Risk factors associated with acute kidney injury in a pediatric intensive care unit in Addis Ababa, Ethiopia. Case control study

Background: Acute kidney injury (AKI) is a serious problem in critically ill children. It is associated with poor treatment outcomes and a high rate of morbidity and mortality. Globally, one in three critically ill admitted children suffer from acute kidney injury. However, limited data are available in Africa, particularly in Ethiopia, highlighting the risk factors related to acute kidney injury. Therefore, this study aimed to identify the risk factors associated with acute kidney injury among critically ill children admitted to the pediatric intensive care unit at the Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods: A facility-based unmatched case-control study was carried out on 253 (85 cases and 168 controls) children admitted to the pediatric intensive care unit from January 2011 to December 2021. Participants were selected using a systematic random sampling technique for the control group and all cases consecutively. Data were collected using a structured checklist. Data were entered using Epi data version 4.6 and analyzed using SPSS version 25. Multivariate analysis was carried out using the adjusted odds ratio (AOR) with a 95% confidence interval (CI) to identify associated factors with acute kidney injury. Statistical significance was set at P < 0.05.

Results: The median age of the participants was two years. About 55.6 % of cases and 53.1% of controls were females. The diagnosis of hypertension (AOR= 5.36; 95% CI: 2.06- 13.93)], shock (AOR=3.88, 95% CI: 1.85- 8.12), exposure to nephrotoxic drugs (AOR=4.09; 95% CI: 1. 45- 11.59), sepsis or infection AOR=3.36; 95% CI: 1.42-7.99), nephritic syndrome (AOR=2.97; 95% CI :1.19, 7.43), and mechanical ventilation AOR=2.25, 95% CI: 1.12, 4.51) were significantly associated with acute kidney injury.

Conclusion: In this study, the diagnosis of sepsis or infection, hypertension, shock, nephrotoxic drugs, demand for mechanical ventilation support, and nephritic syndrome increased the risk of AKI among critically ill children. Multiple risk factors for AKI are associated with illness and its severity. All measures that ensure adequate renal perfusion must be taken in children with identified risk factors to avoid the development of AKI.

Incidence, risk and impact of unplanned ICU readmission on patient outcomes and resource utilisation in tertiary level ICUs in Nepal: A cohort study

Background: Unplanned readmissions to Intensive Care Units (ICUs) result in increased morbidity, mortality, and ICU resource utilisation (e.g. prolonged mechanical ventilation), and as such, is a widely utilised metric of quality of critical care. Most of the evidence on incidence, characteristics, associated risk factors and attributable outcomes of unplanned readmission to ICU are from studies performed in high-income countries This study explores the determinants of risk attributable to unplanned ICU readmission in four ICUs in Kathmandu, Nepal.
Methods: The registry-embedded eCRF reported data on case mix, severity of illness, in-ICU interventions (including organ support), ICU outcome, and readmission characteristics. Data were captured in all adult patients admitted between September 2019 and February 2021. Population and ICU encounter characteristics were compared between those with and without readmission. Independent risk factors for readmission were assessed using univariate analysis.
Results: In total 2948 patients were included in the study. Absolute unplanned ICU readmission rate was 5.60 % (n=165) for all four ICUs. Median time from ICU discharge to readmission was 3 days (IQR=8,1). Of those readmitted, 29.7% (n=49) were discharged at night following their index admission. ICU mortality was higher following readmission to ICU(p=0.016) and mortality was increased further in patients whose primary index discharge was at night(p= 0.019). Primary diagnosis, age, and use of organ support in the first 24hrs of index admission were all independently attributable risk factors for readmission.
Conclusions: Unplanned ICU readmission rates were adversely associated with significantly poorer outcomes, increased ICU resource utilisation. Clinical and organisational characteristics influenced risk of readmission and outcom

The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa

Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa.

The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure).

This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system.

Trial Registration: Not applicable as this study is not a clinical trial.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country

Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population.

A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system’s Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC.

The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery.

PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Haemodynamic monitoring in patients undergoing high-risk surgery: a survey of current practice among anaesthesiologists at the University of the Witwatersrand

Background: Haemodynamic monitoring and optimisation in high-risk surgery patients improve postoperative outcomes. High-income countries (HICs) have reviewed their haemodynamic monitoring and management practices. There is, however, a paucity of literature in low- and middle-income countries (LMICs) in this regard. The aim of this study was to describe the current haemodynamic monitoring practice in high-risk surgery patients among anaesthesiologists at the University of the Witwatersrand.

Methods: A survey was conducted among anaesthesiologists at the University of the Witwatersrand using a convenience sampling method by means of an adapted questionnaire from previous research done on this topic.

Results: A total of 64 out of 76 questionnaires were analysed, attaining a response rate of 84%. Ninety-seven per cent of the respondents either provided or directly supervised anaesthesia for high-risk surgery patients. Ninety-seven per cent of them frequently monitored invasive arterial blood pressure (IABP), 68.8% monitored stroke volume variation (SVV) and 53% monitored cardiac output (CO). The most frequently optimised parameter was IABP (68.8%); while CO was optimised by only 39.1% of the respondents. The VigileoTM monitor was the most frequently used CO device (84.4%). The main reason for not monitoring CO was the use of dynamic parameters of fluid responsiveness as a surrogate for CO (57.8%). Seventy-five per cent of the respondents used SVV as a diagnostic indicator for volume expansion, but the haemodynamic effects of volume expansion were frequently assessed using change in heart rate (78.1%) and blood pressure (76.6%). Most of the respondents (98.4%) believed that their haemodynamic management practice could be improved.

Conclusion: Anaesthesiologists at the University of the Witwatersrand frequently monitored and optimised IABP rather than CO in high-risk surgery patients. The respondents used dynamic parameters of fluid responsiveness as a surrogate for CO monitoring and as an indicator for volume expansion. Most of the respondents believed that their current haemodynamic management practice in this setting could be improved.

The impact of the Fundamental Critical Course on knowledge acquisition in Rwanda

Background. Emerging critical care systems have gained little attention in low- and middle-income countries. In sub-Saharan Africa, only 4% of the healthcare workforce is trained in critical care, and mortality rates are unacceptably high in this patient population.
Aim. We sought to retrospectively describe the knowledge acquisition and confidence improvement of practitioners who attend the Fundamental Critical Care Support (FCCS) course in Rwanda.
Methods. We conducted a retrospective study in which we assessed survey data and multiple-choice question data that were collected before and after course delivery. The purpose of these assessments at the time of delivery was to evaluate participants’ perception and acquisition of critical care knowledge.
Results. Thirty-six interprofessional clinicians completed the training. Performance on the multiple-choice questions improved overall after the course (mean score pre-course of 56.5% to mean score post-course of 65.8%,p-value <0.001) and improved in all content areas with the exception of diagnosis and management of acute coronary syndrome and acute respiratory failure/mechanical ventilation. Both physicians and nurses improved their scores significantly (68.9% to 75.6%,p-value = 0.031 and 52.0% to 63.5%,p-value <0.001, respectively). Self-reported
confidence in level of knowledge also increased in all areas. Survey respondents indicated on open-answer questions that they would like the course offerings at least annually, and that further dissemination of the course in Rwanda was warranted.
Conclusion. Deploying the established FCCS course improved Rwandan healthcare provider knowledge and confidence across most critical care content areas. Therefore, this course represents a good first step in bridging the gaps noted in emerging critical care systems.

Essential Emergency and Critical Care as a health system response to critical illness and the COVID19 pandemic: What does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, low-cost care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in low resource settings with Kenya and Tanzania as case studies.

The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.

The costs per patient day of EECC is estimated to be 1.01 USD, 10.83 USD and 32.84 USD in Tanzania and 1.76 USD, 14.86 USD and 37.43 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13.11 USD and 17.33 USD for severe and 297.30 USD and 369.64 USD for critical COVID-19 patients in Tanzania and Kenya, respectively.

EECC, an approach of providing the essential care to all critically ill patients, is low-cost. The components of EECC are basic and universal and, when assessed against the existing gaps in critical care coverage and costs of advanced critical care, suggest that it should be a priority area of investment for health systems around the globe.

Cost of postoperative sepsis in Vietnam

Despite improvements in medical care, the burden of sepsis remains high. In this study, we evaluated the incremental cost associated with postoperative sepsis and the impact of postoperative sepsis on clinical outcomes among surgical patients in Vietnam. We used the national database that contained 1,241,893 surgical patients undergoing seven types of surgery. We controlled the balance between the groups of patients using propensity score matching method. Generalized gamma regression and logistic regression were utilized to estimate incremental cost, readmission, and reexamination associated with postoperative sepsis. The average incremental cost associated with postoperative sepsis was 724.1 USD (95% CI 553.7–891.7) for the 30 days after surgery, which is equivalent to 28.2% of the per capita GDP in Vietnam in 2018. The highest incremental cost was found in patients undergoing cardiothoracic surgery, at 2,897 USD (95% CI 530.7–5263.2). Postoperative sepsis increased patient odds of readmission (OR = 6.40; 95% CI 6.06–6.76), reexamination (OR = 1.67; 95% CI 1.58–1.76), and also associated with 4.9 days longer of hospital length of stay among surgical patients. Creating appropriate prevention strategies for postoperative sepsis is extremely important, not only to improve the quality of health care but also to save health financial resources each year.

Prospective, observational study of perioperative critical incidents, anaesthesia and mortality in elective paediatric surgical patients at a national referral hospital in Niger

Aims: To describe perioperative critical incidents, the conduct of anaesthesia and perioperative mortality in elective paediatric surgery patients in a national referral hospital in Niger.

Methods: This is a prospective, observational study conducted from January to March 2018. All paediatric patients 15 years an younger, who underwent elective surgery in the Niamey National Hospital were included. The following variables were studied: age, sex, type of surgery, American Society of Anesthesiologists physical status (ASA PS) classification, monitoring system, anaesthesia technique, critical incidents, blood transfusion, analgesia, qualification of the anaesthesia practitioner, postoperative destination and mortality. Data were analysed with Excel 2007 and Epi Info 6™ (Centers for Disease Control and Prevention Atlanta, GA). The chi2 test was used for univariate associations with critical incidents. Statistical significance was considered if p < 0.05. Results: There were 231 (27.2%) paediatric patients of 849 surgical patients during the study period. Within the paediatric group, the mean age was 6 ± 4 years. The male:female sex ratio was 1.65. A full blood count was completed preoperatively in all patients. Three per cent of the patients received a preoperative blood transfusion. The most frequently performed surgery was abdominal (42.4%). Most patients were classified as ASA PS I (55%) and ASA PS II (45%). General anaesthesia was performed in 96.1% of cases and spinal anaesthesia in 3.9%. The median duration of general anaesthesia was 63 (interquartile range 45–90) minutes. There were 27 reported critical incidents (11.7%), ten of which occurred during induction (4.9%), five intraoperatively (2.2%) and 12 postoperatively (5.2%). Multimodal postoperative analgesia was used in 33.8% of these patients. One patient died in the postoperative period (0.43%). Conclusion: Perioperative critical incidents in paediatric surgical patients in Niger remain high. To improve this situation requires paediatric training of anaesthetic staff, and improved paediatric monitoring and the use of safer anaesthesia agents.

The structure, function and implementation of an outcomes database at a Ugandan secondary hospital: the Mbarara Surgical Services Quality Assurance Database

The Mbarara Surgical Services Quality Assurance Database (Mbarara SQUAD) is an outcomes database of surgical, obstetric and anaesthetic/critical care at Mbarara Regional Referral Hospital, a secondary referral hospital in southwestern Uganda. The primary scope of SQUAD is the assessment of the outcomes of care. The primary outcome is mortality. The aim is to improve the quality of care, guide allocation of resources and provide a platform for research. The target population includes all inpatients admitted for treatment to the surgery service, the obstetrics and gynaecology services, and the intensive care unit (ICU). Data collection was initiated in 2013 and closed in 2018. Data were extracted from patient charts and hospital logbooks. The database has over 50 000 patient encounters, including over 20 000 obstetrics and gynaecology admissions, 15 000 surgical admissions and 16 000 otolaryngology outpatient visits. Entries are coded using the International Classification of Diseases, Tenth Revision (ICD-10) for diagnoses, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for procedures. The completeness and accuracy of the data entry and the coding were validated. Governance of data use is by a local steering committee in Mbarara. The structure, function and implementation of this database may be relevant for similar hospital databases in low-income countries.