Cardiovascular |
Angina (exacerbation) | Increase in chest pain requiring start or increase of medications |
Arterial thrombosis/embolism | Include peripheral arterial thrombosis or embolism (not including stroke) (not including stroke) demonstrated by CT, MRI or angiography |
Arrythmia | Any cardiac arrhythmia demonstrated on an ECG, except sinus tachycardia and sinus arrhythmia |
Hypertension | Increase in systolic blood pressure requiring start or increase of medications |
Myocardial ischaemia | Include ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) and unstable angina. Diagnosis must have been confirmed following review of the patient by a cardiologist/on-call medical team |
Venous thrombosis, deep vein thrombosis (DVT) | Peripheral venous thrombosis demonstrated by ultrasound, CT, MRI or angiography |
Venous thrombosis, other | Venous thrombosis of the abdominal venous systems, including the coeliac, splenic, hepatic and mesenteric veins. Thrombosis should be demonstrated by CT or MRI |
Metabolic |
Hypoglycaemia | Low blood sugar requiring intervention |
Hyperglycaemia | High blood sugar requiring increase or start of new medications |
Hypokalaemia | Low serum potassium requiring intervention |
Hyperkalaemia | High serum potassium requiring intervention |
Hypomagnesaemia | Low serum magnesium requiring intervention |
Hyponatraemia | Low serum sodium requiring intervention. Include syndrome of inappropriate antidiuretic hormone secretion (SIADH) |
Hypernatraemia | High serum sodium requiring intervention |
Hypophosphatemia | Low serum phosphate requiring intervention |
Neurological | |
Head injury | Include extradural haemorrhage, subdural haemorrhage, subarachnoid haemorrhage, cerebral contusion demonstrated on CT or MRI |
Stroke/TIA, | Include transient ischaemic attack (TIA), ischaemic or haemorrhagic stroke. Diagnosis must have been confirmed following review of the patient by a stroke physician/on call medical team |
Renal |
Acute kidney injury | Acutely deranged renal function, with serum creatine increased to at least 1.5 times greater than the most recent preoperative baseline |
Urinary retention | Failure to pass urine, requiring urinary catheterisation |
Urinary tract infection (UTI) | The patient has had clinical evidence of urinary tract infection. UTI must be proven by mid-stream/catheter specimen culture |
Respiratory |
Acute respiratory distress syndrome (ARDS) | Respiratory failure not explained by cardiac failure or fluid overload, with chest radiograph or CT scan demonstrating bilateral opacities not fully explained by effusions, lobar/lung collapse or nodules |
Atelectasis | Collapse of part of the lung, confirmed by chest X-ray or CT scan |
Haemothorax | Presence of blood in the pleural space, confirmed by chest X-ray or CT scan |
Pleural effusion | Presence of fluid in the pleural space, confirmed by chest X-ray or CT scan |
Pneumonia, aspiration | Pulmonary inflammation caused by infection, confirmed by chest X-ray or CT scan. Include pneumonias thought to be caused by aspiration of feed or fluid in to the lungs |
Pneumonia, hospital acquired | Pulmonary inflammation caused by infection, confirmed by chest X-ray or CT scan. Include all pneumonias other than aspiration pneumonias |
Pneumothorax | Presence of gas in the pleural space, confirmed by chest X-ray or CT scan |
Pulmonary embolus | Include pulmonary emboli (PE) confirmed by CT pulmonary angiogram (CTPA) or ventilation/perfusion (V/Q) scans |
Pulmonary oedema | Fluid accumulation in the lung parenchyma, confirmed by chest X-ray or CT scan |
Surgical |
Abscess | Collection of fluid containing pus. Include any intra-abdominal or intrapelvic abscess, detected clinically, by ultrasound or CT scan and/or intraoperatively |
Anastomotic leak | Include all anastomotic leaks. Include leaks detected by CT scan and/or intraoperatively; and leaks managed conservatively or surgically |
Bile duct injury | Intraoperative injury to the bile ducts requiring further postoperative management |
Bile leak | Include all bile leaks. Include leaks detected by CT scan and/or intraoperatively; and leaks managed conservatively or surgically |
Bladder injury | Intraoperative injury to the bladder requiring further postoperative management |
Chylothorax | Presence of lymphatic fluid in the pleural space, confirmed by chest X-ray or CT scan |
Clostridium difficile | C. difficile infection must be confirmed by detection of C. difficile toxin in faeces |
Enterotomy | Accidental surgical incision in to the bowel. Include leaks from enterotomies detected by CT scan and/or intraoperatively; and leaks managed conservatively or surgically |
Haematoma | Collection of fluid-containing blood, diagnosed clinically or by ultrasound or CT scan |
Haemorrhage, reactionary | Haemorrhage from operative sites within 48 h of operation |
Haemorrhage, secondary | Haemorrhage from operative sites after 48 h of operation |
Ileus | Delay to return to normal gut function, defined as intolerance to solid food and/or failure to pass flatus >3 days following operation |
Ischaemic colitis | Inflammation of the colon caused by inadequate blood supply, diagnosed clinically, by CT scan and/or intraoperatively |
Postoperative nausea | Postoperative nausea requiring intervention |
Seroma | Collection of serous fluid, diagnosed clinically or by ultrasound or CT scan |
Splenic injury | Intraoperative injury to the spleen requiring further postoperative management |
Upper gastrointestinal (upper GI) bleed | Include upper GI bleed of any aetiology other than haemorrhage from operative sites (select ‘haemorrhage, reactionary/secondary’ for these) |
Ureteric injury | Intraoperative injury to the ureters requiring further postoperative management |
Wound dehiscence | Rupture of a surgical wound along the suture line |
Wound infection | We advise adherence to the Centre for Disease Control's definition of surgical site infection, which is any one of: Purulent drainage from the incision At least two of: pain or tenderness; localised swelling; redness; heat; fever; AND The incision is opened deliberately to manage infection or the clinician diagnoses a surgical site infection Wound organisms AND pus cells from aspirate/swab
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Miscellaneous |
Blood stream infection | An infection not related to infection at another site, with a recognised pathogen cultured from blood cultures which is not related to an infection at another site |
Cellulitis | Bacterial infection involving the skin |
Central line infection | Infected peripherally inserted central catheter (PICC) or central lines, confirmed by culture of line tip |
Fracture | Any fracture sustained postoperatively, diagnosed by plain film X-ray, CT or MRI |
Peripheral line infection | Localised cellulitis (erythaema and swelling) around a peripheral cannula insertion site |
Pressure sore | Decubitus ulcers, localised injuries to the skin and/or underlying tissue as a result of pressure usually over a bony prominence |
Other | Please enter free text |