Impact and burden of sickle cell disease in critically ill obstetric patients in a high dependency unit in Sierra Leone-a registry based evaluation.

INTRODUCTION: Sickle cell disease (SCD) in pregnancy is associated with worse maternal and neonatal outcomes. There is limited available data describing the burden and outcomes of critically ill obstetric patients affected by SCD in low-income settings. OBJECTIVES: We aimed to define SCD burden and impact on mortality in critically-ill obstetric patients admitted to an urban referral hospital in Sierra Leone. We hypothesized that SCD burden is high and independently associated with increased mortality. METHODS: We performed a registry-based cross-sectional study from March 2020 to December 2021 in the high-dependency unit (HDU) of Princess Christian Maternity Hospital PCMH, Freetown. Primary endpoints were the proportion of patients identified in the SCD group and HDU mortality. Secondary endpoints included frequency of maternal direct obstetric complications (MDOCs) and the maternal early obstetric warning score (MEOWS). RESULTS: Out of a total of 497 patients, 25 (5.5%) qualified to be included in the SCD group. MEOWS on admission was not different between patients with and without SCD and SCD patients had also less frequently reported MDOCs. Yet, crude HDU mortality in the SCD group was 36%, compared to 9.5% in the non SCD group (P < 0.01), with an independent association between SCD group exposure and mortality when accounting for severity on admission (hazard ratio 3.40; 95%CI 1.57-7.39; P = 0.002). Patients with SCD had a tendency to longer HDU length of stay. CONCLUSIONS: One out of twenty patients accessing a HDU in Sierra Leone fulfilled criteria for SCD. Despite comparable severity on admission, mortality in SCD patients was four times higher than patients without SCD. Optimization of intermediate and intensive care for this group of patients should be prioritized in low-resource settings with high maternal mortality.

Lung Ultrasound for Detection of Pulmonary Complications in Critically Ill Obstetric Patients in a Resource-Limited Setting.

Critically ill parturients have an increased risk of developing pulmonary complications. Lung ultrasound (LUS) could be effective in addressing the cause of respiratory distress in resource-limited settings with high maternal mortality. We aimed to determine the frequency, timing of appearance, and type of pulmonary complications in critically ill parturients in an obstetric unit in Sierra Leone. In this prospective observational study, LUS examinations were performed on admission, after 24 and 48 hours, and in case of respiratory deterioration. Primary endpoint was the proportion of parturients with one or more pulmonary complications, stratified for the presence of respiratory distress. Secondary endpoints included timing and types of complications, and their association with "poor outcome," defined as a composite of transfer for escalation of care or death. Of 166 patients enrolled, 35 patients (21% [95% CI: 15-28]) had one or more pulmonary complications, the majority diagnosed on admission. Acute respiratory distress syndrome (period prevalence 4%) and hydrostatic pulmonary edema (4%) were only observed in patients with respiratory distress. Pneumonia (2%), atelectasis (10%), and pleural effusion (7%) were present, irrespective of respiratory distress. When ultrasound excluded pulmonary complications, respiratory distress was related to anemia or metabolic acidosis. Pulmonary complications were associated with an increased risk of poor outcome (odds ratio: 5.0; 95% CI: 1.7-14.6; P = 0.003). In critically ill parturients in a resource-limited obstetric unit, LUS contributed to address the cause of respiratory distress by identifying or excluding pulmonary complications. These were associated with a poor outcome.

Epidemiology, Outcomes, and Risk Factors for Mortality in Critically Ill Women Admitted to an Obstetric High-Dependency Unit in Sierra Leone.

A better understanding of the context-specific epidemiology, outcomes, and risk factors for death of critically ill parturients in resource-poor hospitals is needed to tackle the still alarming in-hospital maternal mortality in African countries. From October 2017 to October 2018, we performed a 1-year retrospective cohort study in a referral maternity hospital in Freetown, Sierra Leone. The primary endpoint was the association between risk factors and high-dependency unit (HDU) mortality. Five hundred twenty-three patients (median age 25 years, interquartile range [IQR]: 21-30 years) were admitted to the HDU for a median of 2 (IQR: 1-3) days. Among them, 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week; 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were ward rather than postoperative referrals (odds ratio [OR]: 3.21; 95% CI: 1.48-7.01; P = 0.003); admissions with red (high impairment of patients' vital signs) versus yellow (impairment of vital signs) or green (little or no impairment of patients' vital signs) OEWS (OR: 3.66; 95% CI: 1.15-16.96; P = 0.04); responsiveness to pain or unresponsiveness on the alert, voice, pain unresponsive scale (OR: 5.25; 95% CI: 2.64-10.94; P ≤ 0.0001); and use of vasopressors (OR: 3.24; 95% CI: 1.32-7.66; P = 0.008). Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Despite the provided interventions, death in the HDU was frequent, affecting one of 10 critically ill parturients. Medical admission, a red OEWS code, and a poor neurological and hemodynamic status were independently associated with mortality, whereas adequate oxygenation was associated with survival.

Ebola Holding Units at government hospitals in Sierra Leone: evidence for a flexible and effective model for safe isolation, early treatment initiation, hospital safety and health system functioning.

The 2014-2015 West African outbreak of Ebola Virus Disease (EVD) claimed the lives of more than 11,000 people and infected over 27,000 across seven countries. Traditional approaches to containing EVD proved inadequate and new approaches for controlling the outbreak were required. The Ministry of Health & Sanitation and King's Sierra Leone Partnership developed a model for Ebola Holding Units (EHUs) at Government Hospitals in the capital city Freetown. The EHUs isolated screened or referred suspect patients, provided initial clinical care, undertook laboratory testing to confirm EVD status, referred onward positive cases to an Ebola Treatment Centre or negative cases to the general wards, and safely stored corpses pending collection by burial teams. Between 29th May 2014 and 19th January 2015, our five units had isolated approximately 37% (1159) of the 3097 confirmed cases within Western Urban and Rural district. Nosocomial transmission of EVD within the units appears lower than previously documented at other facilities and staff infection rates were also low. We found that EHUs are a flexible and effective model of rapid diagnosis, safe isolation and early initial treatment. We also demonstrated that it is possible for international partners and government facilities to collaborate closely during a humanitarian crisis.

Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study.

BACKGROUND: The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis. METHODS: In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospital's Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease. RESULTS: Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3-4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure. INTERPRETATION: Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease. FUNDING: None.

Assessing unmet anaesthesia need in Sierra Leone: a secondary analysis of a cluster-randomized, cross-sectional, countrywide survey.

OBJECTIVES: To determine the unmet anaesthesia need in a low resource region. INTRODUCTION: Surgery and anæsthesia services in low- and middle-income countries (LMICs) are under-equipped, under-staffed, and unable to meet current surgical need. There is little objective measure as to the true extent and nature of unmet need. Without such an understanding it is impossible to formulate solutions. Therefore, we re-examined Surgeons OverSeas (SOSAS) unmet surgical need data to extrapolate unmet anaesthesia need. METHODS: For the untreated surgical conditions identified by SOSAS, we assigned anaesthetic technique required to carry out the procedure. The chosen anaesthetic was based on common practice in the region. Procedures were categorized into minimal anaesthesia, spinal anæsthesia, regional anaesthesia, ketamine/monitored anaesthesia care (MAC), and general endotracheal anæsthesia (GETA). DISCUSSIONS: Ninety-two per cent (687 of 745) of untreated surgical conditions in Sierra Leone would require some form of anaesthesia. Seventeen per cent (125 of 745) would require MAC, 22% (167 of 745) would require spinal anaesthesia, and 53% (395 of 745) would require GETA. CONCLUSION: Analyses such as this can provide guidance as to the rational and efficient production and distribution of personnel, drugs and equipment.