Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

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Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

Background: Spontaneous muscle hematomas (SMH) are rare but potentially life-threatening. We report three patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia who developed hemorrhagic shock, due to large SMHs, during their intensive care unit stay. Case Presentation: All the patients were receiving mechanical ventilation and anticoagulation therapy with enoxaparin. The bleeding was located in the gluteal muscles in two of the patients and in the iliopsoas muscle with retroperitoneal extension in the other. Anemia and hemodynamic instability were the main signs; however, because of their gradual onset, they were initially confused with the anemia of the critically ill patient and sepsis related to secondary infections. All received conservative medical treatment, but unfortunately one patient died within hours of diagnosis. Conclusion: This report highlights that clinicians should also be alert to major spontaneous hemorrhage in patients with SARSCoV- 2 infection. Since it is a novel disease, a possible association with bleeding events cannot be disregarded and, on the contrary, should be considered, particularly to determine the appropriate use of anticoagulation in this type of patients.

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