Southern African Journal of Critical Care
The SAJCC publishes scientific articles related to multidisciplinary critical and intensive medical care and the emergency care of critically ill humans.
The SAJCC is published under an 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.
Copyright (c) 2025 https://creativecommons.org/licenses/by-nc/4.0
Early mobilisation practices in Windhoek intensive care units: A retrospective review of patient profiles and physiotherapy practice
Background. Early mobilisation (EM) is safe and feasible with positive patient outcomes in various settings. However, data from Namibia in southern Africa are lacking, and the status of intensive care unit (ICU)-based mobilisation is unknown. Objectives. To describe the mobility practices and profiles of critically ill patients in ICUs in Windhoek, Namibia. Methods. A retrospective, descriptive record review was conducted in two private hospitals in Windhoek. Data were extracted using a self-designed electronic data abstraction form. The primary outcomes were the profile of ICU patients and documented mobility practices. Secondary outcomes included the timing and frequency of mobilisation, physiotherapy techniques used, and adverse events during physiotherapy. Patients with incomplete datasets or illegible records were excluded. Results. The review included charts of 870 adult patients admitted to the participating ICUs between January and December 2016. Patients were predominantly male (61.8%; n=538), with a mean (standard deviation (SD)) age of 56 (14.9) years. Most admissions were planned (66.3%; n=577), mainly for coronary angiograms (20.6%; n=179), cardiac conditions (13.0%; n=113) and cardiac surgery (10.3%; n=90). The mean (SD) length of ICU stay was 3.41 (3.3) days, and the mean duration of mechanical ventilation was 0.7 (2.1) days. The overall ICU mortality rate was 5.2% (n=45). Of the 870 patients, 352 (40.5%) received physiotherapy, with 345 of these (98.0%) being mobilised. The median (interquartile range) length of ICU stay for mobilised patients was 3 (2 - 5) days, compared with 2 (2 - 3) days for non-mobilised patients (p<0.0001). Adverse events during physiotherapy were rare, occurring in only 5 patients (1.4%). Conclusion. EM is often implemented as part of physiotherapy practice in Windhoek ICUs; however, fewer than half of the patients in this study received physiotherapy, highlighting the need for improved implementation of EM protocols and screening for readiness to mobilise.
Early mobilisation; critical illness; patient profile, acute rehabilitation
Copyright (c) 2025 I du Plessis, S Francis, B Morrow https://creativecommons.org/licenses/by-nc/4.0
Beyond survival: Functionality and health-related quality of life among a cohort of ICU survivors 6 months after hospital discharge – a single-centre study in the Eastern Cape Province of South Africa
Background. New or worsened impairments in physical, cognitive and/or psychological health may persist after critical care discharge and impact negatively on survivors’ health-related quality of life (HRQOL), functionality and life roles. Objective. To describe functionality, changes in life roles and HRQOL among an Eastern Cape single-centre cohort of ICU survivors, 6 months after hospital discharge. Methods. The study was conducted in a multidisciplinary tertiary ICU in the Eastern Cape and enrolled critically ill patients who required organ support and had an ICU stay for at least 48 hours. Patients were assessed at 6 weeks and 6 months post hospital discharge. The Lawton’s Instrumental Activities of Daily Living (IADL) score and employment/educational status were determined. The Rand Short Form- 36 HRQOL questionnaire’s physical and mental component scores (PCS and MCS) were used to determine quality of life at baseline and study visits. Results. A total of 107 patients with a median age of 42, half of whom had COVID-19, completed the 6-month follow-up. At the 6-month follow-up, 17.5% of previously non-frail patients were still unable to complete at least two IADLs, and 24.3% one IADL. Overall, 34% had not returned to their life roles of home making, studying or remunerative work due to ill-health. At 6 months, 58.9% and 62.6% had significantly lower mean PCS and MCS scores, respectively. Overall, 62.6 % of survivors had either a significantly lower PCS and/or MCS at 6 months. Conclusion. This relatively young cohort of ICU survivors, with minimal previous comorbidities, demonstrated a high incidence of significantly lower HRQOL scores at the 6-month follow-up, affecting 6 out of every 10 patients. The proportion of patients who were unable to complete all IADLs at follow-up, explains the reported changes in relation to life roles, including remunerative employment. These findings have implications for the introduction or reengineering of rehabilitation resources and ICU follow-up services.
critical care, health-related quality of life, activities of daily living, functionality, return to work, Post ICU Syndrome
Copyright (c) 2025 E van der Merwe, L Stroud, G Sharp, N van Vuuren, M Mosola , T Fodo, F Paruk https://creativecommons.org/licenses/by-nc/4.0
Classification and predictive models using supervised machine learning: A conceptual review
Supervised machine learning models (SMLMs) are likely to be a prevalent approach in the literature on medical machine learning. These models have considerable potential to improve clinical decision-making through enhanced prediction and classification. In this review, we present an overview of SMLMs. We provide a discussion of the conceptual domains relevant to machine learning, model development, validation, and model explanation. This discussion is accompanied by clinical examples to illustrate key concepts.
Copyright (c) 2025 M A Pienaar, K Naidoo https://creativecommons.org/licenses/by-nc/4.0
Ventilation distribution in mechanically ventilated children in response to positioning: An exploratory study
Background. Traditionally, it was understood that children universally show greater ventilation of the non-dependent lung. Recent studies have questioned the understanding of ventilation distribution patterns in the paediatric population. There are no studies examining the effect of body position in mechanically ventilated infants/children. Objectives. To determine the effect of body position on regional ventilation distribution in mechanically ventilated children. Methods. Thoracic electrical impedance tomography (EIT) measurements were taken in left- and right-side lying, supine and prone positions in mechanically ventilated infants/children. Functional EIT images were produced, and regional relative tidal impedance (ΔZ) in the left, right, ventral and dorsal lung regions was calculated. The proportion of ventilation occurring in large lung regions and regional filling were also calculated. Results. Seventeen children (n=8; 47% male) aged 6 months - 6 years are presented. Many of the children (n=8; 47%) consistently showed greater ventilation in the right lung in both side-lying positions, and in the dorsal lung region (n=6; 35%) in both the supine and prone positions. Regional filling was similar between lung regions in the different body positions. Conclusion. Ventilation distribution in mechanically ventilated infants/children with mild lung disease is variable and similar to that of healthy spontaneously breathing infants/children.
Copyright (c) 2025 A Lupton-Smith, A Argent, B Morrow https://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2024 https://creativecommons.org/licenses/by-nc/4.0
Making sense of the outcome of a rehabilitation implementation trial in the intensive care unit: Mixed methods
Background. Evidence for implementation of evidence-based protocols (EBPs) in resource-constrained intensive care units (ICUs) is sparse. Objectives. To evaluate a tailored best-practice multifaceted strategy for implementation of a validated physiotherapy EBP for the management of surgical ICU (SICU) patients. Also, to explore the physiotherapists’ perceptions regarding the implementation process and factors affecting protocol adherence, guided by the Consolidated Framework for Implementation Research. Methods. A type 2 hybrid implementation study design was applied, including all adult patients admitted over 16 months to two (control and experimental) SICUs in Western Cape Province, South Africa. The physiotherapists eligible to participate in the qualitative study (N=17) were those who participated in the implementation process and worked in the experimental SICU. The Therapeutic Index Scoring System-28 (TISS-28) and four process of care indicators (POCIs) were the primary and secondary outcomes, respectively, both analysed in Stata version 15. Thematic content analysis of textual data generated physiotherapists’ perceptions of the implementation process. Results. The intervention strategy did not result in protocol adherence, with no significant difference (p>0.05) in TISS-28 and POCI outcomes during and after implementation in the experimental unit and all phases of the control. Physiotherapists (71%; n=12/17) perceived that the process affected their thinking and clinical decision-making, but not the organisation of physiotherapy services, except for a more multidisciplinary approach to care in the experimental unit. Organisational factors (time constraints, workload/flow barriers) affected adherence, explaining the lack of practice change. Conclusion. The importance of organisational change and support of the physiotherapy departments providing services to ICUs while also addressing the healthcare needs of a diverse group of hospitalised patients is highlighted.
Copyright (c) 2025 F Karachi, J J Maritz, T M Esterhuizen, R Gosselink, S D Hanekom https://creativecommons.org/licenses/by-nc/4.0
Evaluating complications in a South African neurocritical care unit: A 1-year retrospective audit
Background. The benefits of setting up a dedicated neurocritical care unit (NCCU) for critically ill neurological patients are well documented. These units are specifically designed to care for individuals with conditions affecting the brain and spine. However, complications particular to these units in low- and middle-income countries are not widely reported. Objectives. To describe the complications observed in an NCCU at a tertiary-level academic hospital over the course of 1 year and examine their link with intensive care unit (ICU) length of stay (LOS) and mortality rates. Methods. The study involved retrospective analysis of complications experienced by critically ill neurological patients admitted to the NCCU between 1 January and 31 December 2020, according to the NCCU patient data registry. Results. A total of 850 patients, most of whom were male (61.2% in the high-care unit (HCU) and 68.1% in the ICU), were admitted to the NCCU, with a median age of 43 years and 41 years in the HCU and the ICU, respectively. The overall rate of complications was 38.2% (n=325/850 patients). Statistically significant complications (p<0.05) included metabolic and electrolyte imbalances, infections (including ventilator-associated pneumonia, surgical site infections and central line-associated bloodstream infections), and deep-vein thrombosis. The most common complication was metabolic disturbances (28.2%), particularly sodium homoeostasis abnormalities. The number of complications significantly affected NCCU LOS (p<0.001), but did not have a statistically significant impact on mortality (p=0.067). Conclusion. Complications occurred in 38.2% of critically ill neurological patients in a specialised NCCU in a tertiary-level academic hospital in South Africa, primarily involving electrolyte disturbances and infections. These complications were linked to longer LOS in the ICU, but did not significantly increase the risk of mortality.
Neuro-critical care, Complications, neurosurgery
Copyright (c) 2025 B A Kgaodi, C Arnold-Day, S Linde, P Semple https://creativecommons.org/licenses/by-nc/4.0
Validating the Measure of Processes of Care for Service Providers (MPOC-SP(A)) tool in adult intensive care units
Background. The Measures of Process of Care for Service Providers (MPOC-SP(A)) tool, developed by the CanChild Centre for Childhood Disability Research in Canada, assesses service providers’ perceptions of family-centred care (FCC) in adult rehabilitation. It consists of 27 items categorised into four domains: ‘showing interpersonal sensitivity’, ‘providing general information’, ‘communicating specific information’, and ‘treating people respectfully’. Each domain encompasses a distinct aspect of family-centred care applicable in the intensive care unit (ICU). An earlier version of the tool was previously validated for use in neonatal ICUs. However, this tool has not been validated for use in adult ICUs. Objective. To validate the content validity index of the MPOC-SP(A) tool for healthcare professionals working in adult ICUs in South Africa. Method. Following approval from the Human Research Ethics Committee, a multidisciplinary group of experienced ICU healthcare professionals was invited to review the MPOC-SP(A) tool, rating each item’s relevance on a four-point scale to avoid neutrality. The content validity index (CVI) was calculated for each item (I-CVI) and domain (S-CVI/Ave) using Microsoft Excel. An I-CVI of 0.83 and S-CVI/Ave of 0.9 were deemed acceptable. Items with a CVI below 0.83 were discarded. Results. The scale-level CVI (S-CVI/Ave) for every domain was 0.9 and above, which is acceptable. Two items in domain A and one item in domain B were deleted owing to low I-CVI values. Two items were revised to improve the item’s clarity. Thus, a 24-item MPOC-SP(A) tool applicable to adult ICUs was generated following the content validity analysis. Conclusion. The content experts’ assessment of the instrument’s items is essential to ensure its validity. This study has finalised the content validation process of the MPOC-SP(A) tool for use in the adult ICU. The refined tool is now ready for the next phase of validation focusing on construct and internal consistency.
Copyright (c) 2025 C O N Oghenetega, S Chetty https://creativecommons.org/licenses/by-nc/4.0
Shock epidemiology and outcomes among internal medicine patients
Background. Shock, characterised by circulatory hypoperfusion and cellular hypoxia, represents a critical medical condition requiring immediate attention. Despite its significance, there are limited data on shock incidence and outcomes, particularly within the context of Thailand. Objectives. This retrospective observational study aimed to investigate the incidence, management and outcomes of shock patients admitted to the internal medicine department of Siriraj Hospital, a referral university hospital in Bangkok, Thailand. Additionally, the study sought to identify factors associated with mortality among these patients. Methods. Medical records of patients admitted were reviewed. Shock cases were identified based on specific diagnostic criteria, and demographic and clinical data were extracted for analysis. Results. A total of 125 patients were included in the study, with septic shock being the most prevalent condition (40.0%), followed by cardiogenic shock (39.2%), hypovolaemic shock (18.4%) and obstructive shock (2.4%). The overall intensive care unit (ICU) admission rate was 46.7%, varying among shock types, with cardiogenic shock patients exhibiting the highest rate. The overall 28-day mortality rate was 23.7%, with septic shock patients admitted to the ICU demonstrating the highest mortality rate (50.0%). The multivariate analysis identified factors associated with mortality, including colloid resuscitation (adjusted odds ratio (aOR) 3.10 (1.08 - 8.9), p=0.036); vasopressor dose of more than 0.2 μg/kg/min (aOR 4.38 (1.39 - 13.74), p=0.011); and renal replacement therapy (aOR 3.43 (1.04 - 11.28), p=0.043). Conclusions. This study provides significant insights into shock incidence, management and outcomes in a tertiary referral hospital in Thailand. It also highlights challenges related to ICU bed availability and identifies predictors of mortality. Early recognition and tailored interventions are crucial for improving outcomes in shock patients.
Copyright (c) 2025 C Maluangnon, B Joyjumroon, C Phawanawichian, S Tongyoo https://creativecommons.org/licenses/by-nc/4.0
Ventilator-associated pneumonia rates in a level I trauma intensive care unit in KwaZulu-Natal Province, South Africa, compared with international benchmarks
Background. Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critically ill patients in intensive care units (ICUs) worldwide. Despite the huge healthcare economic burden and the significant negative morbidity and mortality impact of VAP, its incidence and outcomes in the trauma ICU (TICU) population were poorly documented in South Africa (SA). Objectives. To determine the incidence of VAP in a level I trauma centre at Inkosi Albert Luthuli Central Hospital in Durban, SA, compared with international benchmarks. Determining mortality rates, the average length and cost of ICU stay, ventilator days and antibiotic consumption was a secondary objective. Methods. This retrospective chart review of the trauma registry at the centre examined the incidence of VAP and secondary outcomes over the period January 2017 - December 2019. A data pro forma was used with VAP diagnoses as per the 2015 Centers for Disease Control and Prevention definitions. The comparator was international literature-based benchmark VAP rates in TICUs. Results. The study included 395 patients, of whom 143 (36.2%) were diagnosed with VAP. The VAP rate was calculated to be 35.6 per 1 000 ventilator days. Thirty-one patients with VAP (21.7%) died in the ICU, a similar figure to that for the non-VAP group (22.6%). There were no statistically significant differences in age, sex, mechanism of injury or Injury Severity Score between the VAP and non-VAP groups (p>0.05). There were statistically significant differences between the two groups in number of days on mechanical ventilation, ICU length of stay and ICU cost. The VAP group had a median of 12 ventilation days v. 5 days for the non-VAP group (p<0.001), and spent a median of 7 days longer in the ICU (p<0.001). The median cost of ICU stay for VAP patients was almost double that for non-VAP patients (p<0.001). Conclusion. VAP rates in this local TICU were similar to international rates. Trauma patients, especially those with traumatic brain injury, are at higher risk of VAP than general ICU patients, so strict adherence to evidence-based VAP prevention bundles is necessary among TICU staff.
Copyright (c) 2024 B Ngxabi, T C Hardcastle https://creativecommons.org/licenses/by-nc/4.0
Emergency care capacity of private primary healthcare facilities in Gauteng, South Africa
Background. Strengthening emergency care at the primary healthcare (PHC) level has been identified as a strategy for improving the emergency care system, which should include the private sector as well. As the National Health Insurance Act will soon come into effect, more non-medical aid users are expected to access private healthcare facilities. There is a great need for further assessment of the emergency care capacity at private primary healthcare facilities. Objective. To use a standardised facility-based assessment tool to assess if private PHC facilities in Gauteng have the capacity to deliver emergency care services using the HEAT (Hospital Emergency Unit Assessment Tool). Method. The Hospital Emergency Unit Assessment Tool (HEAT) – a standardised tool – was used for quantitative description of the critical functions and structure of an emergency unit (EU) at any facility level of PHC facilities in a private healthcare group. Results. More than half (n/N=10/19) of the facilities participated in the study. Facilities demonstrated adequate equipment, resources and staffing for basic emergency care despite a lack of specific skills and specialised protocols. Conclusion. All private primary healthcare facilities met the listed infrastructure and essential equipment requirements for emergency care, including a resuscitation area; however, none of the facilities had an area specifically for triage. Common barriers to performing emergency care procedures across most facilities were due to a lack of training in emergency protocols and procedures.
Copyright (c) 2025 M Cluff, M L Botes https://creativecommons.org/licenses/by-nc/4.0
Validation of the APACHE‐II scoring system in critically ill patients diagnosed with COVID‐19 and admitted at a regional‐level hospital intensive care unit: A retrospective study
Background. The use of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scoring system to predict mortality in the intensive care unit (ICU) has not been validated for use in the coronavirus-19 (COVID-19) pandemic in the South African context. Objectives. To provide data on the outcomes and clinical characteristics of ICU patients in a regional hospital diagnosed with COVID-19. The primary objective was to measure the validity of the APACHE-II scoring system in predicting mortality in these patients. Secondary objectives included the description of clinical characteristics, potential risk factors for mortality and length of ICU stay. Methods. This study was a single-centre, retrospective, observational cohort study conducted from 2020 to 2022. Data were obtained from electronic databases and patient records to determine diagnosis of COVID-19, demographics, comorbidities, history, clinical parameters and patient outcome. A receiver operating characteristic (ROC) analysis was performed to assess the discriminative power of the APACHE-II score in predicting mortality. Results. A total of 96 patients with confirmed COVID-19 diagnoses had sufficient data to calculate the APACHE-II score. The observed in-hospital mortality was 57.3%, while the APACHE-II score predicted a mortality of 25%. An ROC analysis showed poor discrimination (area under the ROC curve 0.58). Patients who had increased odds of death were those with increased age: odds ratio (OR) 1.01 (confidence interval (CI) 1.00 - 1.02), and those who were peripartum: OR 4.35 (CI 1.06 - 29.30). Other factors were not significantly associated with mortality. The median (interquartile range) length of hospital stay was 5.00 (4.00 - 9.25) days. Conclusion. The APACHE-II scoring system is a poor discriminator between death and survival in this cohort of COVID-19 ICU patients. ICU patients who were diagnosed with COVID-19 were more likely to die despite a relatively low APACHE-II score. Information regarding clinical characteristics of these ICU patients and their outcomes provides some insight into the nature of the COVID-19 pandemic.
Copyright (c) 2025 Y-C Chang, J Invernizzi, T Mcizana https://creativecommons.org/licenses/by-nc/4.0
Factors influencing knowledge translation into critical care practice: The reality facing intensive care nurses in Limpopo Province
Background. Nurses working in intensive care units (ICUs) must incorporate new knowledge and evidence-based practice (EBP) into their daily routines to enhance patient outcomes. However, this integration often falls short in ICU settings. Weekly clinical audits reveal incidents where ICU nurses neglect evidence-based interventions, impacting patient outcomes and ICU stays. Objective. To explore the factors influencing the translation of knowledge into ICU practice. Methods. We conducted exploratory, qualitative research to investigate ICU nurses’ perspectives on knowledge translation into ICU practices. The study employed purposive sampling to select ICU nurses. We used paired interviews and group discussions to gather insights from ICU nurses regarding the factors influencing the translation of knowledge into ICU practices. Data analysis was performed using Boomer and McCormack’s nine steps of creative hermeneutic data analysis. Results. One main theme, ‘We are just surviving’ emerged, encompassing two sub-themes: management and workplace culture. Under management, participants described barriers, such as resource scarcity, behaviour, outdated evidence-informed protocols and workload. Under workplace culture, participants mentioned negative attitudes and a lack of teamwork, contributing to poor-quality care. Conclusion. In ICUs, nurses are expected to integrate new knowledge and scientific evidence into their daily practice, yet they face challenges in doing so. Interventions should be implemented to address management and workplace culture.
Copyright (c) 2024 M R Kgadima, I M Coetzee, T Heyns https://creativecommons.org/licenses/by-nc/4.0
Critical pertussis infection in the paediatric intensive care unit: A case series in an outbreak
Background. Bordetella pertussis is a highly infectious disease associated with increased mortality in young infants. Critical pertussis is defined as pertussis disease resulting in paediatric intensive care unit admission or death. Objective. This study describes the clinical profile, morbidity, mortality and management of children with critical pertussis admitted to a South African paediatric intensive care unit (PICU). Study design. A retrospective analysis of children with critical pertussis admitted to the PICU over 1 year (January 2022 - December 2022). Results. There were 1 273 PICU admissions during the study period, of which 101 (7.9%) were tested and 19 (1.5%) tested positive for B. pertussis. Of those, 13 (68.4%) were completely unimmunised, mainly owing to young age (n=9). The median (interquartile range) total duration of ventilation was 7.0 (3.0 - 21.0) days, with a maximum of 35 days. Mortality was 36.8% (n=7) in those with B. pertussis; with more deaths in HIV-exposed patients (n=3/7,42.9% v. n=3/12, 25%; p<0.001) and preterm infants (n=4/7,57.1% v. n=4/12, 33.3%; p<0.001), as well as those with septic shock (n=7/7, 100% v. n=4/7, 33.3%; p = 0.02) and acute kidney injury (n=6/7, 85.7% v. n=2/12, 16.7%; p<0.001). The maximum white cell count was significantly lower in survivors (27.75 v. 76.32; p<0.001). None of the variables was independently associated with mortality on multivariable regression. Conclusion. Critical B. pertussis infection is associated with significant morbidity and mortality in this setting. The low rate of vaccination is a concern, and advocacy is needed to promote access to vaccination during the third trimester of pregnancy as well as strengthening current immunisation programmes. Further research is required to identify the prevalence of critical pertussis and risk factors for poor outcomes in resource-limited settings.
Copyright (c) 2025 H Crichton, N Nkado, S Salie, C Procter https://creativecommons.org/licenses/by-nc/4.0
Association between serum procalcitonin levels and outcomes of patients admitted to two tertiary paediatric intensive care units in Bloemfontein: A retrospective analytical study
Background. Procalcitonin (PCT) is used in the diagnosis of sepsis. Its capability as a prognostic marker is unclear. The association between PCT and paediatric intensive care unit (PICU) outcomes has not been investigated in the South African setting. Objectives. To determine the association between admission PCT, and trends within 72 hours of admission, and outcomes of patients admitted to the PICU at two tertiary academic hospitals. Methods. The study was a two-year, double centre, retrospective, analytical cross-sectional medical record review. Results. A total of 381 participants were included in the study; 55 died and 220 required mechanical ventilation. Non-survivors had a higher median admission PCT than survivors (p<0.0001, 95% confidence interval (CI) 1.28 - 15.12). Non-survivors had a higher median PCT at 48 - 72 hours than survivors (p<0.0001, 95% CI 2.50 - 21.72). Non-survivors had less of a median decrease in PCT than survivors (p=0.22, 95% CI -0.59 - 4.72). The area under the receiver operating characteristics curve (AUROCC) for admission PCT to discriminate for mortality was 0.6702 and for the 48 - 72 hour PCT it was 0.7369. There was a positive correlation between PCT and number of ventilator days (Spearman correlation co-efficient =0.1477, p=0.0138). There was no correlation between the length of PICU stay and admission PCT (p=0.7579) or PCT change (p=0.2034). Conclusion. Single PCT measurements display some ability to discriminate for PICU mortality. Serial PCT measurements provide greater prognostic information. Non-survivors had a significantly greater median admission PCT, median PCT at 48 - 72 hours and a lower median PCT decrease than survivors.
Copyright (c) 2025 A M Luyo Sanchez, M A Pienaar https://creativecommons.org/licenses/by-nc/4.0
A profile of children with traumatic brain injury admitted to the paediatric intensive care unit of Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, between 2015 and 2019
Background. Paediatric traumatic brain injury (TBI) is a public health problem with high morbidity and mortality. Objectives. To highlight risk factors and describe associated morbidity and mortality of children admitted with TBI to the Paediatric Intensive Care Unit (PICU) at Red Cross War Memorial Children’s Hospital, Cape Town. Methods. We retrospectively documented the hospitalisation of all children with TBI admitted into our PICU between 2015 and 2019. Results. Of 320 children identified, 314 were enrolled: 267 (85%) had severe TBI (Glasgow Coma Scale (GCS) ≤8), 36 (11.5%) moderate TBI (GCS 9 - 12) and 11 (3.5%) mild TBI (GCS ≥13). Median age was 6.5 (interquartile range (IQR) 3.5 - 8.9) years; 194 (61.8%) were male. Motor vehicle collisions accounted for 75% (235) of injuries. Two hundred and seventy-nine (88.9%) children were invasively ventilated for a median of 4.5 (IQR 1 - 8) days; 13.9% (38/273) had a failed extubation and 10.8% (30/277) required tracheostomies. One hundred and sixty-three children (52.2%, n=312) had intracranial pressure monitoring. Almost a third (81/257) required vasopressor support. Approximately 40% (113/286) developed trauma-related seizures; 15.4% (44/286) required a thiopentone infusion and 6% (17/280) a decompressive craniectomy. Common complications were as follows: 12.2% developed post-extubation stridor (34/279), 10.5% a hemiparesis (33/314) and 6.4% diabetes insipidus (19/298). Median PICU stay was 4 (IQR 1 - 10) days, and hospitalisation 11 (IQR 5 - 21) days. Ninety-three (29.6%) children were transferred for further rehabilitation; 38 (12.1%) died. Conclusion. Children admitted to our PICU with TBI had considerable morbidity and mortality, but this is a marked improvement since the 1990s. Enhanced primary preventive strategies, especially for motor vehicle collisions, are imperative to prevent TBI in children.
Copyright (c) 2024 E Du Plooy, S Salie, A A Figaji https://creativecommons.org/licenses/by-nc/4.0
Professor Mochichi Samuel (Sam) Mokgokong
Copyright (c) 2024 G Richards https://creativecommons.org/licenses/by-nc/4.0
Relevance and application of clinical practice guidelines in different settings
Copyright (c) 2024 R Blaauw https://creativecommons.org/licenses/by-nc/4.0
Outcomes of HIV-exposed infected and HIV-exposed uninfected children admitted to two paediatric intensive care units in South Africa: A retrospective analytical cohort study
Background. Reduced vertical transmission of HIV has led to an increased proportion of HIV-exposed uninfected children (HEU) in South Africa. Increased infective morbidity and mortality creates a need to better understand outcomes and morbidity in this population. Objectives. To describe and compare critical care outcomes in terms of survival and disease severity between HIV-unexposed children (HUU), HIV-exposed infected children (HEI) and HEU. Methods. A retrospective analytical cohort study was carried out from 1 January 2017 to 31 December 2021. Paediatric intensive care unit admissions of children aged 1 month - 5 years were included. Outcomes for HEU and HEI were compared with those of HUU, with a significance threshold set at p=0.05. Multivariate logistic regression analysis was conducted. Results. Of 1 015 children, 633 (62.4%) were HUU, 318 (31.3%) were HEU and 64 (6.3%) were HEI. Mortality was higher in HEU (15.8%; p=0.1) and HEI (17.2%; p=0.4) compared with HUU (11.4%), but this was not statistically significant. HEU and HEI were younger (p<0.001) and more frequently underweight (p<0.001). HEU (and HEI) had an increased risk of acute kidney injury (AKI) (odds ratio 1.19; 95% confidence interval 1.07 - 1.81; p=0.014) and a lower minimum estimated glomerular filtration rate (p<0.001) compared with HUU. Septic shock was more frequent in HEU (28.6%; p=0.001) and HEI (43.8%; p<0.001) compared with HUU (20.1%). HEI had more frequent mechanical ventilation (p=0.003), more prolonged mechanical ventilation (p<0.001) and lower admission haemoglobin concentrations (p<0.001) than HUU. Conclusion. Compared with HUU, both HEU and HEI demonstrated a trend towards increased mortality, but this was not statistically significant. HEU and HEI experienced increased AKI and other morbidity.
Copyright (c) 2025 M van der Merwe, J B Sempa, M A Pienaar https://creativecommons.org/licenses/by-nc/4.0
Bed occupancy and nosocomial infections in the intensive care unit: A retrospective observational study in a tertiary hospital
Background. Healthcare-associated infections (HAI) are a major problem globally, contributing to prolonged hospital admissions and poor outcomes. Objective. To examine HAI incidence and risk factors in an intensive care unit (ICU) during high v. low occupancy periods. Methods. This retrospective, descriptive analysis investigated HAI incidence among adult patients admitted to the ICU at Chris Hani Baragwanath (CHBH) during a high (H2019) and low (L2020) occupancy. Data were extracted from the clinical records of 440 eligible patients. Results. We found an increased risk of HAI during H2019 compared with L2020 (relative risk (RR) 1.42, 95% confidence interval (CI) 1.03 - 1.94). The overall frequency density of HAI was 25/1 000 ICU days. There was no difference in the distribution of the site of infection (blood v. other) (p=0.27) or bacterial category (Gram stain) (p=0.62). Five organisms accounted for 89% of pathogens: Klebsiella (26%), Staphylococcus (21%), Acinetobacter (16%), Candida (16%) and Enterobacter (10%). The incidence of multidrug-resistant/extensively drug-resistant (MDR/XDR) organisms was 4.2-fold higher (95% CI 1.3 - 13.4) during H2019 compared with L2020. Logistic regression analysis revealed two independent predictors of nosocomial infection: ICU length of stay (odds ratio (OR) 1.12, 95% CI 1.02 - 1.22) and intercostal drain duration in days (OR 1.27, 95% CI 1.09 - 1.47). Conclusion. High occupancy in the ICU was associated with an increased risk of HAI and a greater incidence of MDR and XDR pathogens. Increasing ICU length of stay and invasive device duration were independent predictors of HAI.
Copyright (c) 2024 T Wilson, D Nolte, S Omar https://creativecommons.org/licenses/by-nc/4.0
Use of intravenous immunoglobulin for the treatment of severe COVID‐19 in the Chris Hani Baragwanath Academic Hospital intensive care unit, Johannesburg, South Africa
Background. COVID‐19 infection has a variable clinical presentation, with a small subgroup of patients developing severe disease, requiring intensive care with mechanical ventilation, with an increased mortality rate. South Africa (SA) has experienced multiple waves of this pandemic, spanning the pre‐vaccine and vaccine periods. The method and initiation of treatment is a debated topic, changing according to evolving research and the literature. The present study investigated the use of high‐dose intravenous immunoglobulin (IVIg) as a salvage therapy after initial medical treatment failure. Objectives. To compare disease progression among critically ill COVID‐19 pneumonia patients receiving IVIg therapy with that in patients receiving standard of care (SoC), in respect of inflammation, organ dysfunction and oxygenation. Methods. This was a single‐centre, retrospective study of patients admitted to the intensive care unit (ICU) at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, during the pre‐vaccine COVID‐19 pandemic. Demographics, inflammatory markers (C‐reactive protein (CRP)), organ function (Sequential Organ Failure Assessment (SOFA) score), oxygenation (ratio of partial pressure of oxygen in arterial blood to fraction of inspiratory oxygen (P/F ratio)), overall mortality and complications (nosocomial infections and thromboembolism) were recorded and compared. Results. We included 113 eligible patients in the study. The IVIg cohort had a significantly lower initial P/F ratio than the SoC cohort (p=0.01), but the change in P/F ratio was similar (p=0.54). Initial CRP and changes in CRP were similar in the two groups (p=0.38 and p=0.75, respectively), as were initial SOFA score and changes in SOFA score (p=0.18 and p=0.08, respectively) and vasopressor dose on day 0 and day 5 (p=0.97 and p=0.93, respectively). Duration of mechanical ventilation did not differ significantly between the IVIg group and the SoC group (p=0.13). There were no significant differences in measured complications between the two groups. On univariate analysis, the relative risk of death was 1.6 times higher (95% confidence interval (CI) 1.1 ‐ 2.3) in the IVIg group; however, a logistical regression model demonstrated that only a higher P/F ratio (odds ratio (OR) 0.991; 95% CI 0.983 ‐ 0.997) and higher mean airway pressure (OR 1.283; 95% CI 1.026 ‐ 1.604) were significantly associated with ICU mortality. Conclusion. Use of IVIg in our study was directed at an older population, with significantly worse oxygenation. We found no evidence of adverse effects of immunoglobulin therapy; however, we found no benefit either. Only the P/F ratio and mean airway pressure independently predicted ICU mortality.
COVID-19, Intravenous immunoglobulin (IVIg), Standard of Care (Soc), Intensive Care Unit, Sequential Organ Failure Assessment Score (SOFA), C-reactive protein (CRP), Horowits ratio (P/F ratio).
Copyright (c) 2024 G Mensky, A van Blydenstein, J Damelin, S Omar https://creativecommons.org/licenses/by-nc/4.0
Critical care nurses’ orientations to caring for patients and their families at a selected hospital in KwaZulu-Natal
Background. Caring in a critical care environment may be conceptualised differently compared with other nursing disciplines because of the patient’s critical condition and the specialised staffing categories and skills. However, critical care nurses who prioritise caring can meaningfully connect with critically ill patient and their families, resulting in positive healthcare outcomes. Objective. To assess critical care nurses’ orientations to caring for critically ill patient and their families. Methods. A quantitative, descriptive, cross-sectional study was conducted with 139 purposively sampled critical care nurses working in a tertiary referral hospital in KwaZulu-Natal, South Africa. Data were collected using the Caring Assessment for Caregivers questionnaire, and analysis included descriptive and comparative statistics. Results. The overall mean score of critical care nurses’ orientations to caring was 116.01 (range of 25 - 125). Of the five subscales (dimensions), the dimension of ‘Maintaining belief ’ had the highest mean score of 24.25 and the dimension of ‘Being with’ had the lowest mean score of 22.70 (range 5 - 25). Conclusion. While critical care nurses reported high overall orientations to caring, lower mean scores on the subscale ‘Being with’ suggest that there are areas for critical care nurses to grow in their role as carers. Further research using qualitative approaches may shed valuable insights into how the critical care environment impacts the caring orientations of critical care nurses.
Caring; critical care nurses; patients; families; orientation.
Copyright (c) 2024 W Emmamally, M Jugroop https://creativecommons.org/licenses/by-nc/4.0
Bedside critical care training: A quasi-experimental study in the paediatric emergency department of a referral hospital in Nigeria
Background. There is a need for critical care services outside intensive care units (ICUs), especially in emergency departments (EDs). However, there is a paucity of skilled manpower for ED critical care or emergency critical care (ECC) in resource-limited settings. Objective. To evaluate the impact of bedside training on emergency critical care practices of clinical staff. Methods. This was a quasi-experimental study using a pretest - post-test design in a paediatric ED. The intervention was a six-week structured bedside training on bubble continuous positive airway pressure (CPAP) high-flow nasal cannula (HFNC) and mechanical ventilation. Participants’ actual ECC practices pre and post training were evaluated, including their perceived proficiency on an uncalibrated 100 mm visual analogue scale (VAS). Descriptive and inferential analyses were done; p<0.05 was considered significant. Results. A total of 35 clinical staff participated in the training, comprising 9 (24.3%) paediatric registrars, 12 (32.5%) senior registrars, 10 (27.0%) nurses, 4 (10.8%) house officers and 2 (5.4%) paediatric consultants. The male:female ratio of the participants was 1:1.6, and their mean (SD) age was 33.24 (6.30 years. Participants’ understanding of testing the CPAP circuit, connecting the patient and weaning significantly improved following training (p=0.004). Their capacity to select appropriate HFNC parameters improved (p=0.013). They performed more endotracheal intubations in the post-training period (p=0.001). Their pretest-post-test proficiency in mechanical ventilation increased on VAS (mean scores 45.26+31.99 v. 63.26+22.26; p=0.038). Also, there was a significant increase in their perceived proficiency in paediatric analgesia/sedation (30.83+29.86 v. 49.83+23.90; p=0.029). Conclusion. Short-term bedside critical care training enhanced the self-reported competency of paediatric ED staff. There is a need for on-the-job ECC training and retraining of clinical staff in our setting.
emergency critical care, bedside training, clinical staff
Copyright (c) 2024 M T Abiodun, E A Ochaba, A Kpongo-Ogieva https://creativecommons.org/licenses/by-nc/4.0
Knowledge, attitudes and practices of administration of intravenous antimicrobial medicines among intensive care nurses: A descriptive cross-sectional study
Background. Antimicrobial stewardship (AMS) has become integral to healthcare. In the case of antimicrobial medicines, nurses are responsible for preparing medication, and ensuring its correct and safe administration. Objective. To describe intensive care nurses’ knowledge, attitudes and practices of intravenous antimicrobial infusion administration in the context of access to AMS teaching. Method. Convenience sampling was conducted of all 161 bedside nurses working in three general intensive care units. The nursing unit manager from each unit was requested to provide information detailing unit demographics and AMS activity within the unit (e.g. existence of AMS; nurse inclusion on the AMS team; frequency of AMS rounds; availability of AMS policies, protocols or guidelines; and training on the administration of intravenous antimicrobial medicines). Results. Intensive care nursing management reported cessation of AMS programmes in all three units during COVID-19, with minimal activity in one intensive care unit even before the onset of the pandemic. Responses from bedside nurses emphasised the unavailability of in-service AMS teaching in the units (46.4%). Questions on antibiotic groups scored poorly (55.7%). Respondents (63.8%) indicated that the hospital intravenous antibiotic policy was useful but 21.7% reported that they had never seen this policy in their unit. Opportunities for training on intravenous administration of antimicrobial medications were provided on induction to the hospital (14.5%), or in-service (30.4%) by the clinical facilitators (34.8%), or by doctors (24.6%). Fifty-one percent of respondents reported administering antibiotics through a dedicated antibiotic infusion line. Forty-five percent of respondents used a non-dedicated line, and 56.5% of respondents flushed the line between doses. Conclusion. Results suggest inadequate training. This, coupled with the evident poor access to policies and protocols, may adversely affect nurse knowledge of principles to prevent antimicrobial resistance.
Copyright (c) 2024 J Rout, S Essack, P Brysiewicz https://creativecommons.org/licenses/by-nc/4.0
CO2 gap changes compared with cardiac output changes in response to intravenous volume expansion and/or vasopressor therapy in septic shock
Background. The difference in partial pressure of carbon dioxide (PCO2) between mixed or central venous blood and arterial blood, known as the ∆PCO2 or CO2 gap, has demonstrated a strong relationship with cardiac index during septic shock resuscitation. Early monitoring of the ∆PCO2 can help assess the cardiac output (CO) adequacy for tissue perfusion. Objectives. To investigate the value of ∆PCO2 changes in early septic shock management compared with CO. Methods. This observational prospective study included 76 patients diagnosed with septic shock admitted to Cairo University Hospital’s Critical Care Department between December 2020 and March 2022. Patients were categorised by initial resuscitation response, initial ∆PCO2 and 28-day mortality. The primary outcome was the relationship between the ∆PCO2 and CO changes before and after initial resuscitation, with secondary outcomes including ICU length of stay (LOS) and 28-day mortality. Results. Peri-resuscitation ∆PCO2 changes predicted a ≥15% change in the cardiac index (CI) (area under the curve (AUC) 0.727; 95% CI 0.614 - 0.840) with 66.7% sensitivity and 62.8% specificity. The optimal ∆PCO2 change cut-off value was <−1.85, corresponding to a <−22% threshold for a 15% cardiac index increase. The PCO2 gap ratio (gap/gap ratio of T1- PCO2 gap to T0-PCO2 gap) also predicted a ≥15% change in cardiac index (AUC 745; 95% CI 0.634 - 0.855) with 63.6% sensitivity and 79.1% specificity. The optimal CO2 gap/gap ratio cut-off value was <0.71. A significant difference in 28-day mortality was noted based on the gap/gap ratio. Conclusion. Peri-resuscitation ∆PCO2 and the gap/gap ratio are useful non-invasive bedside markers for predicting changes in CO and preload responsiveness.
Copyright (c) 2024 F Faris, A El-Houfi, M El Shahat, H Khalid, A Al-Azab https://creativecommons.org/licenses/by-nc/4.0
Physical function measures in ICU survivors, where to now? A scoping review
Background. Growing evidence is describing the long-term morbidity experienced by critical illness survivors, a major contributing factor being impaired physical function. Consensus is yet to be reached on which physical function measures should be included in this population. This review aimed to describe physical functioning measurement instruments used in longitudinal studies of critical illness survivors, based on the International Classification of Function (ICF). Methods. An electronic database search of EbscoHost, Web of Science and Scopus was conducted from inception to November 2023. Two reviewers independently applied the inclusion and exclusion criteria to titles, abstracts and full text-studies. Extracted data included year of publication; country; participant age; follow-up timeframes and physical measurement instruments used. Instruments were classified according to ICF domains. Results. Eighty studies published between 1995 and November 2023 were included. Forty-four different outcome measures were identified. Most studies (68) included multiple followed-up points and were completed within a year, and few studies (12) follow-up beyond a year. Based on the ICF, 11 (25%) instruments measured impairments and 33 (75%) activity limitations. Muscle power functions were the most frequently measured impairment (65%), utilising manual muscle testing (37.3%). The six-minute walk test (6MWT) was the most frequently used instrument in the activity/participation domain (31.6%). Only one instrument addressed all five the physical activity/participation domains, while the majority focused on mobility domain. Conclusions. Multiple tools are used to report on physical deficits experienced by ICU survivors, either measuring impairments or activity/ participation limitations. Most studies report on physical function within the first year of survival. The heterogeneity and inconsistency over time of instruments used prevents synthesis of data to determine intervention efficacy. The validity, predictive value and sensitivity of the reported measures within ICU survivors needs to be established, only then can intervention studies be designed to measure effectiveness.
Critical care; Critical illness; Outcome assessment; Rehabilitation; Postintensive Care Syndrome
Copyright (c) 2024 I Du Plessis, A Lupton-Smith, S Hanekom https://creativecommons.org/licenses/by-nc/4.0
Implementation strategies to overcome barriers to early mobilisation practices in Zimbabwean and South African public sector ICUs: A Delphi study
Background. Barriers to early mobilisation in healthcare settings encompass various factors, including practical challenges, accountability and the crucial role of leadership. Objective. To gain consensus from multidisciplinary team members in South African (SA) and Zimbabwean public sector hospitals to formulate implementation strategies addressing identified barriers for early mobilisation. Methods. An online two-round modified Delphi study including 23 experts from SA and Zimbabwe was undertaken. The implementation strategies were aligned with the Consolidated Framework for Implementation Research that outlines five areas impacting implementation. Results. The expert panel included intensive care unit (ICU) clinicians, academics and managers, who participated in both Delphi rounds. The median years of ICU experience was 8.5 (range 5 - 17) years, with 16 (80.0%) having a general ICU background. The panel reached consensus on several strategies to standardise early mobilisation practices in ICUs, including defining specific early mobilisation activities, appointing champion leaders, ensuring timely management of fractures, promoting patient admission to specialised units, creating dedicated physiotherapy positions, and providing skills training for staff responsible for implementing early mobilisation activities in ICUs. Conclusion. The strategies developed represent an important step toward implementation of early mobilisation in routine ICU patient care.
Copyright (c) 2024 C Tadyanemhandu, V Ntsiea, H van Aswegen https://creativecommons.org/licenses/by-nc/4.0
Critical Care Congress 2023 in association with SASPEN
12 - 15 October 2023 The Boardwalk Convention Centre Gqeberha/Port Elizabeth
Copyright (c) 2023 https://creativecommons.org/licenses/by-nc/4.0
Patient perceptions of ICU physiotherapy: ‘Your body needs to go somewhere to be recharged ... ’
Background. Patient satisfaction is an essential concept to consider for the improvement of quality care in healthcare centres and hospitals and has been linked to increased patient compliance with treatment plans, better patient safety and improved clinical outcomes. Objective. As part of a before-and-after clinical trial aimed to investigate the implementation of an evidence-based and -validated physiotherapy protocol within a surgical intensive care unit (ICU), we decided to include the patient perception of physiotherapy received in the intervention unit. Method. A nested, exploratory, descriptive, qualitative study design was adopted. Purposively selected adult patients discharged from ICU during the implementation phase of the trial were interviewed. Results. Eighteen patients (10 male) with a median age of 44 years and median ICU length of stay (LOS) of six days were included. Three themes and nine categories emerged: (i) linking therapy to clinical outcome (patient expectations and understanding; physiotherapy activities and the implication of mobilisation; physiotherapy benefits and progression); (ii) the importance of developing a trusting relationship (physiotherapy value; safety; continuity of care); and (iii) communication (satisfaction; interactions and patient perception and experience of physiotherapy). Conclusion. While confirming barriers to early mobility, patients perceived participation in mobility activities as a marked jolt in their journey to recovery following a critical incident. Effective communication and preservation of trust between physiotherapist and patient are essential for understanding expectations and can facilitate improved outcomes. Clinicians can use the information when managing critically ill patients. Including patient-reported outcomes to measure physiotherapy interventions used in the ICU is feasible and can inform the development of such outcomes.
Copyright (c) 2023 F Karachi, M B Van Nes, S Hanekom, R Gosselink https://creativecommons.org/licenses/by-nc/4.0