Evidence-based management of adult traumatic brain injury with raised intracranial pressure in intensive critical care unit at resource-limited settings: a literature review.

Background: In underdeveloped countries, there is a greater incidence of mortality and morbidity arising from trauma, with traumatic brain injury (TBI) accounting for 50% of all trauma-related deaths. The occurrence of elevated intracranial pressure (ICP), which is a common pathophysiological phenomenon in cases of TBI, acts as a contributing factor to unfavorable outcomes. The aim of this systematic review is to analyze the existing literature regarding the management of adult TBI with raised ICP in an intensive critical care unit, despite limited resources. Methods: This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol. Search engines such as PubMed, the Cochrane database, and Google Scholar were utilized to locate high-level evidence that would facilitate the formation of sound conclusions. Result: A total of 11 715 articles were identified and individually assessed to determine their eligibility for inclusion or exclusion based on predetermined criteria and outcome variables. The methodological quality of each study was evaluated using recommended criteria. Ultimately, the review consisted of 51 articles. Conclusion: Physical examination results and noninvasive assessments of the optic nerve sheath diameter (ONSD) via sonography are positively associated with elevated ICP, and are employed as diagnostic and monitoring tools for elevated ICP in resource-limited settings. Management of elevated ICP necessitates an algorithmic approach that utilizes prophylactic measures and acute intervention treatments to mitigate the risk of secondary brain injury.

The effect of preoperative anemia on perioperative outcomes among patients undergoing emergency surgery: A multicenter prospective cohort study.

Introduction: Preoperative anemia is a common finding among surgical patients. It is associated with an increased risk of perioperative morbidity and mortality. Outcomes among emergency surgical patients are not established. This study aimed to assess the effect of preoperative anemia on perioperative outcomes among patients undergoing emergency surgery in selected Southern Ethiopia governmental teaching hospitals, Southern Ethiopia, 2022. Method: A multicenter prospective cohort study was conducted. Data were collected at selected hospitals, after obtaining ethical approval from the institutional review board. Descriptive statistics, cross-tabulation, and multivariable binary logistic regression analysis were performed. A P-value less than 0.05 were taken as statistically significant. Result: A total of 200 patients who underwent emergency surgery were grouped into the anemia group (100 patients) while the rest were in the non-anemia group. There was no statistically significant difference between the groups regarding socio-demographic and intraoperative patient characteristics. Based on multivariate logistic regression, anemia group had a significant risk of perioperative transfusion requirement (Relative Risk (RR) = 4.030, p < 0.001), developing postoperative complications (RR = 1.868, p = 0.017), occurring in-hospital mortality (RR = 5.763, p = 0.045), prolong the length of hospital stay (RR = 4.028, p < 0.001), and requiring postoperative intensive care unit admission (RR = 6.332, p = 0.003) compared with non-anemia groups. Conclusion: Preoperative anemia was associated with a higher rate of perioperative transfusion requirements, along with increased postoperative complication, increased in-hospital mortality, increased Intensive Critical Care Unit admission rate, and prolonged length of hospital stay. We recommend adequate preoperative assessment and correction of hemoglobin concentrations to normal values to improve surgical outcomes and reduce complications.

Determinants of postoperative emergence delirium in patient undergoing general anesthesia in Dilla University referral hospital. A case-control study.

Background: Delirium is affecting of concentration, decreases the ability to forward-thinking, attention, sustainability, change, and decreases orientation to the environment. Delirium has a serious impact on the overall outcome of the patient. Post-operative emergence delirium (POED) increases hospital mortality by 5% and post-discharge hospitalization by 33%, compared to those without postoperative delirium. Postoperative delirium incidence has different summative risk factors and recognizing the multiple risks of delirium complications may help the clinician to design supportive measures to prevent delirium. Delirium can cause a series of outcomes and is increase the length of hospital stay, independent predictor for intensive care unit (ICU) admission and institutional morbidity and mortality, increase institutional care, for those patients and increase hospital expenses. Methodology: Unmatched case-control study was employed from September 2019 to October 2020. This study was conducted on 264 patients above 18years. A structured questionnaire prepared in English was used for data collection. Data were analyzed by using the SPSS software. Bivariate and multiple logistic regression models were used to identify associated risk factors for incidence of POED and a P-Value of less than 0.05 was the risk factor for this medical condition. Result: Out of 264 participants included in the study 56.4% were female. ASA I and II constitute 97.4%. Substance abuse, premediate with diazepam, & ketamine were high risk for POD with p-value of 0.000, 0.005, & 0.047 respectively. Conclusion: We conclude that older age, current substance use, Coexisting disease, Benzodiazepine exposures, Ketamine, ASA physical status, and coexisting disease were determinant risk factors for postoperative delirium clients undergoing general anesthesia.

Evaluation of Essential and Emergency Surgery Provide in Primary Hospitals of Gedeo Zone and Sidama Region, South, Ethiopia, 2020.

Background: Surgical services at level referral hospitals were an essential part of overall health care. The surgical uhservice was approximated to account for 11% of the worldwide load of disease, with a large percentage of that burden being uncovered in resource-constraint settings. Even though the surgery service is significant and growing across all economic sectors, the majority of resource-limited countries have been unable to provide essential surgical services. Objective: To investigate the capacity of essential and emergency surgical services in primary hospital facilities in the Gedeo zone and Sidama region. Methodology: In the Gedeo zone and Sidama region, a cross-sectional study was undertaken in eight district hospitals. By looking at four areas of data: infrastructure, human resources, interventions available, and equipment, a World Health Organization tool for conditional analysis was used to assess a health set-up competence to perform essential surgical and anesthetic procedures. The tool looked for eight different categories of healthcare giving 35 surgical procedures, and 67 different pieces of instruments. Results: This research found that 48.57% of the 35 essential interventions counted in the test, including cesarean section, were available at all hospitals. Prior to admission, each hospital reported a total of 53 beds, with an average travel distance of 28 kilometers. There were 189 healthcare providers in the eight facilities. According to the research, basic instruments were not always present at all of the sites. Conclusion: Infrastructure, health profession, service supply, and key instruments and supplies deficiencies reveal major inadequacies in hospitals' capacity to perform EESC and efficiently treat the growing surgical load of disease and damage in primary care.

Determinants of neonatal mortality in the neonatal intensive care unit of Dilla University Referral Hospital, Southern Ethiopia; 2019-2020; A matched, case-control study.

Background: Neonatal mortality rate (NMR) refers to the number of deaths occurring from birth to 28 days of life per-1000 Live Births (LB). The global NMR declined from 37 deaths per- 1,000 LB in 1990 to 18 in 2017, whereas it was 27 deaths per 1000 LB in the Sub-Saharan region. Ethiopia plans to reduce the NMR from 28 deaths to 11 deaths per 1,000 LB by 2020 and to end all preventable child deaths by 2035. The aim of this study was to identify the determinants of neonatal mortality in the neonatal intensive care unit (NICU) of Dilla University Referral Hospital (DURH). Methods: An age-matched case control study was conducted at DURH's NICU. Two controls having age 2 days before or after the case were used for matching. One hundred eighteen cases (died) and 236 controls (survived) neonates admitted to the NICU from January 11, 2018, to February 25, 2020, were studied. Missed data were filled by multiple imputations. Multicollinearity was checked by the variance inflation factor. For variables with a P-value <0.2 on bivariable conditional logistic regression, multivariable conditional logistic regression analysis was performed to control for confounders using clogit command in a survival package to identify the risk factors for neonatal mortality using R version 3.6.3. Result: Gestational age <37 weeks (Adjusted matched odds ratio (AmOR): 14.02; 95% confidence interval (CI): 3.68-53.46), first-minute APGAR score <7 (AmOR: 5.68; 95% CI: 1.76-18.31), perinatal asphyxia (PNA) (AmOR: 4.62; 95% CI: 1.15-18.53) and being twins (AmOR: 6.84; 95% CI: 1.34-34.96) were significantly associated with neonatal deaths in our study. Furthermore, antenatal care and follow-up during pregnancy (AmOR: 0.15; 95% CI: 0.04-0.53) and having a normal random blood sugar level at admission (AmOR: 0.1; 95% CI: (0.02-0.66) were found to be determinant of neonatal mortalities in our study. Conclusion: Gestational age less than 37 weeks, first-minute APGAR scores <7, being twins, diagnosis of PNA, antenatal care and follow-up of mothers during pregnancy and normoglycemia in neonates at admission were significant determinant of neonatal death in the NICU of DURH.

Effect of anesthesia choice on hemodynamic stability and fetomaternal outcome of the preeclamptic patient undergoing cesarean section.

Background: The main aim of this study is to compare hemodynamic stability and feto-maternal outcome between general and spinal anesthesia in pre-eclampsia patients undergoing C/S. Methods: A prospective cohort study was used with a calculated sample size of 266. Comparison of numerical variables between study groups was done using unpaired student t-test and Manny Whitney U test for symmetric and asymmetric data respectively. A P-value <0.05 considered significant. Result: There is a comparable distribution of socio-demographic, obstetric variables, and baseline hemodynamic variables between groups. The change in a hemodynamic variable from baseline and during the first 24 h was also comparable between groups. The numbers of ICU admission were comparable between groups (8.03% vs. 10.41%, p = 0.549) in spinal and general anesthesia groups respectively. With regards to hospital stay patients in general anesthesia groups had longer hospital stay 5.92 days compared to 4.67 days in the spinal anesthesia group, with a statistically significant difference,(p = 0.024). The Spinal anesthesia group showed lower maternal mortality 2.6% compared to 14.8% in the general anesthesia group during the first 48th hour (p = 0.027). At the first 48 h only 7.14% of neonates in the spinal anesthesia group, and 16.6% o in the general anesthesia group had reported dead (p = 0.315). Conclusion: Spinal anesthesia (SA) was alternative to general anesthesia regarding hemodynamic stability. Regarding maternal outcome, SA overall shows a better maternal outcome during the first 48 h. The numbers of ICU admission were comparable between groups. The SA group showed lower maternal mortality at the 48th hr.

The impact of novel coronavirus disease (COVID-19) on emergency and essential surgical care in Gedeo and Sidama zone hospitals: An institutional-based multicenter cross-sectional study.

Background: COVID-19 was initially detected in China's Wuhan, the capital of Hubei Province, in December 2019, and has since spread throughout the world, including Ethiopia. Long-term epidemics will overwhelm the capacity of hospitals and the health system as a whole, with dire consequences for the developing world's damaged health systems. Focusing on COVID-19-related activities while continuing to provide essential services such as emergency and essential surgical care is critical not only to maintaining public trust in the health system but also to reducing morbidity and mortality from other illnesses. The goal of this study was to see how COVID-19 affected essential and emergency surgical care in Gedeo and Sidama zone hospitals. Method: ology: A cross-sectional study was carried out in ten (10) hospitals in the Gedeo and Sidama zone. The information was gathered with the help of the world health organization (WHO) situational analysis tool for determining emergency and essential surgical care (EESC) capability. Infrastructure, human resources, interventions, and EESC equipment and supplies were used to assess the hospitals' capacity. Result: 54.3% of the 35 fundamental therapies indicated in the instrument were available before COVID-19 at all sites, while 25.2 percent were available after the COVID-19 pandemic. During the COVID-19 pandemic, there was a sharing of resources for treatment centers, such as a scarcity of oxygen and anesthesia machines, and emergency surgery was postponed. Before admission, the average distance traveled was 58 km. Conclusion: The COVID-19 pandemic, as well as existing disparities in infrastructure, human resources, service provision, and essential equipment and supplies, reveal significant gaps in hospitals' capacity to provide emergency and essential surgical services and effectively address the growing surgical burden of disease and injury in Gedeo and Sidama zone primary, general, and referral hospitals.

Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article.

Background: Postoperative delirium is the highest prevalence and life-threatening complication following geriatric surgery. The overall incidence rate varies from 5% to 52% of hospitalized surgical patients based on the type of surgery that often began in the postanesthesia care unit and continues up to 5 days post-surgery. Postoperative delirium manifests as a hypoactive, hyperactive and mixed subtype. The mechanism of delirium development is not clear, but it is accepted that delirium is a result of the patient's underlying vulnerabilities or risk factors combined with an outside stressor such as infection or surgery. Objective: To develop evidence-based recommendations for the prevention, diagnosis, and treatment of postoperative delirium. Methods: Literature was searched from PubMed, CINAH, Google Scholar, and Cochrane databases that are published from 2010 to 2021 by formulating inclusion and exclusion criteria. Filtering was made depending on methodological quality, outcome, and data on population. Finally, 11 meta-analysis, 11 systematic reviews, 7 interventional studies, 11 observational studies, and recommendations of the previous clinical practice guideline developed by the American and European are included in this review. Results: A total of 43 studies were considered in this evaluation. The development of this guideline was based on nine studies on risk stratification for postoperative delirium, eighteen studies on risk minimization and prevention for postoperative delirium, five studies on diagnosis for postoperative delirium, and eleven studies on treatments for postoperative delirium. Conclusion: Postoperative delirium management can be categorized into risk assessment, risk minimization, early diagnosis, and treatment. Early diagnosis is critical to trigger focused and effective treatment. Non-pharmacological interventions are the first-line management for both hypoactive and hyperactive postoperative with considering contributory factors and underlying causes. Antipsychotics should only be used for hyperactive delirium individuals who try to harm themselves. Current evidence suggested that dexmedetomidine can be used as a treatment option for postoperative delirium.

Knowledge, attitude, and practice of healthcare workers toward COVID-19 and its prevention in Ethiopia: A multicenter study.

BACKGROUND: An emerging respiratory disease abbreviated as coronavirus disease 2019 was first reported in December 2019 in Wuhan city of China. The virus is zoonotic and tends to be transmitted between animals to humans and humans to humans. The major route of transmission of coronavirus disease 2019 is droplet and close contact. The Ethiopian Ministry of Health has initiated training for health care workers at a different level. Thus, the main objective of this study is to assess the knowledge, attitudes, and practices of health workers in Ethiopia toward coronavirus disease 2019 and its prevention techniques. METHOD: An institution-based multicenter cross-sectional study was conducted in each of eight teaching and referral hospitals. A total of 422 Ethiopian healthcare workers were selected for the assessment of knowledge, attitude, and practice toward coronavirus disease 2019. Data were collected using a structured questionnaire. A logistic regression model was used to identify factors associated with the attitude and knowledge of healthcare workers toward coronavirus disease 2019 at a significance level of p < 0.05. RESULT: Three hundred ninety-seven healthcare workers participated in the study, with a response rate of 94%. Among these, 88.2% and 94.7% of respondents had good knowledge and positive attitudes, respectively. A respondent with a history of chronic medical illness (odds ratio: 0.193, 95% confidence interval: 0.063-0.593), social media, telecommunication, and television/radio as a source of information were significantly associated with knowledge (odds ratio: 3.4, 95% confidence interval: 1.5-7.4, OR: 4.3, 95% confidence interval: 1.3-14.3 and odds ratio: 3.2, 95% confidence interval: 1.4-7.2). In addition, respondents with a history of chronic medical illness were significantly associated with a negative attitude toward coronavirus disease 2019. CONCLUSION: The knowledge and attitude were good while; the practice was relatively low. Sources of information such as social media, telecommunication, and television/radio were positively associated with healthcare workers' knowledge about coronavirus disease 2019.

Comparison of thiopentone with lidocaine spray vs propofol for laryngeal mask airway insertion at tikur anbessa specialized hospital. A prospective cohort study.

BACKGROUND: Insertion of laryngeal mask airway (LMA) requires an adequate depth of anesthesia. Optimal insertion conditions and hemodynamic stability during LMA insertion are mainly influenced by the choice of the intravenous induction agent. Propofol was recommended as a standard induction agent for LMA insertion. Due to unavailability and cost for treatment Propofol is not easily availed, thus this study aimed at assessing the effect of thiopentone with lidocaine spray compared to Propofol on hemodynamic change and LMA insertion on the patient undergoing elective surgery. METHODS: Eighty-four participants were followed in a prospective cohort study based on the induction type of either thiopentone-lidocaine group (TL) or Propofol (P). Hemodynamic variables, LMA insertion condition, apneic time, and cost of treatment during the perioperative time were recorded. Data were checked for normality using the Shapiro-Wilk test. Numeric data were analyzed unpaired student's t-test or Manny Whitney test. Categorical data were analyzed by the chi-square test. A p-value ≤ 0.05 was considered a statistically significant difference. RESULT: The comparison of data showed that a significant reduction in mean arterial blood pressure (MAP) in the Propofol group during the first 10 min. The MAP at first minute after LMA insertion was 78.4 ± 5.5 in the Propofol group compared to 81.8 ± 5.6 in thiopentone-lidocaine group p < 0.001. the mean MAP at 5th and 10th minutes after LMA insertion is also significantly lower in the Propofol group compared to the thiopentone-lidocaine group, p < 0.05. There were no statistically significant differences regarding the heart rate change and insertion conditions between the two groups. Mean apneic time was 138 ± 45.8 s in the Propofol group and 85 ± 13.8 s in thiopentone-lidocaine group p < 0.001. Thiopentone-lidocaine group had a lower treatment cost compared to the Propofol group. CONCLUSION: Thiopentone with 10% topical Lignocaine is an alternative for the insertion of LMA to Propofol, with better hemodynamic stability and cost-effectiveness.

Magnitude and Associated Factors for Attitude and Practice Toward COVID-19 and Its Prevention Among the Residents of Gedeo Zone, Southern Ethiopia: A Community-Based Cross-Sectional Study.

BACKGROUND: COVID-19 first broke out in China, Hubei province on December 29, 2019, since then it took hundreds of thousand lives worldwide. Although all countries are taking varying degrees of measures to curb the dissemination, the virus is still spreading rapidly in all parts of the world. Adherence of people for COVID-19 precaution measures is one of the most important factors which determine the effectiveness of curbing the spread. However, without having a good attitude, the adherence of people toward precaution measures could be challenging. Therefore, this study aims to assess the attitude, practice, and associated factors of Gedeo zone of Southern Ethiopia region residents toward COVID-19 and its prevention. METHODS: A community-based cross-sectional study was conducted among 600 Gedeo zone residents of Southern Ethiopia. Bivariate and multivariate binary logistic regression were used to determine the association between dependent and independent variables. An adjusted odds ratio with 95% CI was used to show the strength of association. P-value<0.05 was used to decide a statistically significant association. RESULTS: Most of the study participants (90.3%) have a good attitude toward COVID-19 and its prevention. Being a younger age group (AOR=3.82, 95% CI=1.76-19.07), having a diploma and above (AOR=2.53, 95% CI=1.15-7.50), having a chronic medical illness (AOR=2.73, 95% CI=1.01-7.44), and using television/radio as a source of information (AOR=2.65, 95% CI=1.27-5.54) were significantly associated with a good attitude toward COVID-19. On the other hand, only 20% of the study participants had good practice toward COVID-19 prevention. Educational status (P-value=0.00), occupation (P-value=0.01), and having a chronic medical illness (P-value=0.03), and use of religious teaching as information sources (P-value=0.02) were among the factors associated with good practice toward COVID-19 infection. CONCLUSION: We conclude that, despite the presence of a good attitude in the majority of respondents, much work is needed to improve the poor practice of COVID-19 preventive measures.

Evidence-Based Guideline for Adult Sedation, Pain Assessment, and Analgesia in a Low Resource Setting Intensive Care Unit: Review Article.

BACKGROUND: Agitation and anxiety occur frequently in ICU and affect about 30-80% of patients in ICU present with delirium worldwide, and it is associated with adverse clinical outcomes. This review aimed to systematically review articles and finally draw an evidence-based guideline for an area with limited resources. METHODS: The review was reported based on preferred reporting items for systemic and meta-analysis (PRISMA) protocol. We searched literature from PubMed, Google Scholar, and Medline database using keywords like the level of sedation, sedation score, pain assessment in ICU, and sedative drugs in ICU from an article published in English. After extraction with a patient population and exclusion, five randomized clinical trials, four systemic reviews and meta-analysis, four observation cohort study, and two practical guidelines were used for the review. CONCLUSION: In addition to high validity and reliability, RASS has the advantage of easiness to remember for nurses making it a preferred sedation assessment tool in an adult ICU setting. Light sedation with daily interruption was recommended with an aim of an awake and alert patient ready for the weaning trial. Propofol was preferred when sedation is for a short duration and when intermittent awakening is required. Ketamine is the preferred induction for asthmatic hypotensive and patient requiring prolonged continuous sedation. With a similar time for sedation, diazepam shows a shorter time for intubation compared to midazolam. Besides diazepam has shown a cheaper cost of sedation than midazolam. This makes it a drug of preference in a low resource setting.

Comparing Analgesic Effect of Intravenous Fentanyl, Femoral Nerve Block and Fascia Iliaca Block During Spinal Anesthesia Positioning in Elective Adult Patients Undergoing Femoral Fracture Surgery: a Randomized Controlled Trial.

BACKGROUND: Femoral fracture is the most painful bone injury and performing spinal anesthesia is extremely challenging due to very poor positioning unless we have a very good mode of analgesia. Intravenous strong opioids are commonly used but to date nerve blocks are also being utilized. The reliability and effectiveness of the aforementioned methods are not conclusive to practice worldwide. The objective of the study was to compare the analgesic effect of intravenous fentanyl, femoral nerve block (FNB) and fascia iliaca block (FICB) during positioning patients with femoral fracture for spinal anesthesia. METHODS: A randomized controlled trial study was conducted on 72 elective adult patients with femoral fracture aged 18-65 years and ASA I and II those were allocated randomly into three groups. The intravenous fentanyl (IVFE) group received 1µg/kg IV fentanyl, FNB group received nerve stimulator guided FNB with 30 mL of 1% lidocaine with adrenaline and FICB group received FICB with 30 mL of 1% lidocaine with adrenaline. Pain intensity in numeric rating score (NRS), time to perform spinal anesthesia, quality of positioning and patient acceptance were assessed. SPSS version 26 and Kruskal-Wallis test were used to analyze data and p value <0.05 was considered significant. RESULTS: NRS Pain score during positioning was significantly lower in FNB and FICB groups than IVFE group [median (IQR)]; 2 (1-2.5), 2 (2-3)) vs. 3 (3-4) respectively; P<0.001 and P=0.001. However, FNB and FICB groups were not significantly different with (P=1.000). Time to perform spinal anesthesia was significantly longer in IVFE group 9.5 (9-10) minutes than both FNB and FICB groups 7 (6-8), 8 (6-8) respectively, P<0.001. The quality of positioning was significantly lower in the IVFE group than both FNB and FICB groups (P<0.001). CONCLUSION: Preoperative FNB and FICB reduce pain score during positioning, shorten time to perform spinal anesthesia, better patient positioning and higher patient acceptance in a patient undergoing elective femoral bone fracture surgery. TRIAL REGISTRATION: Pan African Clinical Trial Registry, PACTR202006669166858, registered on June 19, 2020. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12127.