Outcome in Children Admitted to the First PICU in Malawi.

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.

Training and practice of pediatric surgery in Africa: past, present, and future.

The evolution and recognition of pediatric surgery as a specialty in Africa can be divided into 4 distinct phases, starting from early 1920s till the present. The pace of development has been quite variable in different parts of Africa. Despite all recent developments, the practice of pediatric surgery in Africa continues to face multiple challenges, including limited facilities, manpower shortages, the large number of sick children, disease patterns specific to the region, late presentation and advanced pathology, lack of pediatric surgeons outside the tertiary hospitals, and inadequate governmental support. Standardization of pediatric surgery training across the continent is advocated. Collaboration with well-established pediatric surgical training centers in Africa and other developed countries is necessary. The problems of delivery of pediatric surgical services need to be addressed urgently, if the African child is to have access to essential pediatric surgical services like his or her counterpart in the high-income parts of the world.

Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa.

BACKGROUND: Little is known about the burden of surgical disease in rural sub-Saharan Africa, where district and rural hospitals are the main providers of care. The present study sought to analyze what is known about the met and unmet need of surgical disease. METHODS: The PubMed and EMBASE databases were searched for studies of surveys in rural areas, information on surgical admissions, and operations performed within rural and district hospitals. Data were extrapolated to calculate the amount of surgical disease per 100,000 population and the number of operations performed per 100,000 population. These extrapolations were used to estimate the total, the met, and the unmet need of surgical disease. RESULTS: The estimated overall incidence of nonfatal injury is at least 1,690/100,000 population per year. Morbidity as a result of injury is up to 190/100,000 population per year, and the annual mortality from injury is 53-92/100,000. District hospitals perform 6 fracture reductions (95% CI: 0.1-12)/100,000 population per year and 14 laparotomies (95% CI: 7-21)/100,000 per year. The incidence of peritonitis and bowel obstruction is unknown, although it may be as high as 1,364/100,000 population for the acute abdomen. The annual total need for inguinal hernia repair is estimated to be a minimum of 205/100,000 population. The average district hospital performs 30 hernia repairs (95% CI: 18-41)/100,000 population per year, leaving an unmet need of 175/100,000 population annually. CONCLUSIONS: District hospitals are not meeting the surgical needs of the populations they serve. Urgent intervention is required to build up their capacity, to train healthcare personnel in safe surgery and anesthesia, and to overcome obstacles to timely emergency care.