Clinical overview
Figure F1.1 — Performance status is reserve versus insult: the operative outcome is the patient's physiological reserve minus the magnitude of the surgical insult, weighed against the urgency of operation.
Performance status is the single most useful summary judgement a gynaecologist makes before booking an operation: can this patient's body tolerate the physiological insult I am about to impose, and survive the recovery? It is not a number on a form. It is the synthesis of how much the patient can physically do, what reserve their heart, lungs, kidneys and brain hold against the demand of surgery, and how those reserves intersect with the operation planned. A laparoscopic sterilisation and a debulking laparotomy for advanced ovarian cancer make wholly different demands; the same frail 72-year-old may sail through one and die of the other. The HOTS framing of this objective is deliberate — the examiners are not testing whether you can recite the ASA classes, they are testing whether you can weigh a patient against an operation and decide whether, when, where and by whom it should be done.
This judgement carries real weight in South Africa, where the surgical population is shaped by a young but heavily HIV-burdened demographic, late presentation of gynaecological malignancy, high rates of obesity, hypertension and undiagnosed diabetes, anaemia from chronic menorrhagia and parasitic disease, and a constrained critical-care footprint. A patient who would be admitted to a high-care bed without question in a tertiary centre may have no such bed available at a district hospital. Considering performance status therefore means considering the system as much as the patient: the level of care, the availability of blood, the anaesthetic seniority on call, and whether transfer to a referral centre is the safest "operation" of all. This chapter pairs closely with eras-principles, perioperative-fluids and, for the cancer patient, pregnancy-and-neoplasia and the obstetric crossover of high-risk-pregnancy-risks.
Core knowledge
What "performance status" actually means
Performance status is an umbrella for several overlapping but distinct constructs, and a strong candidate keeps them separate:
- Functional capacity — what the patient can physically do, expressed as metabolic equivalents (METs). One MET is resting oxygen consumption; climbing two flights of stairs or walking up a hill is classically taken as roughly 4 METs, the conventional threshold above which perioperative cardiac risk is reassuring. Inability to achieve ~4 METs (cannot climb a flight of stairs, breathless walking on the flat) flags poor reserve and warrants closer cardiopulmonary scrutiny. Functional capacity is standard preoperative teaching and the MET threshold is a long-standing convention rather than a precise cut-point — treat it as a screen, not a verdict.
- ASA physical status — the American Society of Anesthesiologists' I–VI scale grading the systemic burden of comorbidity (see table). It predicts perioperative mortality robustly but is a clinician's gestalt, with known inter-rater variability; it does not measure organ-specific reserve.
- Oncological performance status — the ECOG (0–4) and Karnofsky (100–0) scales, used to decide fitness for chemotherapy, radical surgery and trial enrolment in gynae-oncology. These are central to deciding whether a woman with advanced ovarian or cervical cancer can withstand primary debulking or should have neoadjuvant chemotherapy first.
- Frailty — a syndrome of diminished physiological reserve across multiple systems, only loosely correlated with chronological age, increasingly recognised as a better predictor of adverse surgical outcome in the elderly than any single comorbidity. Assessed with tools such as the Clinical Frailty Scale.
ASA physical status classification
| Class | Description | Typical gynaecological example |
|---|---|---|
| ASA I | Normal healthy patient | Fit young woman for laparoscopic sterilisation |
| ASA II | Mild systemic disease, no functional limitation | Well-controlled hypertension; well-controlled HIV on ART; BMI 30–40 |
| ASA III | Severe systemic disease, functional limitation | Poorly controlled diabetes; symptomatic chronic kidney disease; BMI ≥40; stable angina |
| ASA IV | Severe systemic disease that is a constant threat to life | Recent MI/stroke, decompensated cardiac failure, sepsis with organ dysfunction |
| ASA V | Moribund, not expected to survive without the operation | Ruptured ectopic with profound shock, comatose |
| ASA VI | Brain-dead, organ procurement | — |
The suffix E is added for emergency operations (e.g. ASA IIIE), and emergency status independently raises risk because there is no time to optimise.
Why this matters physiologically
Surgery triggers a neuroendocrine and inflammatory stress response — catecholamine and cortisol surge, insulin resistance, a procoagulant shift, fluid sequestration into the "third space", and increased myocardial oxygen demand. A patient with ample reserve absorbs this; a patient near the edge of cardiac, respiratory or renal compensation is tipped into failure. Performance status is, in effect, a clinical estimate of how much of this stress response the patient can absorb. Modern enteral preparation and the ERAS philosophy exist precisely to blunt that stress response (avoiding prolonged fasting, opioid-sparing analgesia, early feeding and mobilisation), which is why optimisation and ERAS are two sides of the same coin.
South African context
The conditions that most often degrade performance status in our population are common and frequently undiagnosed: anaemia (menorrhagia, iron deficiency, HIV, TB), hypertension and diabetes (a large proportion only detected at the pre-anaesthetic visit), HIV (consider CD4 count, viral suppression on TLD per the SA ART guidelines, and intercurrent opportunistic infection — well-controlled HIV is not in itself a contraindication and should not delay necessary surgery), active or treated TB, and rheumatic or hypertensive heart disease. The 2024 NDoH guidance and Saving Mothers repeatedly identify substandard pre-operative assessment and delayed referral as avoidable contributors to death — the lesson transfers directly to gynaecological surgery.
Assessment
This is the heart of a HOTS objective: the process of weighing the patient against the operation.
History
- Functional capacity in plain questions: how far can you walk? Can you climb stairs without stopping? Do household chores? Quantify in METs.
- Cardiovascular: chest pain, dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, syncope, claudication; prior MI, stents, heart failure, valve disease, arrhythmia.
- Respiratory: asthma/COPD control, exercise tolerance, smoking pack-years, obstructive sleep apnoea symptoms (snoring, daytime somnolence), recent respiratory infection, TB history.
- Other systems: diabetes (control, end-organ disease), renal disease, liver disease, thyroid, neurological deficits, bleeding tendency or thrombosis history (relevant to perioperative-fluids and VTE prophylaxis).
- HIV status, ART regimen and adherence, last CD4 and viral load.
- Drugs: anticoagulants and antiplatelets (when last taken, why), antihypertensives, oral hypoglycaemics and insulin, steroids (adrenal suppression risk), herbal/traditional medicines, allergies.
- Anaesthetic history: previous difficult intubation, suxamethonium apnoea, malignant hyperthermia, postoperative nausea, family anaesthetic deaths.
- Social: smoking, alcohol, recreational drugs, home support for recovery, fasting/last meal in emergencies.
Examination
- Vital signs including a resting oxygen saturation; BMI; pallor and clinical anaemia; jaundice; volume status.
- Airway assessment (Mallampati, mouth opening, thyromental distance, neck mobility, dentition) — anticipate the difficult airway before induction.
- Cardiovascular and respiratory examination for murmurs, raised JVP, oedema, crepitations, bronchospasm.
- A focused look for sepsis (the commonest reason an "elective" case should be deferred) and for the surgical disease itself (mass, ascites, distension).
Investigations — targeted, not reflexive
Indiscriminate "routine" preoperative bloods waste resources and generate misleading results. NICE NG45 (Routine preoperative tests for elective surgery) makes the modern point: investigations should be driven by ASA grade and the magnitude of surgery, not ordered as a blanket panel. In practice for gynaecology:
- Full blood count — anaemia is common and correctable; a haemoglobin should be available before any operation with meaningful blood loss. Treating preoperative anaemia (oral or IV iron) is a core ERAS measure.
- Group and save / crossmatch — for any laparotomy, oncology debulking, large fibroid uterus, or anticipated significant loss; ensure blood is actually available before incision in resource-limited settings.
- U&E, creatinine — for ASA II+, diabetics, hypertensives, the elderly, those on diuretics/ACE inhibitors, and where large fluid shifts are expected.
- Glucose / HbA1c — to detect and quantify diabetes.
- Coagulation — only when clinically indicated (liver disease, anticoagulation, bleeding history) — not routine.
- HIV testing with consent; CD4/viral load where positive or where opportunistic infection is suspected.
- ECG — for cardiac history, symptoms, or significant comorbidity at ASA III+; not routine in the young and well.
- Echocardiography — for a murmur of unknown significance, suspected heart failure, or known valve disease, before major surgery.
- Chest radiograph — not routine; reserve for active cardiopulmonary signs or suspected TB/malignant effusion.
- Spirometry / cardiopulmonary exercise testing (CPET) — selectively, before major surgery in patients with poor functional capacity, where available.
Synthesising the judgement
Bring history, examination and investigation together against the planned procedure. A useful internal algorithm:
- How big is the physiological insult? Minor (hysteroscopy, laparoscopy) vs intermediate (TAH/vaginal hysterectomy) vs major (debulking, exenteration, obstetric near-miss laparotomy).
- What is the patient's reserve? METs, ASA, frailty, organ-specific findings.
- Is the indication elective, urgent or an emergency? This sets how much optimisation time you have.
- Can reserve be improved before surgery? Treat anaemia, optimise glycaemia and blood pressure, suppress HIV viral load, treat sepsis/TB, stop smoking.
- Match the venue and team. Right level of care, right anaesthetist, blood available, high-care/ICU bed if needed — or refer up.
For the cancer patient, ECOG status directly drives the choice between primary debulking surgery and neoadjuvant chemotherapy: a patient with poor performance status (ECOG ≥2) and high disease burden is often better served by neoadjuvant chemotherapy with interval surgery, an approach grounded in the ERAS gynae-oncology pathway and standard gynae-oncology MDT practice.
Management
"Management" of performance status means optimise, decide, and document — modifying what is modifiable, then making and recording a defensible decision about the operation.
Optimise the modifiable (elective surgery)
- Anaemia: iron repletion (oral, or IV iron if time-pressured or oral-intolerant); investigate and treat the cause; transfuse only on clear indication, not to reach an arbitrary number.
- Glycaemia and blood pressure: bring under control; agree a perioperative insulin/oral-agent plan; do not cancel for a single high reading but do address sustained poor control before major surgery.
- HIV: ensure ART adherence and, where feasible, viral suppression; treat intercurrent opportunistic infection; do not withhold necessary surgery for HIV status alone.
- Smoking cessation: even short-term cessation reduces respiratory complications; offer support.
- Nutrition and prehabilitation: correct malnutrition; the ERAS bundle of carbohydrate loading, avoidance of prolonged fasting, multimodal analgesia and early mobilisation reduces complications and length of stay.
- VTE risk: assess and prescribe mechanical and/or pharmacological prophylaxis per a recognised risk-assessment tool; this is a Saving Mothers and RCOG recurring theme.
- Medicines: bridge or stop anticoagulants/antiplatelets per protocol; continue most antihypertensives (with care around ACE inhibitors/ARBs on the morning of surgery); steroid cover for the adrenally suppressed.
Decide — and decide where
The output of the assessment is a decision among: proceed now; proceed after optimisation; modify the operation (less radical, staged, or minimally invasive); refer to a higher level of care; or, occasionally, decide that surgery is not in the patient's interest at all (palliative or conservative management). In the SA system this is explicitly a level-of-care decision: a high-risk ASA III–IV patient, an anticipated difficult airway, or a case needing postoperative critical care should be done at a regional or tertiary centre with the appropriate anaesthetic seniority and an ICU/high-care bed identified before the list. Booking a frail, comorbid patient for major surgery at a district hospital with no blood and no high-care bed is a system error, not a clinical one — and the safest "procedure" may be timely referral.
Multidisciplinary and consent
High-risk decisions belong to a team: anaesthetist, physician/cardiologist, the gynae-oncology MDT for cancer. The patient must give informed consent that genuinely conveys their individual risk, in line with HPCSA guidance and the National Health Act — generic risk figures are not enough for a high-risk patient.
Emergency surgery — the drill
When the indication is a true emergency — ruptured ectopic with shock, torsion, uncontrolled intra-abdominal haemorrhage, sepsis source-control — the calculus inverts: the danger of delay outweighs the danger of operating on an unoptimised patient, and you optimise in parallel with, not before, surgery.
EMERGENCY DRILL — the unstable patient who needs surgery now
- Call for help early — most senior surgeon and anaesthetist, theatre, blood bank.
- A–B–C resuscitation simultaneously with preparation — high-flow oxygen, two large-bore IV cannulae, bloods (FBC, U&E, crossmatch, clotting, pregnancy test).
- Activate the major-haemorrhage protocol and get blood to theatre; do not wait for a "perfect" haemoglobin.
- Do not delay source control for resuscitation that will only succeed once the bleeding is stopped — in haemorrhagic shock, the operation is the resuscitation.
- ASA-E: accept the higher risk, document the time-critical reasoning and consent (or treat under emergency/necessity where consent is impossible).
- Plan postoperative critical care and transfer if the venue cannot provide it.
The mark of a good registrar in the emergency is recognising when "consideration of performance status" must be fast and parallel rather than thorough and sequential — and saying so explicitly.
Red flags / pitfalls
- Treating ASA as a number, not a judgement. ASA grades systemic disease, not the airway, not frailty, and not the operation. Always pair it with functional capacity and the magnitude of surgery.
- Reflex "routine" bloods and X-rays in fit young patients — wasteful and misleading; tailor investigation to ASA grade and surgical magnitude.
- Missing anaemia, then operating into a patient with no reserve and no blood available. Correct anaemia before elective surgery and confirm blood is on hand for any case with meaningful loss.
- Withholding necessary surgery because the patient is HIV-positive — well-controlled HIV is not a contraindication; do not delay for status alone.
- Failing the airway assessment — the difficult airway must be anticipated, not discovered at induction.
- Operating through unrecognised sepsis in an "elective" case — defer and treat the source unless the operation itself is the source control.
- Booking high-risk patients at the wrong level of care — no high-care bed, no senior anaesthetist, no blood. Refer up before the list, not after the crisis.
- Over-optimising in an emergency — in haemorrhagic shock, delay to "stabilise first" kills. Resuscitate in parallel; the operation is the resuscitation.
- Generic consent for a high-risk patient — risk disclosure must be individualised.
- Ignoring frailty in the elderly — chronological age is a poor proxy; a formal frailty assessment predicts outcome better than any single comorbidity.
Evidence anchors
- ASA Physical Status Classification and functional capacity (METs) — the standard frameworks for preoperative risk stratification; MET thresholds are conventional screening cut-points rather than precise rules.
- NICE NG45 — Routine preoperative tests for elective surgery — investigations driven by ASA grade and surgical magnitude, not blanket panels. (Standard preoperative-assessment reference; cross-check current edition before citing a number.)
- ERAS Society gynaecologic/oncology guidelines — preoperative optimisation, anaemia correction, carbohydrate loading, opioid-sparing analgesia, early feeding and mobilisation; the framework for blunting the surgical stress response (see eras-principles).
- ECOG and Karnofsky performance-status scales — standard tools driving fitness-for-treatment and the primary-debulking-versus-neoadjuvant decision in gynae-oncology.
- WHO Surgical Safety Checklist — team-based final check that captures airway risk, blood availability and anticipated blood loss.
- SA National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) and Saving Mothers / NCCEMD reports — recurring identification of substandard preoperative assessment, delayed referral and inadequate VTE prophylaxis as avoidable contributors to death; level-of-care and referral discipline.
- South African National HIV / ART Consolidated Guidelines (2023, TLD first-line) — HIV status and viral suppression inform but should not, alone, delay necessary surgery.
- HPCSA ethical guidelines and the National Health Act 61 of 2003 — individualised informed consent for high-risk surgery (see informed-consent).
Note: the Clinical Frailty Scale, the specific ~4-MET threshold, and stress-response physiology are stated as standard teaching; they are not line-itemed guideline thresholds and should be read as conventional rather than precise.