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.

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Background Airway management is a commonly performed procedure in the Emergency Department (ED) and Intensive Care Unit (ICU), being tracheal intubation the gold standard with relatively high rates of complications in these settings. The purpose of our study was to analyse the airway approach in our institution at ED and ICU identifying the main complications associated and taking notice of possible factors related to them. Methods Prospective observational study conducted between May and September 2014 in the ICU and ED of Santo Antonio Hospital, with the primary aim of identifying the main complications of the airway approach in the critical patient and secondary aim to take notice of possible factors related with complications of the airway approach related to technical skills of the operator, patient´s specificities and airway approach techniques. The statistical analysis was done in cooperation with the Medical Informatics and Biostatistics Department of the Faculty of Medicine of the University of Porto. P values <0.05 were considered significant for all hypothesis testing. The analysis was done using the statistical analysis program SPSS® v.21.0 Results A total of 182 patients were included, corresponding to 257 attempted tracheal intubations (ATI). The rate of successful first-pass orotracheal intubation was 67%. Complications related to ATI were reported in 30% of all attempts, being most frequently among residents (81%, p=0.001) and those with little experience in airway approach (46%, p<0.001). The majority of complications was failed intubation (18%). In the group with complications, relation with an identifiable obvious cause was seen in 87% of cases (p<0.001), the major being inexperience in 42% of operators with complications, instead of 1% in the group without complications (p<0.001). Conclusions Failed ATI and its complications are largely dependent on operator´s expertise. Factors related to patient, lack of appropriate equipment and inappropriate strategy delineation also play a role. Recognition of patients at particular risk of difficult airway management is crucial.

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