Perioperative capacity and contextual challenges in teaching hospitals of southern Ethiopia: explanatory sequential mixed-methods research.

BACKGROUND: Previous Ethiopian literature on surgical capacity and challenges has focused on quantitative investigations, lacking contextual understanding. This explanatory sequential mixed-methods research (MMR) aimed to assess perioperative capacity and contextual challenges at three teaching hospitals in southern Ethiopia. METHODS: A quantitative survey assessed workforce, infrastructure, service delivery, financing, and information systems. The survey findings were explained by qualitative semi-structured interviews of twenty perioperative providers. Descriptive statistics were integrated with qualitative thematic analysis findings using the narrative waving approach. Key findings from both datasets were linked using a joint display table. RESULTS: The survey revealed shortages in the specialist workforce (with a ratio of 0.58 per 100,000 population), surgical volume (at 115 surgeries per 100,000 population), equipment, supplies, financing, and perioperative data tracking. Hospitals' radiology services and blood products were only available 25-50% of the time, while anesthetic agents and essential laboratory services were often available 51-75% of the time. Perioperative management protocols were used rarely (1-25% of the time). Over 90% of patients lack health insurance coverage. Qualitative data also revealed scarcity of perioperative resources and equipment; unaffordable perioperative costs, lack of health insurance coverage, and unforeseen expenses; poor patient safety culture and communication barriers across the perioperative continuum of care; workforce shortages, job dissatisfaction, and concerns of competence; and weak national governance, and sociopolitical turmoil, and global market volatility exacerbating local challenges. These challenges are linked to risks in quality of care and patient safety, according to clinicians. CONCLUSION: The study identifies deficiencies in the health system and sociopolitical landscape affecting safe surgery conduct. It highlights the need for comprehensive health system strengthening to expand workforce, upgrade facilities, improve safety culture, resilience, and leadership to ensure timely access to essential surgery. Exploring external factors, such as the impact of national governance and sociopolitical stability on reform efforts is also essential.

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.

Perioperative mortality and its predictors among patients undergoing emergency laparotomy at selected southern Ethiopian governmental hospitals, 2022: a multicenter prospective cohort study.

Globally, emergency laparotomy is a frequently performed type of surgery with high morbidity and mortality rates, even in the best healthcare systems. There is limited knowledge regarding the outcome of emergency laparotomy performed in Ethiopia. Objective: To assess perioperative mortality and its predictors among patients undergoing emergency laparotomy at selected southern Ethiopian governmental hospitals. Methods: A multicenter prospective cohort study was conducted, and data were collected at selected hospitals after obtaining ethical approval from the Institutional Review Board. Data were analyzed using SPSS version 26. Results: The rate of postoperative complications after emergency laparotomy surgery was 39.3%, with an in-hospital mortality rate of 8.4% and a length of hospital stay of 9±6.5 days. The predictors of postoperative mortality were the age of the patient greater than 65 [adjusted odds ratio (AOR)=8.46, 95% CI=1.3-57.1], presence of intraoperative complications (AOR=7.26, 95% CI=1.3-41.3), and postoperative ICU admission (AOR=8.5, 95% CI=1.5-49.6). Conclusion: Our study revealed a significant level of postoperative complications and in-hospital mortality. The identified predictors should be sorted and applied to the preoperative optimization, risk assessment, and standardization of effective postoperative care following emergency laparotomy.

Pattern of disease and determinants of mortality among ICU patients on mechanical ventilator in Sub-Saharan Africa: a multilevel analysis.

BACKGROUND: The global mortality rate of patients with MV is very high, despite a significant variation worldwide. Previous studies conducted in Sub-Saharan Africa among ICU patients focused on the pattern of admission and the incidence of mortality. However, the body of evidence on the clinical outcomes among patients with MV is still uncertain. OBJECTIVE: The objective of this study was to investigate the pattern of disease and determinants of mortality among patients receiving mechanical ventilation in Southern Ethiopia. METHODS: Six hundred and thirty patients on mechanical ventilation were followed for 28 days, and multilevel analysis was used to account for the clustering effect of ICU care in the region. RESULTS: The incidence of 28-day mortality among patients with MV was 49% (95% CI: 36-58). The multilevel multivariate analysis revealed that being diabetic, having GSC < 8, and night time admission (AOR = 7.4; 95% CI: 2.96-18.38), (AOR = 5.9; (5% CI: 3.23, 10.69), and (AOR = 2.5; 95% CI: 1.24, 5.05) were predictors. CONCLUSION: The higher 28-day mortality among ICU patients on mechanical ventilation in our study might be attributed to factors such as delayed patient presentation, lack of resources, insufficient healthcare infrastructure, lack of trained staff, and financial constraints. TRIAL REGISTRATION: The protocol was registered retrospectively on ( NCT05303831 ).

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.

Analgesic Efficacy of Spinal Morphine in Comparison With Transversus Abdominis Plane Block for Postoperative Pain Management in Patients Undergoing Cesarean Section Under Spinal Anesthesia: A Randomized Controlled Trial.

BACKGROUND: Cesarean section (CS) has been one of the most frequently performed major surgical interventions and causes severe postoperative pain. Spinal opioid and abdominal field block have been investigated as effective analgesia for postoperative pain and reduce the need for systemic medications and associated side effects. The aim of the current study is to compare spinal morphine (SM) and bilateral landmark oriented transversus abdominis plane (TAP) block for postoperative pain management. METHOD: In this randomized controlled trial, 114 pregnant mothers scheduled for CS under spinal anesthesia were allocated randomly to receive either SM 0.1 mg (group SM; n = 56) or bilateral landmark-oriented TAP block with 20 ml of 0.25% of bupivacaine (group TAP; n = 52). A comparison of numerical variables between study groups was done using unpaired student t-test and Mann-Whitney test for symmetric and asymmetric data, respectively. Time to event variable was analyzed by using Kaplan-Meir's survival function. A p-value of < 0.05 was considered statistically significant. RESULT: A total of 114 patients were recruited and randomly assigned and received interventions. Among them, 108 patients completed this study. Time to first analgesic request was significantly shorter in the TAP block compared to SM. Twenty-four-hour median morphine consumption was reduced in the SM group compared to the TAP block (p < 0.001). Median postoperative pain score during movement and rest shows statistically significant differences between groups (p < 0.001). CONCLUSION: The addition of preservative-free 100 µg SM provides prolonged postoperative analgesia time, superior postoperative analgesia, and less postoperative opioid consumption compared to the TAP block.

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.

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.

Determinants of Dyslipidemia in Africa: A Systematic Review and Meta-Analysis.

Background: Dyslipidemia is a common public health problem in Africa. It has emerged as an important cardiovascular risk factor. It has been steadily increasing due to economic growth, urbanization, and unhealthy dietary pattern. Therefore, it is essential to identify determinants of dyslipidemia to prevent the condition and reduce its long-term sequel. Methods: Combinations of search terms with Boolean operators were used to retrieve studies from PubMed, EMBASE, Cochrane Database, Cinahl, Scopus, Mednar, and Google Scholar. The methodological quality of each article was evaluated based on the 2017 Joanna Briggs Institute (JBI) Critical Appraisal checklist for prevalence studies. After evaluation of each study against these criteria, studies with a minimum score of 7 or above out of 9 JBI checklists were included. We included articles presented in the English language. The Cochrane Q test was used to assess the heterogeneity across studies. The visual assessment of publication bias was done by creating a funnel plot. The possible causes of heterogeneity were explored by subgroup analyses. Egger's weighted regression test was used to assess the presence of publication bias. Statistical analyses were done by using the STATA software version 14. Result: A total of 24 articles involving 37,902 participants from 10 African countries were included. The overall pooled prevalence of dyslipidemia was 52.8 (95% CI 40.8-64.9). Individuals with a body mass index (BMI) >25.0 kg/m2 and waist circumference (WC) >94 cm were, respectively, 2.36 (95% CI (1.33-4.18), p < 0.001) and 2.33 (95% CI (0.75-0.29) p < 0.001) times more likely to develop dyslipidemia than those with lower values. Furthermore, patients with diabetes mellitus (DM) and hypertension (HTN) were 2.32 (95% CI (0.89-6.05) p < 0.001) and 2.05 (95% CI (1.31-3.21), p < 0.001) times more likely to present with dyslipidemia than non-diabetic patients and those without HTN. Conclusion: This study revealed that the prevalence of dyslipidemia is relatively high among study participants in African countries and the independent predictors of dyslipidemia were BMI >25.0 kg/m2, WC > 94 cm, raised blood glucose level, and raised blood pressure. Therefore, there should be a pressing public health measure to prevent, identify, and treat dyslipidemia with the special emphasis on obese, diabetic, and hypertensive patients.

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.

Knowledge of COVID-19 and its prevention among residents of the Gedeo zone, South Ethiopia. Sources of information as a factor.

BACKGROUND: COVID-19 was declared as a pandemic in March 2020. After confirming the first case, the Ethiopian government has been working a lot to prevent transmission. Most of the reported cases were identified from traveling abroad. Effective prevention and control practices depend on awareness and compliance among the population at all levels. The main objective of this study is to determine the knowledge level and its association with sources of information towards COVID-19 and its prevention techniques in the Gedeo Zone of Southern Ethiopia. METHODS: There are 10 knowledge questions regarding COVID-19 and its prevention techniques. The maximum knowledge score for each question was 1 and the minimum 0, where 0 was scored for incorrect and 1 for correct answers. The overall knowledge score ranges from 0 to 10, where a score of 0-5 as poor knowledge and a score from 6-10 as good knowledge. Bivariate and multivariate binary logistic regression was used to determine the association between dependent and independent variables. The adjusted odds ratio with their 95% CI was used to show the strength of association. p Value < .05 was used to declare a statistically significant association. RESULTS: Among 1170 study participants, 58.1% of the study participants were male. Protestant constitutes 50.6% of the study participants in religion. Regarding knowledge level, 60.5% have good knowledge about COVID-19 and its prevention techniques. Concerning sources of information about COVID-19 and its prevention; internet, family/peer, religious and health workers contributes less <20% whereas telecommunication and television/Radio contributes the largest 56.1% and 85.8% as a source of information respectively. Internet as a source of information AOR: 1.99 (CI: 1.05-3.78, p = .034), information from health worker AOR: 2.324 (CI: 1.228-4.397, p = .010) and information from television or radio AOR: 2.737 (CI: 1.471-5.092, p = .001) has been significantly associated with good knowledge with p value < .05. CONCLUSION: Sources of information had a significant association on the level of knowledge. Residents who had internet, television/radio, and health workers as their information sources had better knowledge regarding COVID-19 and its prevention. Based on this, we recommend increasing internet access, television and radio service, and public health education by trained health workers for effective approaches to fight COVID-19.

Effectiveness of Leg Elevation to Prevent Spinal Anesthesia-Induced Hypotension during Cesarean Delivery in the Resource-Limited Area: Open Randomized Controlled Trial.

BACKGROUND: Postspinal hypotension is the most common complication after spinal anesthesia for cesarean section (CS). Hypotension mainly occurs due to the reductions of vascular tone leading to decreased systemic vascular resistance and decreased venous return. The aim of this study was to assess the effectiveness of leg elevation (LE) as a method of prevention of postspinal hypotension in patients who undergo cesarean section under spinal anesthesia. METHODS: This is a single-center parallel-randomized controlled trial study, and 52 full-term parturients scheduled for elective cesarean section who meets inclusion criteria were included in the study. The randomization sequence was created by a researcher not participating in patient management using a computer random generator. The participant was randomly assigned to the leg elevation group (n = 26) or to the control group (n = 26) of usual perioperative care. RESULTS: The proportions of patients who develop hypotension are lower (8 (33.3%)) in the leg elevation group than the control group (15 (62.5%)) with an X 2 (1, N = 48) = 4.09, P=0.043. The relative risk of developing postspinal hypotension in the leg elevation group compared to the control group was 0.47 (95% CI, 0.28-1.00). The proportion of severe hypotension was significantly decreased in the leg elevation group at a P value of 0.02. CONCLUSION: Performing leg elevation immediately after spinal anesthesia reduced the incidence of hypotension. The trial is registered with PACTR201908713181850.

Incidence and associated factors for hypotension after spinal anesthesia during cesarean section at Gandhi Memorial Hospital Addis Ababa, Ethiopia.

BACKGROUND: Spinal anesthesia is a type of regional anesthesia that has been practicing for obstetric anesthesia since the beginning of the 20th century. Despite the simplicity and lower maternal mortality risk, compared to general anesthesia, spinal anesthesia is linked to different adverse effects, of which hypotension is the most common complication. The main aim of this study was to determine the incidence and associated factors of hypotension after spinal anesthesia during cesarean section. METHOD: Institution-based cross-sectional study was conducted with 410 clients. The study was conducted on cesarean section under spinal anesthesia from 5th January to 30th April 2019, at the Gandhi Memorial Hospital, Addis Ababa, Ethiopia. Both bivariable and multivariable logistic regression analysis were done on the associated factors. The level of statistical significance was represented at p<0.05. RESULTS: The incidence of hypotension among mothers who underwent a cesarean section after spinal anesthesia was 64%. Newborn weight ≥4kg (AOR = 5.373; 95%CI: (1.627-17.740)) showed an increase risk of association with hypotension. A baseline systolic blood pressure < 120mmHg (AOR = 6.293; (95%CI: 2.999-13.204)) was found to be associated with increased risk of hypotension. Sensory block height >T6 AOR = 2.230; 95%CI: (1.329-3.741), the time interval between spinal induction and skin incision > 6minutes AOR = 1.803; 95%CI: (1.044-3.114) and anesthetist experience AOR = 5.033(95%CI: 2.144-11.818) were also associated with hypotension. CONCLUSION: The identified risk factors for hypotension, after spinal anesthesia are sensory height block, weight of the baby, the time interval between spinal induction and skin incision, baseline systolic blood pressure, and anesthetist experience.