Global Anesthesiology and Intraoperative Neuromonitoring: Report from a Sustainable Collaboration

The stated mission of the ASA Committee on Global Health is to enhance, support, educate, represent and collaborate for safe anesthesia practice worldwide. As an ASA Committee on Global Health scholarship recipient, Dr. Simmons traveled to CURE Uganda in 2017 and fully felt the pull of that mission. It was during this trip, and subsequent visits thereafter, that the framework was set for the creation of an educational and clinical program that would significantly improve surgical and anesthesia care, support economic development with job creation, and improve career satisfaction of clinicians via the implementation of the first intraoperative neuromonitoring (IONM) program in Uganda. At the University of Colorado Hospital, where Drs. Simmons and Montejano practice, the Section of Neuroanesthesia supervises and directs the IONM program. Utilizing these unique skills and recognizing the need for this technology and its ability to enhance patient outcomes, work began toward training and educating both a supervising physician and IONM technologist. After nearly two years of preparation with meetings and strategy sessions, as well as education and training, the program was launched in March 2022. The overall success of the project demonstrates the great potential of collaboration between departments of anesthesiology, neurosurgery, and hospital leadership despite cultural differences and geographic locations.

Essential maternal health service disruptions in Ethiopia during COVID 19 pandemic: a systematic review

COVID 19 pandemic has challenged the resilience of the most effective health systems in the world. The Ethiopian Ministry of health tried to ensure the continuation of essential maternal health services during the pandemic. Despite several individual studies conducted on the impact of COVID 19 on maternal health services, no evidence can summarize the extent of impact as a nation and which essential maternal health service is most affected.

A systematic review was conducted to summarize the extent of disruption of essential maternal health services and identify the most affected service in the era of the COVID pandemic in Ethiopia. Preferred Reporting Items for Systematic Review and Meta-analysis guidelines were followed. Comprehensive literature was searched using international databases PubMed, Google scholar, and African Online Journal to retrieve related articles. Descriptive analysis was made to answer the review objective.

Overall, 498 articles were retrieved using our search strategy and finally 8 articles were included in the review. We found, ANC (26.35%), skilled birth attendance (23.46%), PNC (30%), family planning (14%), and abortion care (23.7%) maximum disruption of service utilization due to the pandemic. PNC service was the most significantly affected service unit followed by the ANC unit.

Essential maternal health services have been significantly disrupted due to COVID 19 pandemic in Ethiopia. It is expected from all stakeholders to prioritize safe and accessible maternity care during the pandemic and the aftermath and take lesson to reduce maternal and infant morbidity and mortality.

Infection after surgical implant generation network (SIGN) nailing in treatment of long bone shaft fractures in Ethiopia: analysis of a 4-year results

One of the challenge to manage long bone fracture is the risk of infection. Intramedullary nailing is the standard treatment of long bone shaft fractures. Infection from the surgical site during orthopedic management is posing postoperative burdens in different perspectives like patient perspectives and healthcare facilities. However, there is limited information on the magnitude of infection in Ethiopia after surgical implant generation network (SIGN) nailing in the treatment of long bone shaft fractures. Therefore, the current study aimed to assess the prevalence of infection in patients with long bone shaft fractures treated with surgical implant generation network (SIGN) nailing.

To assess prevalence of infection in patients with long bone shaft fractures treated with SIGN nailing at Felege Hiwot Referral Hospital from January 1, 2015, to December 31, 2018, Bahir Dar, Northwest, Ethiopia.

This was a retrospective study over a period of 4 years. SIGN surgical-related data, presence or absence of infection from the documented information were collected from the chart/the source. The types of infection were also collected with the standard classification as superficial, deep and deep with osteomyelitis. Age, sex, fracture pattern, nature of fracture, mechanism of injury, prophylaxis antibiotics, nail type, follow-up in weeks and other factors were also extracted from the patients’ charts with structured checklist. Data were analyzed with statistical package for social sciences (SPSS) version 23. The analyzed data were presented with texts, tables and a graph.

Three hundred and eighty-two long bone fractures were treated by locked SIGN intramedullary nailing during the study period. After screening the inclusion criteria, a total of 311 cases were included in this study. A total of 13 (4.2%) patients who treated with SIGN intramedullary nailing developed infection.

We conclude that the overall prevalence of infection with SIGN intramedullary nailing is almost similar with the surgeries done in the developed countries.

Prevalence, Risk Factors, and Microbiological Profile of Early Surgical Site Infection Following Orthopaedic Implant Surgery at Kenyatta National Hospital

Background: The prevalence of surgical site infections (SSI) in orthopaedic surgery has been on the rise especially in low and middle-income countries (LMIC). This has been attributed to the increased number of trauma patients due to the increased incidence of motor vehicle and motor cycle crashes. Kenya has witnessed a similar increase, more so from motor cycle related crashes, leading to an increase in the number of fractures treated operatively. Time to ORIF, duration of surgery, antibiotic prophylaxis are some of the risk factors for SSI, however, data on prevalence and risk factors of SSI within our population to inform preventive strategies remain scarce. Study objective: To determine the prevalence, risk factors and causative bacterial pathogens using microscopy culture and antibiotic sensitivity patterns of SSI following surgery for long bone fractures at level 6 referral hospital Kenyatta(KNH). Study design: Prospective observational analytic . Study setting: The study was carried out in orthopaedic clinic (OC) and wards (OW) at the Kenyatta National Hospital (KNH) between 11th February 2022 and 2nd May 2022 Patients and methods: The collected data were transferred from password-coded data digital collection sheets into analysis software for data cleaning and coding prior to analysis. Data was stored in password-protected computer folders to maintain anonymity of the study subjects. Data analysis was carried out using the Prism 7 (GraphPad Software, San Diego, CA, USA) and SPSS (IBM Statistics Software Version 25, Armonk, New York, USA). Categorial data was reported as frequencies (%). Continuous data were subjected to normality tests (histogram and Q-Q plots with Kolmogorov-Smirnov test) and reported as mean and standard deviation (SD). Comparison of patient and fracture characteristics between patients with and without SSI was carried out using the Independent Student’s-t test (continuous variables) and Chi-square xii statistic (categorical variables). Multivariate logistic regression analysis was performed to identify risk factors for SSI, adjusting for the age,BMI ,sex and comorbidities, and to calculate adjusted odds ratios (ORs) with the corresponding 95% Wald CI. Throughout the analysis, a p<0.05 was considered statistically significant at a 95% confidence interval. Results: A total of 130 patients were recruited into this study. They were generally young (mean age: 33±12.8 years) with a male predominance (83%). The mean body mass index (BMI) was 23.7±2.1 Kg/M2, with 13 (10%) having diabetes mellitus (DM). The most fractured bone was femur (n=66 patients, 50.8%). The mean injury severity score (ISS), pre-operative hospital stay and ASA (American Society of Anaesthesiology) score were 21.6±11.2, 12±9.2 days 1.0±0.1 and respectively. A total of 18 patients (13.8%) developed surgical site infection (SSI). Compared to those without SSI, patients with SSI were predominantly male (p=0.007), had higher BMI (p=0.003) and diabetes mellitus (DM) (p=0.007), had higher incidence of open fractures (p=0.046), higher ISS (p=0.008), and were more likely to require pre-operative blood transfusion (p<0.001) and ICU admission (p<0.001). In the multivariate adjusted logistic regression model, female sex (OR= 5.52, 95% CI 1.15-26.65, p=0.033), presence of diabetes (OR= 9.72, 95% CI 1.83-51.76, p=0.008), higher BMI (OR= 1.31, 95% CI 1.02-1.69, p=0.033), need for pre-operative blood transfusion (OR= 68.21, 95% CI 5.42-858.32, p<0.001) and need for ICU admission (OR= 8.10, 95% CI 5.18-12.65, p<0.001) were significant predictors of development of SSI. The commonest organism isolated was staphylococcus aureus (SA) (70%). Conclusion: The burden of surgical site infections (SSI) following orthopaedic surgery remains high. Diabetes mellitus (DM), higher body mass index (BMI), pre-operative blood transfusion and intensive care unit admission were associated as risk factors for SSI in this study cohort. Commonest isolated organism was Staphylococcus aureus (n= 7patients,70%). Culture isolates display a concerning trend of increased resistance to commonly prescribed antibiotics. Recommendation: 1.Increased SSI surveillance mearures in Orthopaedic patients with diabetes and obesity comorbidities 2. Routine establishment of sensitivity patterns of SSI isolates to guide antimicrobial selection is recommended.

Ethiopia’s first minimally invasive surgery program: a novel approach in global surgical education

Complex lung diseases are among the leading causes of death in Ethiopia. Access to thoracic surgery is limited and prior to 2016 no thoracic surgeons were trained in minimally invasive surgery (MIS). A global academic partnership was formed between the University of Toronto and Addis Ababa University (AAU). Here, we describe implementation of the first MIS training program in sub-Sahara Africa and evaluate its safety.
Retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at AAU from January 2016, to June 2021. Baseline demographic, diagnostic, operative, and post-operative outcomes including length of stay (LOS) and complications were compared.
In our bilateral model of surgical education, training is provided in Ethiopia and Canada over two years with focus on capacity building through egalitarian forms of knowledge exchange. Program features included certification in Fundamentals of Laparoscopic Surgery®, high-fidelity lobectomy simulation and hands on training. Overall, 41 open and 56 MIS cases were included in final statistical analysis. The average LOS in the MIS group was 5.2 days versus 11.0 days in the open group (p-value <0.001). The overall complication rate was 18% in the MIS group versus 39% open (p-value 0.020).
Here we demonstrated the successful initiation of sub-Sahara Africa’s first MIS program in thoracic and upper gastrointestinal surgery and characterize its patient safety. We envision the MIS program as a template to continue expanding global partnerships and improving surgical care in other resource-limited settings.

Bridging the know-do gap in low-income surgical environments: Creating contextually appropriate training videos to promote safer surgery in Ethiopia

Although international guidelines exist for the prevention of surgical site infections, their implementation in diverse clinical contexts, especially in low and middle-income countries, is challenging due to the lack of available resources and organizational structure of facilities. The goal of this project was to develop a series of video training aids to highlight best practices in surgical infection prevention in hospitals with limited resources and to provide practical solutions to common challenges faced in these settings.

Using the validated Clean Cut education framework for infection prevention developed by Lifebox, a charity devoted to improving surgical and anesthetic safety, we partnered with clinicians in one Ethiopian hospital to create six educational videos giving practical guidelines for infection prevention under resource variable conditions. These include: 1) proper use of the WHO Surgical Safety Checklist, 2) hand and skin antisepsis, 3) confirming instrument sterility, 4) maintaining the sterile field, 5) antibiotic prophylaxis, and 6) gauze counting.

Gaps in available online educational materials were identified in each of the six areas. Videos were created providing setting-specific education and addressing gaps in existing materials for each of the infection prevention topics. These videos are now integrated into infection prevention curricula through Lifebox in Ethiopia and ongoing data collection to evaluate acceptability and efficacy is ongoing.

Surgical education videos on infection prevention topics addressing location-specific resources and workarounds can be useful to hospitals operating in resource-limited settings for training staff and supporting quality and safety efforts in surgery.

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.

Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data

Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya.
Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care.
Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.

Patterns and Predictors of Timely Presentation and Outcomes of Polytrauma Patients Referred to the Emergency Department of a Tertiary Hospital in Tanzania

Background. Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the frst-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the frst-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. Te outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results. We enrolled 120 (4.5%) referred polytrauma adult patients. Te median age was 30 years (IQR 25–39) and the ISS was 29 (IQR 24–34). The majority (85%) were males. While the median time from injury to frst-health facility was 40 minutes (IQR 33–50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314–469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed
group (95% CI 0.3–5.6). Having a GCS <8 (AOR 16.3 (95% CI 3.1–86.3), hypoxia <92% (AOR 8.3 (95% CI 1.4–50.9), and hypotension <90 mmHg (R 7.3 (95% CI 1.6–33.6) were all independent predictors of mortality. Conclusion. Te majority of polytrauma patients arrive at the tertiary facilities delayed for more than 6 hours and a distance of more than 8 km between facilities is associated with delay. Hypotension, hypoxia, and GCS of less than 8 are independent predictors of poor outcome. In the interim, there is a need to expedite the transfer of polytrauma patients to trauma care capable centers.

Admission Criteria of Obstetric Patients in Selected Intensive Care Units, Khartoum State, Sudan (2022)

The Obstetric admissions to the intensive care unit (ICU) require special care and attention by a multidisciplinary team. Pregnancy is associated with many maternal physiological and organ changes. These changes are primarily due to production of progesterone by the corpus luteum in early pregnancy and the placenta from ten weeks. They are admitted to the ICU for close observation to detect the problems earlier, perform invasive monitoring, increase nursing care or ventilatory support or any intervention that is not available at the wards. The aim of this study was to identify the admission criteria of obstetric patients. A retrospective study was conducted in maternal hospitals, from January to December 2021.70 patients with inclusion criteria were included. The results revealed that most of the patients diagnosed with Preeclampsia25.7%, eclampsia 22.9%, not applicable for the scoring system. Data was collected using a questionnaire filled by researchers from patients’files. The study found that most common cases were admitted to ICU with pre-eclampsia, eclampsia and postpartum hemorrhage, the antenatal care was low, that wasn’t applicable to scoring systems at admission and most patients did not need invasive procedures or mechanical ventilation.