Comparison of outcomes between children ventilated in a non‐paediatric intensive care and a paediatric intensive care unit: A retrospective analysis
Article Sidebar
Main Article Content
Abstract
Background. Lack of paediatric intensive care infrastructure, human resources and expertise in low- and middle-income countries (LMICs) often results in critically ill children being managed in non-intensive-care unit (ICU) settings.
Objectives. To compare the mortality between critically ill patients who required ventilation for more than 24 hours in a non-paediatric ICU (PICU) setting v. those admitted directly to a PICU.
Methods. Participants were enrolled if they were between one month and 13 years of age and were ventilated in a non-PICU ward in a regional hospital and a PICU ward in a tertiary/quaternary hospital during the study period of January 2015 - December 2017 in KwaZulu- Natal, South Africa. Descriptive statistics, chi-square test, Wilcoxon test and binary logistic regression were used for data analysis. Ethics approval was obtained (approval number BE568/18 BREC) from the Biostatistics Research Council of the University of KwaZulu-Natal.
Results. Of the 904 admissions, 25.1% (n=227) were admitted to non-PICU and 74.9% (n=677) to a PICU. A significantly higher proportion of non-PICU patients were malnourished than PICU patients (26.4% v. 13.3%, p<0.001). Patients ventilated in a PICU were 76% less likely to die (p<0.001), while patients who required inotropes were 15.08 (9.68 - 24.34) times more likely to die (p<0.001). There was a statistically significant association between admission setting and survival outcome, with higher mortality in the non-PICU setting than in the PICU setting (46.3% v. 19.5%, p<0.001).
Conclusion. Critically ill children ventilated in a non-PICU setting in KwaZulu-Natal are more likely to be malnourished, require inotropes and have higher mortality. Although increasing access to PICU bed availability is a long-term goal, the high mortality in the non-PICU setting highlights the need to optimise the availability of resources in these non-PICU wards, optimise and train the staff, and improve primary healthcare services.
Downloads
Article Details
Issue
Section
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
How to Cite
References
World Health Organization. Children: Improving survival and well-being, September 2020. https://www.who.int/news-room/fact-sheets/detail/children-reducing- mortality (accessed 22 September 2021).
Kruger I, Gie RP, Harvey J, Kruger M. Outcome of children admitted to a general highcare unit in a regional hospital in the Western Cape, South Africa. S Afr J Child Health 2016;10(3):156.
Slusher TM, Kiragu AW, Day LT, et al. Pediatric critical care in resource-limited
settings-overview and lessons learned. Front Pediatr 2018;6:49. https://doi.
org/10.3389/fped.2018.00049
Murthy S, Leligdowicz A, Adhikari NK. Intensive care unit capacity in low-income countries: A systematic review. PLoS One 2015;10(1):e0116949. https://doi. org/10.1371/journal.pone.0116949
Mujuru HA, Kambarami RA. Mortality within 24 hours of admission to the Paediatric Unit, Harare Central Hospital, Zimbabwe. Cent Afr J Med 2012;58(5-6):17-22
Wammanda R, Ali F. Conditions associated with the risk of death within 24 hours of admission in children in Zaria, Nigeria. Ann Afr Med 2004;3(3):134-137. https://tspace. library.utoronto.ca/bitstream/1807/4099/1/am04033.pdf (accessed 15 December 2021).
Cawood S, Naidoo S, Okudo G, Velaphi S, Verwey C. Outcomes of paediatric patients ventilated in a high-care area outside an intensive care unit. S Afr Med J 2020;110(9):903-909. https://doi.org/10.7196/SAMJ.2020.v110i9.14631.
Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020;21(2):e52-e106. https://doi. org/10.1097/PCC.0000000000002198
Hendricks CL, McKerrow NH, Hendricks RJ. Factors present on admission associated with increased mortality in children admitted to a paediatric intensive care unit (PICU). S Afr J Child Health 2016;10(1):57-62. https://doi.org/10.7196/SAJCH.2016. v10i1.104
Argent AC, Ahrens J, Morrow BM, et al. Pediatric intensive care in South Africa: An account of making optimum use of limited resources at the Red Cross War Memorial Children’s Hospital. Pediatr Crit Care Med 2014;15(1):7-14. https://doi.org/10.1097/ PCC.0000000000000029
Rosenberg DI, Moss MM; American Academy of Pediatrics Section on Critical Care; American Academy of Pediatrics Committee on Hospital Care. Guidelines and levels of care for pediatric intensive care units. Pediatrics 2004;114(4):1114-1125. https://doi. org/10.1542/peds.2004-1599. Erratum in: Pediatrics 2005;116(2):524.
Bland RM, Rollins NC, Van den Broeck J, Coovadia HM; Child Health Group. The use of non-prescribed medication in the first 3 months of life in rural South Africa. Trop Med Int Health 2004;9(1):118-124. https://doi.org/10.1046/j.1365-3156.2003.01148.x
Rusmawatiningtyas D, Rahmawati A, Makrufardi F, et al. Factors associated with mortality of pediatric sepsis patients at the pediatric intensive care unit in a low-resource setting. BMC Pediatr 2021;21(1):471. https://doi.org/10.1186/s12887-021-02945-0
Karunaratne R, Sturgeon JP, Patel R, Prendergast AJ. Predictors of inpatient mortality among children hospitalised for severe acute malnutrition: A systematic review and meta-analysis. Am J Clin Nutr 2020;112(4):1069-1079. https://doi.org/10.1093/ajcn/ nqaa182
Kambale RM, Ngaboyeka GA, Ntagazibwa JN, et al. Severe acute malnutrition in children admitted in an intensive therapeutic and feeding centre of South Kivu, Eastern Democratic Republic of Congo: Why do our patients die? PLoS One 2020;15(7):e0236022. https://doi.org/10.1371/journal.pone.0236022
Gavhi F, Kuonza L, Musekiwa A, Motaze NV. Factors associated with mortality in children under five years old hospitalised for severe acute malnutrition in Limpopo Province, South Africa, 2014-2018: A cross-sectional analytic study. PLoS One 2020;15(5):e0232838. https://doi.org/10.1371/journal.pone.0232838
Grippa RB, Silva PS, Barbosa E, Bresolin NL, Mehta NM, Moreno YM. Nutritional status as a predictor of duration of mechanical ventilation in critically ill children. Nutrition 2017;33:91-95. https://doi.org/10.1016/j.nut.2016.05.002
Bhagwanjee S, Scribante J. National audit of critical care resources in South Africa – unit and bed distribution. S Afr Med J 2007;97(12 Pt 3):1311-1314.
Nupen TL, Argent AC, Morrow B. Characteristics and outcome of long-stay patients in a paediatric intensive care unit in Cape Town, South Africa. S Afr Med J 2016;107(1):70-75. https://doi.org/10.7196/SAMJ.2016.v107.i1.11279
Harley A, George S, King M, et al. Early resuscitation in paediatric sepsis using inotropes - a randomised controlled pilot study in the emergency department (RESPONDED): Study protocol and analysis plan. Front Pediatr 2021;9:663028. https://doi.org/10.3389/fped.2021.663028
Lundberg JS, Perl TM, Wiblin T, et al. Septic shock: An analysis of outcomes for patients with onset on hospital wards versus intensive care units. Crit Care Med 1998;26(6):1020-1024. https://doi.org/10.1097/00003246-199806000-00019
Naidoo K, Singh J, Lalloo U. A critical analysis of ICU/HC beds in South Africa: 2008 – 2009. S Afr Med J 2013;103(10):751-753. https://doi.org/10.7196/samj.6415
Robert R, Coudroy R, Ragot S, et al. Influence of ICU-bed availability on ICU admission decisions. Ann Intensive Care 2015;5(1):55. https://doi.org/10.1186/ s13613-015-0099-z. Epub 2015 Dec 30