Out of Africa--a mother's journey

Factors Associated with the Outcome of a Pediatric Patients Admitted to Intensive Care Unit in Resource-Limited Setup: Cross-Sectional Study

Background

Critical care is a multidisciplinary and interprofessional specialty devoted to treating patients who already have or are at danger of developing acute, life-threatening organ dysfunction. Due to the higher disease load and mortality from preventable illness, patient outcomes in intensive care units are challenging in settings with inadequate resources. This study aimed to determine factors associated with outcomes of pediatric patients admitted to intensive care units.

Methods

A cross-sectional study was conducted at Wolaita Sodo and Hawassa University teaching hospitals in southern Ethiopia. Data were entered and analyzed using SPSS version 25. Normality tests using the Shapiro-Wilk and Kolmogorov-Smirnov data were normally distributed. The frequency, percentage, and cross-tabulation of the different variables were then determined. Finally, the magnitude and associated factors were first analyzed using binary logistic regression and then multivariate logistic regression. Statistical significance was set at P < 0.05.

Results

A total of 396 Pediatric ICU patients were included in this study, and 165 (41.7%) deaths were recorded. The odds of patients from urban areas (AOR = 45%, CI 95%: 8%, 67% p-value = 0.025) were less likely to die than those in rural areas. Patients with co morbidities (AOR = 9.4, CI 95%: 4.5, 19.7, p = 0.000) were more likely to die than pediatric patients with no co-morbidities. Patients admitted with Acute respiratory distress syndrome (AOR = 12.86, CI 95%: 4.3, 39.2, p = 0.000) were more likely to die than those with not. Pediatric patients on mechanical ventilation (AOR = 3, CI 95%: 1.7, 5.9, p = 0.000) more likely to die than not mechanically ventilated.

Conclusion

Mortality of paediatric ICU patients was high (40.7%) in this study. Co-morbid disease, residency, the use of inotropes, and the length of ICU stay were all statistically significant predictors of death.

Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.

Intensive care medicine in rural sub-Saharan Africa

We undertook an audit in a rural Ugandan hospital that describes the epidemiology and mortality of 5147 patients admitted to the intensive care unit. The most frequent admission diagnoses were postoperative state (including following trauma) (2014/5147; 39.1%), medical conditions (709; 13.8%) and traumatic brain injury (629; 12.2%). Intensive care unit mortality was 27.8%, differing between age groups (p < 0.001). Intensive care unit mortality was highest for neonatal tetanus (29/37; 78.4%) and lowest for foreign body aspiration (4/204; 2.0%). Intensive care unit admission following surgery (333/1431; 23.3%), medical conditions (327/1431; 22.9%) and traumatic brain injury (233/1431; 16.3%) caused the highest number of deaths. Of all deaths in the hospital, (1431/11,357; 12.6%) occurred in the intensive care unit. Although the proportion of hospitalised patients admitted to the intensive care unit increased over time, from 0.7% in 2005/6 to 2.8% in 2013/4 (p < 0.001), overall hospital mortality decreased (2005/6, 4.8%; 2013/14, 4.0%; p < 0.001). The proportion of intensive care patients whose lungs were mechanically ventilated was 18.7% (961/5147). This subgroup of patients did not change over time (2006, 16%; 2015, 18.4%; p = 0.12), but their mortality decreased (2006, 59.5%; 2015, 44.3%; p < 0.001).

Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation

PURPOSE

Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement.

METHODS

Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison.

RESULTS

Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism.

CONCLUSIONS

Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

Research priorities for data collection and management within global acute and emergency care systems

Barriers to global emergency care development include a critical lack of data in several areas, including limited documentation of the acute disease burden, lack of agreement on essential components of acute care systems, and a lack of consensus on key analytic elements, such as diagnostic classification schemes and regionally appropriate metrics for impact evaluation. These data gaps obscure the profound health effects of lack of emergency care access in low- and middle-income countries (LMICs). As part of the Academic Emergency Medicine consensus conference "Global Health and Emergency Care: A Research Agenda," a breakout group sought to develop a priority research agenda for data collection and management within global emergency care systems.

Childhood asthma in low income countries: an invisible killer?

Bacterial pneumonia has hitherto been considered the key cause of the high respiratory morbidity and mortality in children under five years of age (under-5s) in low-income countries, while asthma has not been stated as a significant reason. This paper explores the definitions and concepts of pneumonia and asthma/wheezing/bronchiolitis and examines whether asthma in under-5s may be confused with pneumonia. Over-diagnosing of bacterial pneumonia can be suspected from the limited association between clinical pneumonia and confirmatory test results such as chest x-ray and microbiological findings and poor treatment results using antibiotics. Moreover, children diagnosed with recurrent pneumonia in infancy were often later diagnosed with asthma. Recent studies showed a 10-15% prevalence of preschool asthma in low-income countries, although under-5s with long-term cough and difficulty breathing remain undiagnosed. New studies demonstrate that approximately 50% of acutely admitted under-5s diagnosed with pneumonia according to Integrated Management of Childhood Illnesses could be re-diagnosed with asthma or wheezing when using re-defined diagnostic criteria and treatment. It is hypothesised that untreated asthma may contribute to respiratory mortality since respiratory syncytial virus (RSV) is an important cause of respiratory death in childhood, and asthma in under-5s is often exacerbated by viral infections, including RSV. Furthermore, acute respiratory treatment failures were predominantly seen in under-5s without fever, which suggests the diagnosis of asthma/wheezing rather than bacterial pneumonia. Ultimately, underlying asthma may have contributed to malnutrition and fatal bacterial pneumonia. In conclusion, preschool asthma in low-income countries may be significantly under-diagnosed and misdiagnosed as pneumonia, and may be the cause of much morbidity and mortality.

Recommendations for sepsis management in resource-limited settings

PURPOSE

To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis.

METHODS

The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings.

RESULTS

Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included.

CONCLUSION

Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries.