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.

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.

pain and temperature. It is often due to severe hypotension, arteriosclerosis, or physical damage from an embolus or vasospasm. This study describes a case of persistent paralysis in a 32-year-old woman of Ethiopian descent who underwent elective cesarean delivery for breech presentation at 41 and 2/7 weeks.The patient had an unremarkable prenatal course and had delivered 2 previous children vaginally. With both prior deliveries she had slow regression of motor block, and required a walker for several days, but had no permanent effects. Spinal anesthesia was performed with no difficulties and with return of clear cerebrospinal fluid. After 5 minutes, the block height was T4. Four minutes after spinal anesthesia, and then again at the end of surgery, the patient experienced bradycardia and hypotension, which were treated with ephedrine and atropine. Less than 3 hours after spinal anesthesia, she regained pain sensation, but after 9 hours, she still had very little motor function. Magnetic resonance imaging showed no spinal cord compression or abnormalities, although ischemia or inflammation could not be ruled out. Two weeks after delivery, she was sent home and received outpatient physical therapy. After 1 month, she was able to walk without assistance, and she no longer required a urinary catheter. She showed retained hip weakness and developed neuropathic pain that had not disappeared by her 12-month follow-up. The final diagnosis was neuropathic pain after an incomplete spinal cord injury due to anterior spinal artery syndrome.The first case of anterior spinal artery syndrome in a parturient was reported in 1938, and 5 have been reported since. Neuraxial anesthesia was used in 3 of the cases, and not specified in the other 2. The presumed etiologies for these 5 reports were mild hypotension combined with epinephrine-induced vasoconstriction, the hypercoagulable state of pregnancy leading to artery thrombosis, spinal cord ischemia due to reduced compliance of the epidural space, and arterial vasospasm triggered by an epidural catheter. In this case report, the abnormal motor block the patient experienced in previous pregnancies may indicate an underlying vascular abnormality or a predisposition to myelopathy in this patient. The authors concluded that the etiology for this case of anterior spinal artery syndrome was due to a combination of factors including mild hypotension, vasoconstriction from phenylephrine administration, and thrombosis due to the hypercoagulable state of pregnancy.A lthough anesthesia providers will rarely care for a parturient that has undergone a Fontan procedure, improving survival rates and functional status among women post-Fontan mean that obstetrical care for patients with Fontan physiology will become more common. It is therefore important for anesthesiologists to understand the cardiac physiology of after Fontan repair and the impact of the physiological changes of pregnancy. This case report offers an account of the successful use of epidural anesthesia for cesarean delivery in a ...

based on this study, several points must be considered. Although the correlation (−0.26) was statistically significant, it was a weak negative relationship. Furthermore, the coefficient of determination was 0.068. As such, only 6.8% of the variance in the sevoflurane requirements may be explained by serum progesterone concentration. The data are useful, not so much for clinical management, but because this investigation begins to improve our understanding of the effect of pregnancy on anesthetic requirements. Serum progesterone appears to play a minor role. Comment by Robert Gaiser, MD, MSEd Disclosure: The author declares no conflict of interest. REFERENCES 1. Paech MJ, Scott KL, Clavisi O, et al. A prospective study of awareness and recall associated with general anaesthesia for caesarean section. Int J Obstet Anesth. 2008;17:298-303. 2. Jinks SL, Bravo M, Hayes SC. Volatile anesthetic effects on midbrainelicited locomotion suggest that the locomotor network in the ventral spinal cord is the primary site for immobility. Anesthesiology. 2008;108: 1016-1024. 3. Ueyama H, Hagihira S, Takashina M, et al. Pregnancy does not enhance volatile anesthetic sensitivity on the brain: an electroencephalographic analysis study.

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