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.

Outcome of critically ill children before and after the establishment of a pediatric retrieval service as a component of a national strategy for pediatric intensive care.

OBJECTIVE: To compare outcomes of critically ill children transferred for intensive care by specialist and nonspecialist retrieval before and after the establishment of a dedicated pediatric intensive care transfer service. DESIGN: Prospective, observational study. SETTING: All hospitals that admitted children in a defined geographic region of the United Kingdom. PATIENTS: There were a total of 284 critically ill children (<16 yrs old) transferred from a district general hospital to a tertiary pediatric intensive care unit. MEASUREMENTS AND MAIN RESULTS: Age, diagnosis, Pediatric Risk of Mortality score, Therapeutic Intervention Scoring System, details of interhospital transfer, and survival to hospital discharge were analyzed for two periods, before and after the establishment of a regional transfer service. Patients were categorized as low or high risk (predicted mortality, 15%, respectively). Standardized mortality was calculated as the ratio of observed to predicted deaths in each category. After the transfer service was established, a significantly higher proportion of high-risk children were transferred by a specialist team, and there was a decreased standardized mortality rate of transferred patients (1.09 to 0.74). The greatest decrease in standardized mortality rate occurred in low-risk children transferred by nonspecialist teams (2.27 to 0.52). During the equivalent period in the same geographic region, standardized mortality rate of nontransferred children also fell in pediatric intensive care (1.59 to 0.60) and general intensive care units (1.11 to 0.81). CONCLUSIONS: We conclude that the establishment of a regional transfer service coincided with a fall in standardized mortality that reflected more general changes in intensive care performance rather than a specific benefit of a specialist transfer team.