Outcome in Children Admitted to the First PICU in Malawi
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Mirjam A de Visser1,2, Diana Kululanga2, Singatiya S Chikumbanje2,3
1Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
Insights
High mortality was observed in Malawi's first Pediatric Intensive Care Unit (PICU), particularly among neonates. Factors like neonatal age, decreased mental state, and severe hypotension were linked to increased mortality, highlighting the need for improved PICU care bundles in sub-Saharan Africa.
Area of Science:
- Pediatric Intensive Care
- Critical Care Medicine
- Sub-Saharan African Healthcare
Background:
- Dedicated Pediatric Intensive Care Units (PICUs) are emerging in sub-Saharan Africa, but regional data is scarce, hindering prioritization of populations and approaches.
- Establishing PICUs in resource-limited settings presents unique challenges.
- Understanding patient characteristics and outcomes is crucial for developing effective PICU strategies.
Purpose of the Study:
- To describe the characteristics and outcomes of patients admitted to the first PICU in Malawi.
- To identify factors associated with increased mortality in this pediatric intensive care setting.
- To inform the establishment and improvement of PICUs in sub-Saharan Africa.
Main Methods:
- Prospective review of a Pediatric Intensive Care Unit (PICU) database.
- Univariate analysis to assess associations between demographic, clinical, and laboratory factors and mortality.
- Multivariable analysis to identify independent predictors of mortality.
Main Results:
- Of 531 admissions, 149 children (28.1%) died, with significantly higher mortality in neonates (52.7%) versus older children (16.8%).
- Factors associated with increased mortality included neonatal age, decreased mental state, post-cardiac arrest, severe hypotension, elevated lactate, low pH, and low platelet count.
- Sepsis and certain congenital anomalies (gastroschisis, trachea-esophageal fistula) were associated with higher mortality, while some cancers and foreign body aspiration had better survival rates.
Conclusions:
- Malawi's first PICU experienced high mortality, especially in neonates, underscoring the need for enhanced care bundles for vulnerable groups like surgical neonates and septic patients.
- Clinical and laboratory variables, including severe hypotension and blood gas parameters, are critical indicators of mortality, particularly in neonates.
- These findings provide essential evidence for establishing and optimizing Pediatric Intensive Care Units (PICUs) across sub-Saharan Africa.
Objectives:
Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality.
Design:
Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models.
Setting:
A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi.
Patients:
Children admitted to PICU between August 1, 2017, and July 31, 2019.
Interventions:
None.
Measurement And Main Results:
Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality.
Conclusions:
In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.
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