Intensive Care Medicine in 2050: global perspectives

Pattern of disease and determinants of mortality among ICU patients on mechanical ventilator in Sub-Saharan Africa: a multilevel analysis

BACKGROUND

The global mortality rate of patients with MV is very high, despite a significant variation worldwide. Previous studies conducted in Sub-Saharan Africa among ICU patients focused on the pattern of admission and the incidence of mortality. However, the body of evidence on the clinical outcomes among patients with MV is still uncertain.

OBJECTIVE

The objective of this study was to investigate the pattern of disease and determinants of mortality among patients receiving mechanical ventilation in Southern Ethiopia.

METHODS

Six hundred and thirty patients on mechanical ventilation were followed for 28 days, and multilevel analysis was used to account for the clustering effect of ICU care in the region.

RESULTS

The incidence of 28-day mortality among patients with MV was 49% (95% CI: 36-58). The multilevel multivariate analysis revealed that being diabetic, having GSC < 8, and night time admission (AOR = 7.4; 95% CI: 2.96-18.38), (AOR = 5.9; (5% CI: 3.23, 10.69), and (AOR = 2.5; 95% CI: 1.24, 5.05) were predictors.

CONCLUSION

The higher 28-day mortality among ICU patients on mechanical ventilation in our study might be attributed to factors such as delayed patient presentation, lack of resources, insufficient healthcare infrastructure, lack of trained staff, and financial constraints.

TRIAL REGISTRATION

The protocol was registered retrospectively on ( NCT05303831 ).

Survival and predictors of mortality among patients admitted to the intensive care units in southern Ethiopia: A multi-center cohort study

BACKGROUND

The burden of life-threatening conditions requiring intensive care units has grown substantially in low-income countries related to an emerging pandemic, urbanization, and hospital expansion. The rate of ICU mortality varied from region to region in Ethiopia. However, the body of evidence on ICU mortality and its predictors is uncertain. This study was designed to investigate the pattern of disease and predictors of mortality in Southern Ethiopia.

METHODS

After obtaining ethical clearance from the Institutional Review Board (IRB), a multi-center cohort study was conducted among three teaching referral hospital ICUs in Ethiopia from June 2018 to May 2020. Five hundred and seventeen Adult ICU patients were selected. Data were entered in Statistical Package for Social Sciences version 22 and STATA version 16 for analysis. Descriptive statistics were run to see the overall distribution of the variables. Chi-square test and odds ratio were determined to identify the association between independent and dependent variables. Multivariate analysis was conducted to control possible confounders and identify independent predictors of ICU mortality.

RESULTS

The mean (±SD) of the patients admitted in ICU was 34.25(±5.25). The overall ICU mortality rate was 46.8%. The study identified different independent predictors of mortality. Patients with cardiac arrest were approximately 12 times more likely to die as compared to those who didn't, AOR = 11.9(95% CI:6.1 to 23.2).

CONCLUSION

The overall mortality rate in ICU was very high as compared to other studies in Ethiopia as well as globally which entails a rigorous activity from different stakeholders.

[Intensive care and new technologies]

New technologies have a major impact on innovation in intensive care. They are accompanied by a greater openness of the units and challenging evolutions for paramedical professions, particularly concerning their practices. The consequence is an overall, higher quality care focused both on patients and families.

Haemodynamic assessment and support in sepsis and septic shock in resource-limited settings

Background

Recommendations for haemodynamic assessment and support in sepsis and septic shock in resource-limited settings are largely lacking.

Methods

A task force of six international experts in critical care medicine, all of them members of the Global Intensive Care Working Group of the European Society of Intensive Care Medicine and with extensive bedside experience in resource-limited intensive care units, reviewed the literature and provided recommendations regarding haemodynamic assessment and support, keeping aspects of efficacy and effectiveness, availability and feasibility and affordability and safety in mind.

Results

We suggest using capillary refill time, skin mottling scores and skin temperature gradients; suggest a passive leg raise test to guide fluid resuscitation; recommend crystalloid solutions as the initial fluid of choice; recommend initial fluid resuscitation with 30 ml/kg in the first 3 h, but with extreme caution in settings where there is a lack of mechanical ventilation; recommend against an early start of vasopressors; suggest starting a vasopressor in patients with persistent hypotension after initial fluid resuscitation with at least 30 ml/kg, but earlier when there is lack of vasopressors and mechanical ventilation; recommend using norepinephrine (noradrenaline) as a first-line vasopressor; suggest starting an inotrope with persistence of plasma lactate >2 mmol/L or persistence of skin mottling or prolonged capillary refill time when plasma lactate cannot be measured, and only after initial fluid resuscitation; suggest the use of dobutamine as a first-line inotrope; recommend administering vasopressors through a central venous line and suggest administering vasopressors and inotropes via a central venous line using a syringe or infusion pump when available.

Conclusion

Recommendations for haemodynamic assessment and support in sepsis and septic shock in resource-limited settings have been developed by a task force of six international experts in critical care medicine with extensive practical experience in resource-limited settings.

Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future

BACKGROUND

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.

AIM

To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.

FINDINGS

Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.

CONCLUSIONS

Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.