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.

Liver transplantation constitutes the most effective and indispensable treatment of end-stage liver disease (ESLD). Major advances in surgical techniques, anesthesiological management, postoperative care, immunosuppression, and diagnostic approach have led to increased overall survival of patients. Postoperative care poses a great challenge since detrimental occurrences that need prompt treatment may affect the graft or distant organ functionality. Adequate graft function is strongly associated with distant organ restoration and rapid patient recovery. In the ICU setting, the main focal points are hemodynamic stabilization, coagulation and electrolyte disturbances correction, respiratory support, early weaning from mechanical ventilation, and evaluation of graft functionality. It is of paramount importance to facilitate early graft recovery, recognize and promptly treat systematic complications and life-threatening sequelae, and individualize treatment protocols considering graft quality, donor's and recipient's health status, and potential co-morbidities. To achieve those goals, technological advancements in continuous patient monitoring, graft functionality, and its metabolic reserves must be assimilated and implemented in the ICU.