results, or postoperative clinical follow-up data in the hospital records.

Insufficient Functional Documentation: Patients whose clinical or nursing notes are inadequate for retrospective determination of the Clinical Frailty Scale (CFS) score.

Patient Transfer: Patients transferred to another healthcare facility preoperatively or in the immediate postoperative period, leading to incomplete data follow-up.

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