Inter-rater Agreement of the Classification of Intra-operative Adverse Events (ClassIntr®) in Abdominal Surgery

Ann Surg 2021: , ISBN 0003-4932 (Journal)

Krielen P., Gawria L., Stommel M. W. J., Dell-Kuster S., Rosenthal R., Ten Broek R. P. G., van Goor H.

OBJECTIVE AND SUMMARY OF BACKGROUND DATA: Adverse events in surgical patients can occur pre-operatively, intra-operatively and post-operatively. Universally accepted classification systems are not yet available for intra-operative adverse events (iAEs). ClassIntra, has recently been developed and validated as a tool for grading iAEs that occur between skin incision and skin closure irrespective of the origin, i.e. surgery, anesthesia or organizational. The aim of this study is to assess the inter-rater agreement of ClassIntra and assess its predictive value for post-operative complications in elective abdominal surgery. METHODS: This study is a secondary use of data from the LAParotomy or LAParoscopy and ADhesiolysis (LAPAD) study, with detailed data on incidence and management of intra-operative and post-operative complications. Data were collected in a cohort of elective abdominal surgeries. Two teams graded all recorded events in the LAPAD study according to ClassIntra. Cohen's Kappa coefficient was calculated to determine inter-rater agreement. Uni- and multivariable linear regression was used to assess the predictive value of the ClassIntra grades for post-operative complications. RESULTS: IAEs were rated in 333/755 (44%) surgeries by team 1, and in 324/755 (43%) surgeries by team 2. Cohen's kappa coefficient for ClassIntra grades was 0.87 (95% CI 0.84-0.90). Discrepancies in grading were most frequent for intra-operative bleeding and adhesions' associated injuries. At least one post-operative complication was observed in 278 (37%) patients. The risk of a post-operative complications increased with every increase in severity grade of ClassIntra. Intra-operative hypotension (mean difference (MD) 23.41, 95% CI 12.93 - 33.90) and other organ injuries (MD 18.90, 95% CI -4.22 - 42.02) were the strongest predictors for post-operative complications. CONCLUSIONS: ClassIntra has an almost perfect inter-rater agreement for the classification of iAEs. An increasing grade of ClassIntra was associated with a higher incidence of post-operative complications. Discrepancies in grading related to common complications in abdominal procedures mostly consisted of intra-operative bleeding and adhesion-related injuries. Grading of interoperative events in abdominal surgery might further improve by consensus regarding the definitions of a number of frequent events.

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