Assessment of hemodynamic response to fluid resuscitation of patients with intra-abdominal sepsis in low- and middle-income countries.

BACKGROUND: Patients with intra-abdominal infections need to achieve adequate hemodynamic status before being taken to the operating room. Multiple parameters (urinary output [UOP], vital signs, inferior vena cava collapsibility index, and central venous pressure) may be used to assess hemodynamic response to fluid resuscitation, but the options are few in limited-resource settings. This study aimed at assessing if a bedside-performed ultrasound to assess the inferior vena cava collapsibility index is superior to UOP in assessing hemodynamic response to fluid resuscitation. METHODS: All adult patients presenting to a tertiary referral hospital in the capital city of Rwanda with intra-abdominal infection requiring intravenous fluid (IVF) resuscitation before operation were included in this study. Before IVF administration, the baseline inferior vena cava collapsibility index (IVC-CI) and vital parameters were recorded. After initiation of IVF resuscitation, serial measurements of IVC-CI and UOP were recorded every 2 h until the decision was made to take the patient to the operating room. RESULTS: Twenty-four patients were enrolled. The mean duration of symptoms was 4.7 days. Four patients (16%) had altered mental status as a presenting symptom. Half of all patients had generalized peritonitis due to gangrenous bowel as the primary diagnosis (n = 12). The mean difference between time of hemodynamic response based on IVC-CI versus UOP was 2 h (P < 0.001). CONCLUSIONS: Measurement of the IVC-CI can provide early detection of hemodynamic response to fluid therapy in patients with intra-abdominal infection with spontaneous breathing compared to UOP. Future research should utilize this parameter in the preoperative management of hemodynamically unstable patients.

Development of an acute care surgery service in Rwanda.

BACKGROUND: Acute care surgery (ACS) encompasses trauma, critical care, and emergency general surgery. Due to high volumes of emergency surgery, an ACS service was developed at a referral hospital in Rwanda. The aim of this study was to evaluate the epidemiology of ACS and understand the impact of an ACS service on patient outcomes. METHODS: This is a retrospective observational study of ACS patients before and after introduction of an ACS service. χ2 test and Wilcoxon rank-sum test were used to describe the epidemiology and compare outcomes before (pre-ACS)) and after (post-ACS) implementation of the ACS service. RESULTS: Data were available for 120 patients before ACS and 102 patients after ACS. Diagnoses included: intestinal obstruction (n=80, 36%), trauma (n=38, 17%), appendicitis (n=31, 14%), and soft tissue infection (n=17, 8%) with no difference between groups. The most common operation was midline laparotomy (n=138, 62%) with no difference between groups (p=0.910). High American Society of Anesthesiologists (ASA) score (ASA ≥3) (11% vs. 40%, p<0.001) was more common after ACS. There was no difference in intensive care unit admission (8% vs. 8%, p=0.894), unplanned reoperation (22% vs. 13%, p=0.082), or mortality (10% vs. 11%, p=0.848). The median length of hospital stay was longer (11 days vs. 7 days, p<0.001) before ACS. CONCLUSIONS: An ACS service can be implemented in a low-resource setting. In Rwanda, ACS patients are young with few comorbidities, but high rates of mortality and morbidity. In spite of more patients who are critically ill in the post-ACS period, implementation of an ACS service resulted in decreased length of hospital stay with no difference in morbidity and mortality. LEVEL OF EVIDENCE: Prognostic and epidemiologic study type, level III.