Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study

BACKGROUND

The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown.

METHODS

This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used.

RESULTS

Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality.

CONCLUSIONS

Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.

Improving long-lasting insecticidal nets use in Kayange community of north-western Burundi: a pilot study exploring the use of quality improvement methodologies in low-resource community settings

Quality improvement (QI) approaches have demonstrated a lot of promise in improving clinical care processes, both in high-resource and low-resource settings. However, most examples of QI initiatives in healthcare in low-income countries are clinic-based. The objective of this study was to demonstrate feasibility of applying QI methods in low-resource community settings by applying them to the problem of correct utilisation of long-lasting insecticidal nets (LLINs) in a rural community in Burundi. Correct utilisation of LLINs had been shown to be a cost-effective approach to malaria prevention. In Burundi, LLINs utilisation is low. The Model for Improvement, a well-known QI approach, was used to increase LLINs utilisation in a rural community in Burundi. In the baseline, LLINs ownership and weekly utilisation together with factors affecting LLINs non-use were documented for a period of 4 weeks before intervention. Improvement ideas were collaboratively developed by a quality improvement team (QIT) and tested using Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle consisted of the demonstration of how to mount LLINs, the second was an implementation of reminders done by household 'watchdogs', the third cycle consisted of conducting two community reminders every week and the last cycle was a combination of the last two PDSA cycles. The intervention lasted 4 weeks and data were collected weekly. LLINs utilisation was calculated each week and plotted on a run chart to demonstrate improvement trends. LLINs utilisation data were collected for another 3 weeks postintervention. Of 96 households, 83 (87%) households owned at least one LLIN. After intervention, the number of LLINs used increased from 32% to 75% (134% increase) and the number of persons (general population) sleeping under LLINs from 35% to 73% (108% increase). The number of children under 5 years sleeping under LLINs increased from 31% to 76% (145% increase) and the number of pregnant women who slept under LLINs from 43% to 73% (69% increase). Also, the averages of the number of nights in each week that the general population slept under LLINs increased from 2.13 to 5.11 (140% increase), children under 5 years from 1.68 to 4.78 (184% increase) and pregnant women from 1.56 to 4.47 (186% increase). Each of the 4 PDSA cycles led to a significant increase in outcome indicators and the trends appear to persist even after the implementation was complete. While it is impossible to draw generalisable conclusions from a small pilot study, QI approaches appear to be feasible to implement in low-resource community setting and have promise in producing results. More research at larger scale should be encouraged to validate our initial findings.

PO 7167 IMPROVING USE OF LONG-LASTING INSECTICIDAL NETS IN KAYANGE COMMUNITY OF NORTH-WESTERN BURUNDI: A QUALITY IMPROVEMENT STUDY

Background

The use of long-lasting insecticidal nets (LLINs) for malaria prevention is a cost-effective intervention. WHO recommends universal coverage and use of LLINs. In lower- and middle-income countries, LLINs are provided free of charge but are either not used or misused. Our study sought to improve LLIN use in Kayange community of north-western Burundi by using a model for improvement (MFI).

Methods

A one-group, pre/post-test study was conducted. LLIN weekly use was assessed for four weeks before intervention and for another four weeks after intervention. The study was conducted in 96 households. The intervention consisted of testing four different weekly small change actions by using the MFI.

Results

Of the 96 households, 83 households (87%) owned at least one LLIN. However, only 40 households (42%) owned at least one LLIN for every two people. After intervention, the number of LLINs used increased from 32 to 75 per cent (134% increase) and the number of persons (general population) sleeping under LLIN from 35 to 73 per cent (108% increase). The number of children under 5 years old sleeping under LLIN increased from 31 to 76 per cent (145% increase) and the number of pregnant women who slept under LLIN from 43 to 73 per cent (69% increase). Also, the averages of the number of nights in each week that the general population slept under LLIN increased from 2.13 to 5.11 (140% increase), children under 5 years old slept under LLIN from 1.68 to 4.78 (184% increase) and pregnant women slept under LLIN from 1.56 to 4.47 (186% increase).

Conclusion

Our intervention led to significant increase in all outcome indicators. This increase is the result of a combination of an enabling context and an effective implementation of an evidence-based quality improvement intervention. Small tests of change at the community level have the potential for achieving improved outcomes.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

BACKGROUND

There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa.

METHODS

We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899).

FINDINGS

We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died.

INTERPRETATION

Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective.

FUNDING

Medical Research Council of South Africa.

[Treatment of wounds with honey. 40 cases]

Honey has been used long ago to treat wounds and cutaneous ulcers, and its healing properties have recently been rediscovered. Its applications on wounds or infected burns give satisfactory results. In a study of 40 patients with wounds of various origin honey provided healing in 88 percent of the cases. At the end of the healing process a few microorganisms were isolated from the wounds, but they did not prevent consolidation. This treatment, therefore, seems to be effective; moreover, as it is simple and inexpensive it should be better known and added to the list of commonly used antiseptic products.