STARSurg DISCOVER 2014 Guide to Clavien-Dindo Classification

1. Clavien-Dindo Classification of
Surgical Complications
Stephen Chapman
STARSurgII : DISCOVER Protocol Launch
16th September 2014, Royal College of Surgeons of England

2. • Measure of morbidity
• Any deviation from the normal postoperative
course (grades I-V)
• Classification via therapeutic consequence
• Grade allocated to each complication identified
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16th September 2014, Royal College of Surgeons of England

3. Definitions
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I
Any deviation from the normal postoperative course without the need
for pharmacological treatment other than the “allowed therapeutic
regimens”, or surgical, endoscopic and radiological interventions
II
Requiring pharmacological treatment with drugs beyond those allowed
for grade I complications. Blood transfusions and total parenteral
nutrition are also included.
III Requiring surgical, endoscopic or radiological intervention.
IV
Life-threatening complication requiring critical care management; CNS
complications including brain haemorrhage and ischemic stroke
(excluding TIA), sub-arrachnoidal bleeding.
V Death of a patient

4. STARSurgII : DISCOVER Protocol Launch
• Thirty-day complications
 Day of surgery (day 1) – day 30
16th September 2014, Royal College of Surgeons of England
• Categories:
• Cardiovascular
• Metabolic
• Neurological
• Renal
• Respiratory
• Surgical
• Miscellaneous

5. STARSurgII : DISCOVER Protocol Launch
16th September 2014, Royal College of Surgeons of England

6. STARSurgII : DISCOVER Protocol Launch
16th September 2014, Royal College of Surgeons of England

7. Example 1:
A 52 year old man underwent gastrectomy for malignancy. Six
days post-operatively he had left sided facial and limb weakness.
His CT head scan showed no acute changes. He was not
thrombolysed. Several hours later the weakness resolved
spontaneously. A diagnosis of transient ischaemic attack was
made and aspirin 75mg OD was started.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

8. Example 2:
A 65 year old man underwent elective left hepatectomy for
resection of hepatocellular carcinoma (HCC). Following surgery
he experienced significant post-operative nausea and vomiting
(PONV). The symptoms settled with adequate anti-emetic
therapy. He also developed a wound infection requiring
antibiotics according to local policy.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

9. Example 3:
A 69 year old lady underwent laparoscopic cholecystectomy for
cholecystitis. Shortly after the operation, she developed severe
abdominal pain and fever. A bile leak was confirmed and fixed
during emergency laparotomy. She recovered with no further
complications.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

10. Example 4:
A 52 year old man underwent elective left hemicolectomy for
malignancy. In the days following the procedure he developed
pneumonia and was started on empirical antibiotic therapy. His
breathing continued to deteriorate, leading to critical care
escalation with eventual ventilatory support. He recovered
following a prolonged stay in critical care.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

11. Example 5:
A 59 year old man underwent living donor liver transplantation.
His post-operative course was uncomplicated, apart from
moderate PONV requiring anti-emetic therapy.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

12. Example 6:
A 41 year old lady underwent anterior resection for a rectal
tumour. On the first post-operative night he spiked a
temperature and was given intravenous paracetamol. On day 2
he was hypokalaemic and was administered oral potassium
supplementation.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

13. Example 7:
A 61 year old man underwent femoral-popliteal bypass for
worsening arterial insufficiency. Post-operatively, he suffered an
acute myocardial infarction leading to cardiac arrest.
Resuscitation attempts were unsuccessful and the patient was
pronounced dead shortly after.
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

14. Example 8:
A 34 year old man underwent laparoscopic appendicectomy for
acute appendicitis. Post-operatively, he developed an intra-abdominal
collection requiring drainage in theatre. Two days
later he developed a temperature. Nitrites were identified in his
urine, following which antibiotics were commenced
Classification?
STARSurgII : DISCOVER Protocol Launch
Eligible?
16th September 2014, Royal College of Surgeons of England

15. Take home points…
• Classification of morbidity via therapeutic consequence
• Primary outcome measure for the DISCOVER Audit
• Grade for each identified complication
• QUALITY ASSURANCE – Please complete online e-module
prior to embarking on data collection!
STARSurgII : DISCOVER Protocol Launch
16th September 2014, Royal College of Surgeons of England