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Validity of the computerized version of the pediatric triage system CLARIPED for emergency care. J Pediatr (Rio J) 2022; 98:369-375. [PMID: 34571017 PMCID: PMC9432060 DOI: 10.1016/j.jped.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 08/07/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the validity of the computerized version of the pediatric triage system CLARIPED. METHODS Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed. RESULTS 19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%. CONCLUSION The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.
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Yue J, Zheng R, Wei H, Li J, Wu J, Wang P, Zhao H. Childhood Mortality After Fluid Bolus With Septic or Severe Infection Shock: A Systematic Review and Meta-Analysis. Shock 2021; 56:158-166. [PMID: 32881758 DOI: 10.1097/shk.0000000000001657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A considerable debate on whether fluid bolus could decrease childhood mortality in pediatric patients with septic or severe infection shock is still unresolved. A systematic review and meta-analysis was conducted to investigate the mortality rates after fluid bolus among children with septic or severe infection shock. METHODS A systematic electronic search of PubMed, MEDLINE, Cochrane Library, and EMBASE databases was conducted to identify relevant published studies till March 30, 2020. RESULTS A total of 19 studies with 9,321 severe sepsis or septic shock pediatric patients were included and exhibited an acceptable quality. Of the 17 studies that reported mortality at 48 h, no bolus group decreased the mortality rate when compared with bolus group with a risk ratio (RR) of 0.74 [95% confidence interval (CI) = 0.62-0.88, P < 0.01], and showed no heterogeneity (I2 = 0%). Similar results were observed on colloids and crystalloids solution in malaria shock cases with a RR of 0.79 (95% CI = 0.62-1.02). For the subgroup of general shock patients, no significant difference was shown with an RR of 0.79 (95% CI = 0.62-1.02, P = 0.07) and no significant heterogeneity (I2 = 0%). Two studies reported mortality at week 4 and pooled results indicated that no bolus group was protective against mortality when compared with bolus group with RR of 0.71 (95% CI = 0.57-0.88, I2 = 0%). CONCLUSION For the mortality at 48 h, the no bolus group showed decreased mortality when compared with the bolus group, especially in the malaria group. Similar results were found in the colloids and crystalloids solution in patients with malaria shock. Meta-analysis studies with long-term follow-up period and larger sample size are warranted to address the conclusion in the future.
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Affiliation(s)
- Jing Yue
- Emergency Department, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ronghao Zheng
- Department of Pediatric Nephrology, Rheumatology, and Immunology, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiping Wei
- Emergency Department, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Li
- Emergency Department, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiannan Wu
- Emergency Department, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Wang
- Emergency Department, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Zhao
- Emergency Department, Maternity And Child Health Care Hospital Hubei, Women And Children's Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Johansson EW, Lindsjö C, Weiss DJ, Nsona H, Selling KE, Lufesi N, Hildenwall H. Accessibility of basic paediatric emergency care in Malawi: analysis of a national facility census. BMC Public Health 2020; 20:992. [PMID: 32580762 PMCID: PMC7315502 DOI: 10.1186/s12889-020-09043-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 06/03/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Emergency care is among the weakest parts of health systems in low-income countries with both quality and accessibility constraints. Previous studies estimated accessibility to surgical or emergency care based on population travel times to nearest hospital with no assessment of hospital readiness to provide such care. We analysed a Malawi national facility census with comprehensive inventory audits and geocoded facility locations to identify hospitals equipped to provide basic paediatric emergency care with estimated travel times to these hospitals from non-equipped facilities and in relation to Malawi's population distribution. METHODS We analysed a Malawi national facility census in 2013-2014 to identify hospitals equipped to manage critically ill children according to an extended version of WHO Emergency Triage, Assessment and Treatment (ETAT) guidelines. These guidelines include 25 components including staff, transport, equipment, diagnostics, medications, fluids, feeds and consumables that defined an emergency-equipped hospital in our study. We estimated travel times to emergency-equipped hospitals from non-equipped facilities and relative to population distributions using geocoded facility locations and an established accessibility mapping approach using global road network datasets from OpenStreetMap and Google. RESULTS Four (3.5, 95% CI: 1.3-8.9) of 116 Malawi hospitals were emergency-equipped. Least available items were nasogastric tubes in 34.5% of hospitals (95% CI: 26.4-43.6), blood typing services (40.4, 95% CI: 31.9-49.6), micro nebulizers (50.9, 95% CI: 41.9-60.0), and radiology (54.2, 95% CI: 45.1-63.0). Nationally, the median travel time from non-equipped facilities to the nearest emergency-equipped hospital was 73 min (95% CI: 67-77) ranging 1-507 min. Approximately one-quarter (27%) of Malawians lived over 120 min from an emergency-equipped hospital with significantly better accessibility in Central than North and South regions (16% vs. 38 and 35%, p < 0.001). CONCLUSIONS There are unacceptable deficiencies in accessibility of basic paediatric emergency care in Malawi. Reliable supply chains for essential drugs and commodities are needed, particularly nasogastric tubes, asthma drugs and blood, along with improved capacity for time-sensitive referral. Further child mortality reductions will require substantial investments to expand basic paediatric emergency care into all Malawi hospitals for better managing critically ill children at highest mortality risk.
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Affiliation(s)
- Emily White Johansson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset, SE-751 85, Uppsala, Sweden.
| | - Cecilia Lindsjö
- Department of Public Health Sciences, Global Health - Health System and Policy Research Group, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Daniel J Weiss
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7LF, UK
| | - Humphreys Nsona
- Ministry of Health, Integrated Management of Childhood Illness (IMCI) Unit, Lilongwe, Malawi
| | - Katarina Ekholm Selling
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset, SE-751 85, Uppsala, Sweden
| | - Norman Lufesi
- Ministry of Health, Community Health Sciences Unit, Lilongwe, Malawi
| | - Helena Hildenwall
- Department of Public Health Sciences, Global Health - Health System and Policy Research Group, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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Magalhães-Barbosa MCD, Prata-Barbosa A, Raymundo CE, Cunha AJLAD, Lopes CDS. VALIDADE E CONFIABILIDADE DE UM NOVO SISTEMA DE CLASSIFICAÇÃO DE RISCO PARA EMERGÊNCIAS PEDIÁTRICAS: CLARIPED. REVISTA PAULISTA DE PEDIATRIA 2018; 36:398-406. [PMID: 30540107 PMCID: PMC6322794 DOI: 10.1590/1984-0462/;2018;36;4;00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 09/24/2017] [Indexed: 05/30/2023]
Abstract
Objective: To assess the validity and reliability of a triage system for pediatric
emergency care (CLARIPED) developed in Brazil. Methods: Validity phase: prospective observational study with children aged 0 to 15
years who consecutively visited the pediatric emergency department (ED) of a
tertiary hospital from July 2 to 18, 2013. We evaluated the association of
urgency levels with clinical outcomes (resource utilization, ED admission
rate, hospitalization rate, and ED length of stay); and compared the
CLARIPED performance to a reference standard. Inter-rater reliability phase:
a convenience sample of patients who visited the pediatric ED between April
and July 2013 was consecutively and independently double triaged by two
nurses, and the quadratic weighted kappa was estimated. Results: In the validity phase, the distribution of urgency levels in 1,416 visits
was the following: 0.0% red (emergency); 5.9% orange (high urgency); 40.5%
yellow (urgency); 50.6% green (low urgency); and 3.0% blue (no urgency). The
percentage of patients who used two or more resources decreased from the
orange level to the yellow, green, and blue levels (81%, 49%, 22%, and 2%,
respectively, p<0.0001), as did the ED admission rate,
ED length of stay, and hospitalization rate. The sensitivity to identify
patients with high urgency level was 0.89 (confidence interval of 95%
[95%CI] 0.78-0.95), and the undertriage rate was 7.4%. The inter-rater
reliability in 191patients classified by two nurses was substantial
(kw2=0.75; 95%CI 0.74-0.79). Conclusions: The CLARIPED system showed good validity and substantial reliability for
triage in a pediatric emergency department.
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Canarie MF, Shenoi AN. Teaching the Principles of Pediatric Critical Care to Non-Intensivists in Resource Limited Settings: Challenges and Opportunities. Front Pediatr 2018; 6:44. [PMID: 29552547 PMCID: PMC5840157 DOI: 10.3389/fped.2018.00044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/14/2018] [Indexed: 01/17/2023] Open
Affiliation(s)
- Michael F Canarie
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
| | - Asha N Shenoi
- Department of Pediatrics, University of Kentucky, Lexington, KY, United States
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Cox M, Rose L, Kalua K, de Wildt G, Bailey R, Hart J. The prevalence and risk factors for acute respiratory infections in children aged 0-59 months in rural Malawi: A cross-sectional study. Influenza Other Respir Viruses 2017; 11:489-496. [PMID: 28941079 PMCID: PMC5705682 DOI: 10.1111/irv.12481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2017] [Indexed: 11/30/2022] Open
Abstract
Background Acute Respiratory Infections (ARI) are a leading cause of childhood mortality and morbidity. Malawi has high childhood mortality but limited data on the prevalence of disease in the community. Methods A cross‐sectional study of children aged 0‐59 months. Health passports were examined for ARI diagnoses in the preceding 12 months. Children were physically examined for malnutrition or current ARI. Results 828 children participated. The annual prevalence of ARI was 32.6% (95% CI 29.3‐36.0%). Having a sibling with ARI (OR 1.44, P = .01), increasing household density (OR 2.17, P = .02) and acute malnutrition (OR 1.69, P = .01) were predictors of infection in the last year. The point prevalence of ARI was 8.3% (95% CI 6.8‐10.4%). Risk factors for current ARI were acute‐on‐chronic malnutrition (OR 3.06, P = .02), increasing household density (OR1.19, P = .05) and having a sibling with ARI (OR 2.30, P = .02). Conclusion This study provides novel data on the high prevalence of ARI in Malawi. This baseline data can be used in the monitoring and planning of future interventions in this population.
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Affiliation(s)
- Miriam Cox
- School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louis Rose
- School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Khumbo Kalua
- Department of Ophthalmology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gilles de Wildt
- School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Robin Bailey
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - John Hart
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Hansoti B, Jenson A, Keefe D, De Ramirez SS, Anest T, Twomey M, Lobner K, Kelen G, Wallis L. Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review. BMC Pediatr 2017; 17:37. [PMID: 28122537 PMCID: PMC5267450 DOI: 10.1186/s12887-017-0796-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 01/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the high burden of pediatric mortality from preventable conditions in low and middle income countries and the existence of multiple tools to prioritize critically ill children in low-resource settings, no analysis exists of the reliability and validity of these tools in identifying critically ill children in these scenarios. METHODS The authors performed a systematic search of the peer-reviewed literature published, for studies pertaining to for triage and IMCI in low and middle-income countries in English language, from January 01, 2000 to October 22, 2013. An updated literature search was performed on on July 1, 2015. The databases searched included the Cochrane Library, EMBASE, Medline, PubMed and Web of Science. Only studies that presented data on the reliability and validity evaluations of triage tool were included in this review. Two independent reviewers utilized a data abstraction tool to collect data on demographics, triage tool components and the reliability and validity data and summary findings for each triage tool assessed. RESULTS Of the 4,717 studies searched, seven studies evaluating triage tools and 10 studies evaluating IMCI were included. There were wide varieties in method for assessing reliability and validity, with different settings, outcome metrics and statistical methods. CONCLUSIONS Studies evaluating triage tools for pediatric patients in low and middle income countries are scarce. Furthermore the methodology utilized in the conduct of these studies varies greatly and does not allow for the comparison of tools across study sites.
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Affiliation(s)
- Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Alexander Jenson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Devin Keefe
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Sarah Stewart De Ramirez
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Trisha Anest
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Michelle Twomey
- University of Cape Town Division of Emergency Medicine, Private Bag X24, Bellville, 7535 South Africa
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins School of Medicine, Baltimore, USA
| | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Lee Wallis
- University of Cape Town Division of Emergency Medicine, Private Bag X24, Bellville, 7535 South Africa
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Molyneux EM, Langton J, Njiram'madzi J, Robertson AM. Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on. BMJ Paediatr Open 2017; 1:e000014. [PMID: 29637093 PMCID: PMC5842997 DOI: 10.1136/bmjpo-2017-000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 11/16/2022] Open
Abstract
Paediatric emergency care is not recognised as a specialty in many countries in Africa but is being practised increasingly. Setting up a paediatric emergency care unit takes time and often involves trial and error. Here we describe the start of the paediatric emergency department in Blantyre, Malawi, a low-income country and how it has continued to evolve over 15 years, in the hope that our experience will inform and assist others who are already developing their own emergency unit or wishing to do so.
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Affiliation(s)
- Elizabeth M Molyneux
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Jenala Njiram'madzi
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Ann M Robertson
- Emergency Department, Macclesfield Hospital, Macclesfield, UK
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von Saint André A, Pavlinac PB, Jacob ST, Zimmerman J, Walson JL. Fluid resuscitation for children with severe febrile illness and septic shock in resource-limited settings. Hippokratia 2016. [DOI: 10.1002/14651858.cd009655.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Amélie von Saint André
- Seattle Children's Hospital; Department of Pediatrics, Devision of Pediatric Critical Care Medicine, International Respiratory and Severe Illness Center (INTERSECT), University of Washington; 4800 Sand Point Way NE Seattle Washington USA 98105
| | | | - Shevin T Jacob
- University of Washington; International Respiratory and Severe Illness Canter (INTERSECT), Department of Medicine; Seattle USA
| | - Jerry Zimmerman
- University of Washington/Seattle Childrens Hospital; Department of Pediatrics; 4800 Sandpoint Way NE Seattle USA 98105
| | - Judd L Walson
- University of Washington; Departments of Global Health, Medicine (Infectious Disease) and Pediatrics, Epidemiology; Box 359909 325 Ninth Avenue Seattle WA USA 98104
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Abstract
BACKGROUND Although pneumonia is a common cause of death in children in Malawi, healthcare staff frequently encounter patients or carers who refuse oxygen therapy. This qualitative study documents factors that influence acceptance or refusal of oxygen therapy for children in Malawi. METHODS Nine group interviews involving 86 participants were held in community and hospital settings in rural and urban Malawi. Eleven in-depth interviews of healthcare staff providing oxygen were held in a central hospital. Thematic analysis of transcripts of the audio recordings was carried out to identify recurring themes. RESULTS Similar ideas were identified in the group interviews and in-depth staff interviews. Past experiences of oxygen use (direct and indirect, positive and negative) had a strong influence on views of oxygen. A recurrent theme was fear of oxygen, often due to a perceived association between death and recent oxygen use. Fears were intensified by a lack of familiarity with equipment used to deliver oxygen, distrust of medical staff and concerns about cost of oxygen. CONCLUSIONS This study identifies reasons for refusal of oxygen therapy for children in a low-income country. Findings from the study suggest that training of healthcare staff to address fears of parents, and information, education and communication (IEC) approaches that improve public understanding of oxygen and provide positive examples of its use are likely to be helpful in improving uptake of oxygen therapy in Malawi.
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Affiliation(s)
- Anna Clare Stevenson
- Department of Acute Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | | | - Neil Kennedy
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
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Todd J, Heyderman RS, Musoke P, Peto T. When enough is enough: how the decision was made to stop the FEAST trial: data and safety monitoring in an African trial of Fluid Expansion As Supportive Therapy (FEAST) for critically ill children. Trials 2013; 14:85. [PMID: 23531379 PMCID: PMC3617035 DOI: 10.1186/1745-6215-14-85] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 03/13/2013] [Indexed: 01/02/2023] Open
Abstract
In resource-rich countries, bolus fluid expansion is routinely used for the treatment of poor perfusion and shock, but is less commonly used in many African settings. Controversial results from the recently completed FEAST (Fluid Expansion As Supportive Therapy) trial in African children have raised questions about the use of intravenous bolus fluid for the treatment of shock. Prior to the start of the trial, the Independent data monitoring committee (IDMC) developed stopping rules for the proof of benefit that bolus fluid resuscitation would bring. Although careful safety monitoring was put in place, there was less expectation that bolus fluid expansion would be harmful and differential stopping rules for harm were not formulated.In July 2010, two protocol amendments were agreed to increase the sample size from 2,880 to 3,600 children, and to increase bolus fluid administration. There was a non-significant trend against bolus treatment, but although the implications were discussed, the IDMC did not comment on the results, or on the amendments, in order to avoid inadvertent partial unblinding of the study.In January 2011, the trial was stopped for futility, as the combined intervention arms had significantly higher mortality (relative risk 1.46, 95% CI 1.13 to 1.90, P = 0.004) than the control arm. The stopping rule for proof of benefit was not achieved, and the IDMC stopped the trial with a lower level of significance (P = 0.01) due to futility and an increased risk of mortality from bolus fluid expansion in children enrolled in the trial. The basis for this decision was that the local standard of care was not to use bolus fluid for the care of children with shock in these African countries, and this was a different standard of care to that used in the UK. These decisions emphasize two important principles: firstly, the IDMC should avoid inadvertent unblinding of the trial by commenting on amendments, and secondly, when considering stopping a trial, the IDMC should be guided by the local standard of care rather than standards of care in other parts of the world.
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Affiliation(s)
- Jim Todd
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Abstract
OBJECTIVE To outline the journey of a mother of a critically ill child in her quest for care for her infant. This article outlines the barriers faced, disappointments, and the indignity of poverty. Questions and commentary relating to the care of the critically ill in resource-limited environments underline the issues she faces. Critical illness is very common in the developing world with most childhood deaths occurring in Asia and sub-Saharan Africa. These areas are handicapped by limited access to critical care and intensive care facilities. This paper is not intended to review preventive strategies and simple inexpensive treatments that may prevent diseases and diminish critical illnesses. DATA SOURCE Experience obtained from a sabbatical in Africa. STUDY SELECTION A literature search with the following terms was conducted: intensive care, critical care, emergency care, children, developing countries, severe pneumonia, ventilator-associated pneumonia, nosocomial infections. DATA EXTRACTION AND SYNTHESIS Abstracts that seemed to relate to the care of critically ill or injured children from the developing world were then reviewed and relevant aspects were discussed. CONCLUSION Critical illness is common in areas of the world plagued with minimal resources to deal with its ravages. Parents try to do what is best for their critically ill children, but navigation of systems and lack of resources are daunting propositions. On any given day, this story or versions of it occurs in many parts of Africa and in low income countries in general. I saw similar scenes several times daily in Uganda and Kenya and, although the issues are slightly different in South Africa, failures of healthcare processes resulted in similar adverse outcomes in all areas. This is a mother's story.
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Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T. Pneumonia in severely malnourished children in developing countries - mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Trop Med Int Health 2009; 14:1173-89. [PMID: 19772545 DOI: 10.1111/j.1365-3156.2009.02364.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To quantify the degree by which moderate and severe degrees of malnutrition increase the mortality risk in pneumonia, to identify potential differences in the aetiology of pneumonia between children with and without severe malnutrition, and to evaluate the validity of WHO-recommended clinical signs (age-specific fast breathing and chest wall indrawing) for the diagnosis of pneumonia in severely malnourished children. METHODS Systematic search of the existing literature using a variety of databases (Medline, EMBASE, the Web of Science, Scopus and CINAHL). RESULTS Mortality risk: Sixteen relevant studies were identified, which universally showed that children with pneumonia and moderate or severe malnutrition are at higher risk of death. For severe malnutrition, reported relative risks ranged from 2.9 to 121.2; odds ratios ranged from 2.5 to 15.1. For moderate malnutrition, relative risks ranged from 1.2 to 36.5. Aetiology: Eleven studies evaluated the aetiology of pneumonia in severely malnourished children. Commonly isolated bacterial pathogens were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Haemophilus influenzae. The spectrum and frequency of organisms differed from those reported in children without severe malnutrition. There are very few data on the role of respiratory viruses and tuberculosis. Clinical signs: Four studies investigating the validity of clinical signs showed that WHO-recommended clinical signs were less sensitive as predictors of radiographic pneumonia in severely malnourished children. CONCLUSIONS Pneumonia and malnutrition are two of the biggest killers in childhood. Guidelines for the care of children with pneumonia and malnutrition need to take into account this strong and often lethal association if they are to contribute to the UN Millennium Development Goal 4, aiming for substantial reductions in childhood mortality. Additional data regarding the optimal diagnostic approach to and management of pneumonia and malnutrition are required from regions where death from these two diseases is common.
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Affiliation(s)
- Mohammod Jobayer Chisti
- Clinical Science Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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Becker JU, Theodosis C, Jacob ST, Wira CR, Groce NE. Surviving sepsis in low-income and middle-income countries: new directions for care and research. THE LANCET. INFECTIOUS DISEASES 2009; 9:577-82. [PMID: 19695494 DOI: 10.1016/s1473-3099(09)70135-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Sepsis is a disorder characterised by systemic inflammation secondary to infection. Despite recent progress in the understanding and treatment of sepsis, no data or recommendations exist that detail effective approaches to sepsis care in resource-limited low-income and middle-income countries (LMICs). Although few data exist on the burden of sepsis in LMICs, the prevalence of HIV and other comorbid conditions in some LMICs suggest that sepsis is a substantial contributor to mortality in these regions. In well-resourced countries, sepsis management relies on protocols and complex invasive technologies not widely available in most LMICs. However, the key concepts and components of sepsis management are potentially translatable to resource-limited environments. Health personnel in LMICs should be educated in the recognition of sepsis and the importance of early and appropriate antibiotic use. Simple and low-cost standardised laboratory testing should be emphasised to allow accurate diagnosis, prognosis, and monitoring of treatment response. Evidence-based interventions and treatment algorithms tailored to LMIC ecology and resources should thus be developed and validated.
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Affiliation(s)
- Joseph U Becker
- Section of Emergency Medicine, Department of Surgery, Yale University School of Medicine, New Haven, CT 06519, USA.
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Molyneux E. Emergency care for children in resource-constrained countries. Trans R Soc Trop Med Hyg 2009; 103:11-5. [DOI: 10.1016/j.trstmh.2008.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2008] [Revised: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 10/21/2022] Open
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A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Pediatr Emerg Care 2008; 24:647-55. [PMID: 19242131 DOI: 10.1097/pec.0b013e31818844cf] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare the impact of 40 mL/kg of fluid over 15 minutes followed by dopamine and further titration of therapy to achieve therapeutic goals (study protocol) versus 20 mL/kg over 20 minutes up to a maximum of 60 mL/kg over 1 hour followed by dopamine (control protocol) in septic shock. DESIGN AND SETTING Prospective randomized controlled study in the emergency department of a public hospital in India. PATIENTS One hundred forty-seven children older than 1 month presenting with septic shock were enrolled into the study. OUTCOME MEASURES Hospital mortality (primary outcome), 72-hour survival, achievement of therapeutic goals of shock resolution, incidence of hypoxia, hepatomegaly, intubation at 20, 40, and 60 minutes (secondary outcomes) were compared between the arms. RESULTS Seventy-four and 73 children were assigned to the study and control group, respectively. Overall mortality was 17.6%, 26 deaths with 13 in each arm. Mortality in the study cohort was lower than our historical mortality of 50% (P<0.0001), 95% confidence interval (CI), 11.9-24.8. Cumulative survival at 72 hours was 72.5% (95% CI, 58.9-86.1) and 77.6% (95% CI, 66.0%-89.2%) in the control and study groups, respectively. Resolution of shock in the emergency department was associated with survival odds ratio (OR) 9.2 (95% CI, 2.1-40.8). Rapidity of achieving therapeutic goals was not significantly different between groups. Intubation rates were also the same (46.5% in the control group versus 55% in the study group; P=0.28). At 20 minutes, 35.6% of the control group and 70% of the study group had hepatomegaly (P<0.01). CONCLUSION There was no difference in the overall mortality, rapidity of shock resolution, or incidence of complications between the groups. The occurrence of hepatomegaly at 20 minutes following 40 mL/kg is of concern in settings with limited access to post-resuscitation ventilator care.
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Abstract
Heikens discusses a new study published inPLoS Medicine that is helpful in reconsidering the applicability of the WHO treatment guidelines.
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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi.
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Maitland K, Berkley JA, Shebbe M, Peshu N, English M, Newton CRJC. Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol? PLoS Med 2006; 3:e500. [PMID: 17194194 PMCID: PMC1716191 DOI: 10.1371/journal.pmed.0030500] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Accepted: 10/19/2006] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (<48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines. METHODS AND FINDINGS Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended "danger signs" (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%). CONCLUSIONS Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments.
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Affiliation(s)
- Kathryn Maitland
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya.
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Carcillo JA, Tasker RC. Fluid resuscitation of hypovolemic shock: acute medicine's great triumph for children. Intensive Care Med 2006; 32:958-61. [PMID: 16791656 DOI: 10.1007/s00134-006-0189-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Accepted: 04/12/2006] [Indexed: 01/20/2023]
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