Development of a PICU in Nepal: the experience of the first year

Outcome reporting in neonatal septic shock studies: A systematic review

OBJECTIVES

Neonatal septic shock is a critical condition requiring immediate and individualised intervention. Despite extensive research, there is a significant heterogeneity in outcome reporting across studies which may lead to incomparability of study results and limit evidence synthesis. The aim of this systematic review was to identify and analyse outcomes reported in studies focussing on interventions for neonatal septic shock to inform the development of a core outcome set to standardise outcome reporting for future research and practice.

METHODS

We conducted this systematic review following the Core Outcome Measures in Effectiveness Trials initiative framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PubMed, Embase (Ovid), and the Cochrane Library, covering all records until September 2024. Four independent reviewers performed literature screening and data extraction, with disagreements resolved by consensus among two additional reviewers. Extracted outcomes and their definitions were standardised and categorised into core areas and domains using a 38-item standardised taxonomy.

RESULTS

From 7139 records, 25 studies involving 4957 neonates were included, yielding 136 outcomes. After consolidation, 66 unique outcomes were identified and classified into four core areas based on the established taxonomy. The most frequently reported area was physiological/clinical outcomes (72%, 18 of 25 studies), encompassing 32 outcomes. This was followed by death (68%, 17/25), resource use (48%, 12/25), and adverse events (36%, 9/25). In addition, outcomes related to life impact were not measured in the included studies.

CONCLUSIONS

This review demonstrates considerable heterogeneity in outcome reporting across neonatal septic shock studies and highlights the absence of life impact measures. These findings support the need for developing a standardised core outcome set to enhance outcome reporting consistency and clinical relevance.

Etiology, Pathophysiology and Mortality of Shock in Children in Low (Middle) Income Countries: A Systematic Review

OBJECTIVES

Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC.

METHODS

We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected.

RESULTS

We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC.

CONCLUSIONS

Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.

Admission pattern, treatment outcomes, and associated factors for children admitted to pediatric intensive care unit of Tikur Anbessa specialized hospital, 2021: a retrospective cross-sectional study

Background

Assessement of the pattern of admission and treatment outcomes of critically ill pediatrics admitted to pediatric intensive care units (PICU) in developing countries is crucial. In these countries with resource limitations, it may help to identify priorities for resource mobilization that may improve patient service quality. The PICU mortality rate varies globally, depending on the facilities of the intensive care unit, availability of experties, and admission patterns. This study assessed the admission pattern, treatment outcomes, and associated factors for children admitted to the PICU.

Methods

A retrospective cross-sectional study was implemented on 406 randomly selected pediatrics patients admitted to the PICU of Tikur Anbessa Specialized Hospital from 1-Oct-2018 to 30-Sept-2020. The data were collected with a pretested questionnaire. A normality curve was used to check for data the distribution. Both bivariable and multivariable analyses were used to see association of variables. A variable with a p-value of < 0.2 in the bivariable model was a candidate for multivariate analysis. The strength of association was shown by an adjusted odds ratio (AOR) with a 95% Confidence interval (CI), and a p-value of < 0.05 was considered statistically significant. Frequency, percentage,and tables were used to present the data.

Results

A total of 361 (89% response rate) patient charts were studied, 197 (54.6%) were male, and 164(45.4%) were female. The most common pattern for admission was a septic shock (27.14%), whereas the least common pattern was Asthma 9(2.50%). The mortality rate at the pediatric intensive care unit was 43.8%. Moreover, mechanical ventilation need (AOR = 11.2, 95%CI (4.3–28.9), P < 0.001), need for inotropic agents (AOR = 10.7, 95%CI (4.1–27.8), P < 0.001), comorbidity (AOR =8.4, 95%CI (3.5–20.5), P < 0.001), length of PICU stay from 2 to 7 days (AOR = 7.3, 95%CI (1.7–30.6), P = 0.007) and severe GCS (< 8) (AOR = 10.5, 95%CI (3.8–29.1), P < 0.001) were independent clinical outcome predictors (mortality).

Conclusion

The mortality rate at the PICU was 43.8%. Septic shock, and meningitis were the common cause of death and the largest death has happened in less than 7 days of admission.

Prevalence and Management of Septic Shock among Children Admitted at the Kenyatta National Hospital, Longitudinal Survey

BACKGROUND

Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital.

METHODS

A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12.

RESULTS

The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7-11.0), p = 0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively).

CONCLUSION

The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.

Performance comparison in Pediatric Fundamental Critical Care Support among staff from the USA versus those from resource-limited countries

OBJECTIVE

This study aimed to evaluate the performance of participants in the USA compared with international participants taking the Pediatric Fundamental Critical Care Support (PFCCS) course, and the significance of training for resource-limited environments.

METHODS

PFCCS courses were conducted in the USA, El Salvador, Haiti, Kenya, and Nepal between January 2011 and July 2013. All of the participants took pre- and post-tests. We compared the performance of these tests between international and USA participants. All participants answered a post-course survey to evaluate the didactic lectures and skill stations.

RESULTS

A total of 244 participants took the PFCCS course, comprising 71 from the USA, 68 from Kenya, 37 from Haiti, 48 from Nepal, and 20 from El Salvador. The mean pre-test score of USA participants (50.6%) was significantly higher than that of international participants (44.7%). There was no significant difference in the post-test score between USA and international participants (78.6% versus 81.4%). There was a significant difference between pre- and post-test scores. There was better appreciation of the course content by the USA participants.

CONCLUSION

International course takers without prior pediatric intensive care training have similar test scores to USA participants suggesting comparable efficacy.

A "Fundamentals" Train-the-Trainer Approach to Building Pediatric Critical Care Expertise in the Developing World

Pediatric Fundamental Critical Care Support (PFCCS) is an educational tool for training non-intensivists, nurses, and critical care practitioners in diverse health-care settings to deal with the acute deterioration of pediatric patients. Our objective was to evaluate the PFCCS course as a tool for developing a uniform, reproducible, and sustainable model for educating local health-care workers in the optimal management of critically ill children in the Republic of Georgia. Over a period of 18 months and four visits to the country, we worked with Georgian pediatric critical care leadership to complete the following tasks: (1) survey health-care needs within the Republic of Georgia, (2) present representative PFCCS lectures and simulation scenarios to evaluate interest and obtain "buy-in" from key stakeholders throughout the Georgian educational infrastructure, and (3) identify PFCCS instructor candidates. Georgian PFCCS instructor training included the following steps: (1) US PFCCS consultant and content experts presented PFCCS course to Georgian instructor candidates. (2) Simulation learning principles were taught and basic equipment was acquired. (3) Instructor candidates presented PFCCS to Georgian learners, mentored by PFCCS course consultants. Objective evaluation and debriefing with instructor candidates concluded each visit. Between training visits Georgian instructors translated PFCCS slides to the Georgian language. Six candidates were identified and completed PFCCS instructor training. These Georgian instructors independently presented the PFCCS course to 15 Georgian medical students. Student test scores improved significantly from pretest results (n = 14) (pretest: 38.7 ± 7 vs. posttest 62.7 ± 6, p < 0.05). A Likert-type scale of 1 to 5 (1 = not useful or effective, 5 = extremely useful or effective) was used to evaluate each student's perception regarding (1) relevance of course content to clinical work students rated as median (IQR): (a) relevance of PFCCS content to clinical work, 5 (4-5); (b) effectiveness of lecture delivery, 4 (3-4); and (c) value of skill stations for clinical practice, 5 (4-5). Additionally, the mean (±SD) responses were 4.6 (±0.5), 3.7 (±0.6), and 4.5 (±0.6), respectively. Training local PFCCS instructors within an international environment is an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care. Future collaborations will evaluate the clinical impact of PFCCS throughout the Georgian health-care system.

Current State of Pediatric Intensive Care and High Dependency Care in Nepal

OBJECTIVES

To describe the state of pediatric intensive care and high dependency care in Nepal. Pediatric intensive care is now a recognized specialty in high-income nations, but there are few reports from low-income countries. With the large number of critically ill children in Nepal, the importance of pediatric intensive care is increasingly recognized but little is known about its current state.

DESIGN

Survey.

SETTING

All hospitals in Nepal that have separate physical facilities for PICU and high dependency care.

PATIENTS

All children admitted to these facilities.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A questionnaire survey was sent to the chief of each facility. Eighteen hospitals were eligible and 16 responded. Two thirds of the 16 units were established in the last 5 years; they had a total of 93 beds, with median of 5 (range, 2-10) beds per unit. All 16 units had a monitor for each bed but only 75% could manage central venous catheters and only 75% had a blood gas analyzer. Thirty two percent had only one functioning mechanical ventilator and another 38% had two ventilators, the other units had 3-6 ventilators. Six PICUs (38%) had a nurse-to-patient ratio of 1:2 and the others had 1:3 to 1:6. Only one institution had a pediatric intensive care specialist. The majority of patients (88%) came from families with an income of just over a dollar per day. All patients were self funded with a median cost of PICU bed being $25 U.S. dollars (interquartile range, 15-31) per day. The median stay was 6 (interquartile range, 4.8-7) days. The most common age group was 1-5. Sixty percent of units reported respiratory distress/failure as their primary cause for admission. Mortality was 25% (interquartile range, 20-35%) with mechanical ventilation and 1% (interquartile range, 0-5%) without mechanical ventilation.

CONCLUSIONS

Pediatric intensive care in Nepal is still in its infancy, and there is a need for improved organization, services, and training.

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.