Glycaemic profile of children undergoing anaesthesia (GLYCANA) at Mercy James Centre in Malawi: an observational study.

BACKGROUND: Hypoglycaemia and hyperglycaemia may develop during anaesthesia and surgery in children and can lead to severe adverse clinical outcomes. No study, as far as we know, has investigated glucose homeostasis in children undergoing surgery in Malawi. The aim of this study was to assess perioperative glucose levels of the children undergoing anaesthesia at Mercy James Centre (MJC) for Paediatric Surgery, Blantyre, Malawi. METHODOLOGY: This was an observational cross-sectional study. We looked at 100 children aged 1 day to 15 years anaesthetised at MJC. Data were analysed using SPSS 28. Student t test and Analysis of the variance (ANOVA) were used to compare means. The level of significance was 5%. RESULTS: Male children represented 68%. The median age was 2.2 years. Sixten percents of patient were underweight. Fasting times were prolonged for 87%. Maintenance IV fluid with 2.5% dextrose was given to 14%. Overall, there was a significant increase of glycaemia from induction of anaesthesia to the end of the procedure. Hypoglycaemia was rare. The mean fasting glycaemia was 99.04 mg/dL ± 1.8, 116.95 mg/dL ± 34.2 at 30 min into the procedure and 127.62 mg/dL ± 46.8 at the end of the procedure. The differences in means were statistically significant (p < 0.001). Prolonged fasting times was associated with lower blood glucose means whereas nutrition status, type of the procedure, addition of dextrose in the fluid, and duration of procedure were associated with higher glycaemia means. CONCLUSION: Glycaemia increases under anaesthesia and surgery. Recommended fasting times, optimising nutritional status, when possible, no dextrose or lower than 2.5% dextrose in IV maintenance fluid are possible strategies to maintain blood sugar homeostasis during paediatric surgery and anaesthesia.

Complications au cours de l'anesthésie pédiatrique: une série descriptive de cas descriptif de l'Hôpital Matanda et des Cliniques Universitaires du Graben en Ville de Butembo, République Démocratique du Congo / Complications during paediatric anaesthesia: A descriptive case series at the Matanda Hospital and the Cliniques Universitaires du Graben in Butembo, Democratic Republic of Congo

Pediatric anesthesia in developing countries is performed in a context of scarcity of personnel and equipment resources, which puts patients at risk of complications and death. The main objective of this study was to determine the complications occurring during the practice of pediatric anesthesia in Butembo. Methods: A descriptive case series of children aged 0 to 17 who benefited from anesthesia at Matanda Hospital and at the University Clinics of Graben was conducted from January 1 to December 31, 2020. Studied parameters included socio-demographic, pre, per and postoperative and perioperative mortality data. Results: Pediatric surgery represented 315 patients (7.2 %,) out of 4,367 surgeries of which 200 constituted the study sample. Boys were 60.0 % of the cases. Wounds represented 18.5% of the cases and ASA class 1 69.0 %. Nurse anesthetists conducted 196 (98.0 %) procedures. General anesthesia was the technique used in 75.0 % of cases. Ketamine was used in 68.8 % of the cases. Orotracheal intubation was performed in 10.5 %. Complication rates were 6.0 % at induction, 5.5 % at maintenance and 4.5 % postoperatively. The death rate was 1.5 %. Conclusion: The complication rate after pediatric anesthesia is still high. Capacity reinforcement of providers, improved equipment and availability of anaesthetics are the cornerstone measures to reduce these complications.

Contexte et objectif L'anesthésie pédiatrique dans les pays en voie de développement est pratiquée dans un contexte de pénurie des ressources en personnel comme en matériels, ce qui expose les patients au risque des complications et de décès. L'objectif principal de la présente étude était de déterminer les complications survenant au cours de l'anesthésie pédiatrique à Butembo. Méthodes : Il s'agissait d'une série descriptive des cas des enfants de 0 à 17 ans ayant bénéficié une anesthésie à l'hôpital Matanda et aux Cliniques Universitaires du Graben du 1ier janvier au 31 Décembre 2020. Les paramètres étudiés comprenaient les données sociodémographiques, les données pré, per et postopératoires et la mortalité périopératoire. Résultats : La chirurgie pédiatrique a concerné 315 patients (7,2 %) de 4367 opérés dont 200 ont constitué l'échantillon. Les garçons ont représenté 60,0 %. Les plaies ont représenté 18,5 % et la classe ASA 1 69,0 %. Les techniciens anesthésistes réanimateurs ont pratiqué 196 anesthésies (98,0 %). L'anesthésie générale a été pratiquée à 75,0 %. La kétamine a été utilisée à 68,8%. Les taux de complications étaient de 6,0% à l'induction, 5,5 % à l'entretien et de 4,5 % en postopératoire. Le taux de mortalité était de 1,5 %. Conclusion : Le taux de complications après anesthésie pédiatrique reste encore élevé. Le renforcement des capacités du personnel, l'amélioration de l'équipement et la disponibilité des anesthésiques sont la pierre angulaire pour réduire ces complications.

Anaesthesia management for cleft lip in a child with unrepaired Tetralogy of Fallot in Malawi: a case report.

Background: Children with clefts lips often present with cardiac abnormalities, among them the tetralogy of Fallot. Anaesthesia for patients with unrepaired Tetralogy of Fallot coming for a non-cardiac surgery represents an additional risk of increased perioperative morbidity and mortality. Case presentation: We present a case of a 8 years old boy with unrepaired Tetralogy of Fallot scheduled for cleft lip repair. The Child was referred to Mercy James Centre for Paediatric Surgery and Intensive Care from an Operation Smile Mission campaign. Anaesthesia consisted of a balanced general anaesthesia combined with regional anaesthesia by an infraorbital nerve block. The child developed hypercyanotic spells postoperatively which were successfully managed with noradrenaline, morphine, fluid, and oxygen therapy. Conclusion: Children with unrepair Tetralogy of Fallot coming for non-cardiac surgery have increased risk of complications during anaesthesia. The anaesthesia provider should be aware and ready to manage them promptly.

General anaesthesia related mortality in a limited resource settings region: a retrospective study in two teaching hospitals of Butembo.

BACKGROUND: General anaesthesia (GA) in developing countries is still a high-risk practice, especially in Africa, accompanied with high morbidity and mortality. No study has yet been conducted in Butembo in the Democratic Republic of the Congo to determine the mortality related to GA practice. The main objective of this study was to assess mortality related to GA in Butembo. METHODS: This was a retrospective descriptive and analytic study of patients who underwent surgery under GA in the 2 main teaching hospitals of Butembo from January 2011 to December 2015. Data were collected from patients files, anaesthesia registries and were analysed with SPSS 26. RESULTS: From a total of 921 patients, 539 (58.5%) were male and 382 (41.5%) female patients. A total of 83 (9.0%) patients died representing an overall perioperative mortality rate of 90 per 1000. Out of the 83 deaths, 38 occurred within 24 h representing GA related mortality of 41 per 1000. There was a global drop in mortality from 2011 to 2015. The risk factors of death were: being a neonate or a senior adult, emergency operation, ASA physical status > 2 and a single deranged vital sign preoperatively, presenting any complication during GA, anaesthesia duration > 120 minutes as well as visceral surgeries/laparotomies. Ketamine was the most employed anaesthetic. CONCLUSION: GA related mortality is very high in Butembo. Improved GA services and outcomes can be obtained by training more anaesthesia providers, proper patients monitoring, improved infrastructure, better equipment and drugs procurement and considering regional anaesthesia whenever possible.

Practice of standard monitoring during anaesthesia in hospitals of North Kivu: a survey of health facilities of the health antenna of Butembo.

BACKGROUND: Standard monitoring during anaesthesia is a core element of patient safety and practice of safe anesthesia has reduced morbidity and mortality worldwide. The main objective of this study was to assess the practice of standard monitoring during anaesthesia in the hospitals of North Kivu, so as to establish a baseline overview of the situation, and orientate plans towards safe anaesthesia in the region. METHODS: This study was a cross-sectional survey of health facilities of the Health Antenna of Butembo in Democratic Republic of Congo and was conducted from October to December 2018. Questionnaires were brought to anaesthesia providers in the health facilities. The study included 1 answer from the anaesthesia practitioners who accepted to participate. The practices of standard monitoring in the health facilities were compared to WHO-WSFA guidelines. Data was captured and analyzed with Epi Info 7. RESULTS: Forty out of 90 health facilities (44.4%) of 10 health zones responded on the questionnaire. Twenty-three health facilities (57.5%) were from private sector and 17 (42.5%) from public sector. Sixteen health facilities (40.0%) were from the Butembo health zone. The median number of anaesthesia providers was 2 per health facility. Of all the anaesthesia providers, none were physicians, 47.5% were nurses practicing anaesthesia without any training in anaesthesia and 47.5% were nurse anaesthetists. All the health facilities were providing general anaesthesia whereas spinal anaesthesia was provided in 22 out of 40 centers (55%). Seventy percent (28/40) of the facilities were below standard according to WHO-WSFA guidelines. Only 40% (16/40) were using a pulse oximeter and 10% (4/40) declared that ECG was occasionally used. CONCLUSION: The practice of standard monitoring is poor in health facilities of the Health Antenna of Butembo. Efforts should be made to improve monitoring which is a key element of safe anaesthesia.

Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention.

Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.

The "first digit law" - A hypothesis on its possible impact on medicine and development aid.

The "first digit law" or "Benford's law" is a mathematical distribution discovered by Simon Newcomb and Frank Benford. It states, that the probability of the leading number d (d∈{1,…,9}) in many natural datasets follows: P (d)=log10 (d+1)-log10 (d)=log10 (1+1/d). It was successfully used through tax authorities and "forensic accounting" in order to detect fraud and other irregularities. Benfords law was almost neglected for its use outside financial accounting. The planning for health care systems in developing countries is extremely dependant on good, valid data. Whether you plan the catchment area for the future district hospitals, the number of health posts, the staff establishment for the central hospital or the drug budget in the Ministry. The "first digit law" can be used in medicine, public health, physiology and development aid to unmask questionable data, to discover unexpected challenges, difficulties in the data collection process, loss through corruption and criminal fraud. Our hypothesis suggests, that the "first digit law" is a cost effective tool, which is easy to use for most people in the medical profession, which does not really needs complicated statistical software and can be used on the spot, even in the resource restricted conditions of developing countries. Several preconditions (like the size of the data set and its reach over more than two dimensions) have to be fulfilled, but then Benfords law can be used by any clinician, physiologist, public health specialist or aid consultant without difficulties and without deeper statistical knowledge in the four steps, we suggest in this article. The consequences will be different depending on the level (local regional, national, continental, international) on which you will use the law. All levels will be enabled to get insight into the validity of the data-challenges for the other levels without the help of trained statisticians or accountants. We believe that the "first digit law" is a vastly underestimated and neglected, but extremely useful tool for the identification of unexpected challenges, supervision and control in various parts of medicine and public health for almost all aspects of development aid.

Critical Care in a Tertiary Hospital in Malawi.

BACKGROUND: The provision of critical care services is essential to healthcare systems and increasingly a global health focus, but many hospitals in sub-Saharan Africa are unable to meet this need. Intensive care unit (ICU) mortality in this region is high, but studies describing the provision of critical care services are scarce. METHODS: This was a retrospective cohort study of all patients admitted to the ICU at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, between September 1, 2013, and October 17, 2014. We summarized demographics, clinical characteristics, and outcomes, and analyzed factors associated with mortality. RESULTS: Of 390 patients admitted to ICU during the study, 44.9 % of patients were male, and the median age was 22 years (IQR 6-35) years. Although most patients (73.1 %) were admitted with surgical diagnoses, the highest mortality was among patients admitted with sepsis (59.3 %), or obstetric (44.7 %) or medical (40.0 %) diagnoses. Overall ICU mortality was high (23.6 %). CONCLUSIONS: There is a shortage of data describing critical care in low-resource settings, particularly in sub-Saharan Africa. Surgical disease comprises the majority of ICU utilization in this study site, but medical and obstetric illness carried higher ICU mortality. These data may guide strategies for improving critical care in the region.

Continuous flow using an entrainer and t-piece vs drawover apparatus for inhalational induction of anesthesia in children.

BACKGROUND: Inhalational induction in children is easiest to perform with the Ayres t-piece & bag (Mapleson F). Drawover anesthesia systems may be used but have not been studied. The aim of this study was to examine the quality of induction of anesthesia in children comparing a continuous flow system using the Farman entrainer and the pediatric t-piece, to a pediatric drawover system. METHODS: We conducted a randomized controlled trial in accordance with departmental and institutional standards with 60 subjects who received inhalational induction using either apparatus. RESULTS: There was no evidence of a difference in the median Sp02 between the two methods (P = 0.626) neither was there a difference between the method of induction regarding abdominal distension (P = 0.348) or restraint (P = 0.186). Induction time using the pediatric drawover apparatus 240 (range 115-605) seconds was significantly greater than the Farman entrainer/t-piece 146 (range 65-535) seconds (P < 0.05). CONCLUSIONS: We consider that this difference is unlikely to be clinically significant in many cases; however, the increased speed using the entrainer and t-piece may sometimes confer an advantage.

The 'Malawi device': a durable, reusable, low cost device from own materials for emergency ventilation during percutaneous tracheostomy.

The use of a tracheostomy is routine in current intensive care practice to facilitate weaning patients requiring prolonged respiratory support from mechanical ventilation. Percutaneous tracheostomy has become an established technique with an acceptable risk profile in appropriately selected patients, and has the advantage that it can be performed at the bedside without the need for an operating theatre. This is particularly relevant in a resource-poor setting. Ideally, percutaneous tracheostomy requires the presence of two skilled persons; one to perform the tracheostomy while the other controls the airway and withdraws the endo-tracheal tube at the appropriate time. This is not always possible in a resource poor setting with limited manpower. Without two operators, it is possible for the tracheal tube to become displaced before the completion of the tracheostomy with potentially disastrous consequences. We describe a method by which the airway and ventilation can be maintained if accidental tracheal extubation occurs before completion of a percutaneous tracheostomy. The 'Malawi Device', a cheap and simple modification of readily available equipment, enables a single operator to maintain the airway and ventilate the patient when the above scenario occurs.

A new way to measure mid-upper-arm circumference in african villages.

In 2011 we published a study on how to detect the threshold for malnutrition in children, simply using their own hands and without any technical tool. The fight against malnutrition can only be reached when its measurements involve every single child, almost continuously, in the affected villages. In this paper we try to show that, thanks to our method, it is possible to use mid-upper-arm-circumference as a measurement for malnutrition in children, discriminating between severe and moderate malnutrition and providing the basis for the decision on whether to admit a child to a nutritional rehabilitation unit or not. We trained 63 participants in four groups (Group 1: doctors and clinical officers; Group 2: nurses and students; as Group 3 we defined the 20 best participants and Group 4 consisted of 10 more intensely trained participants) to measure the circumference of 9 different artificial arms (between 9 and 13 cm) using their own fingers and hands. The training was short and consisted of an introduction of 5 min, a first training phase of 10-15 min, a test, the critical discussion of the results, a second training phase of 5 min and a final test. We found that 95.3% of participants in the general group and 97.9% in the intensely trained group have identified the severely malnourished child; 87.3% in the general group and 91.9% in the intensely trained group have additionally identified the moderately malnourished child. Both groups haven't admitted the well nourished child to a therapeutic feeding program retaining their resources. The third group reached without any additional training the results in the above categories. A subsequent discussion with the participants on the influence of procurement, maintenance and pricing of our tool, found our method much less vulnerable than others. We conclude that this method should be considered as a future training in the villages to detect the trend towards malnutrition early enough.

A new hypothesis on preventable neuropsychiatric illness in Africa.

BACKGROUND: Communicable diseases are still the most important public health challenge in Africa. Many of them such as malaria, schistosomiasis and pneumonia are frequently treated with quinoline derived substances, which are known to have neuropsychiatric side effects. Millions of Africans have to take two or three of them simultaneously (e.g. quinine and ciprofloxacin or praziquantel). Almost nothing is known about their additive effects or interactions. HYPOTHESIS: We hypothesize, that a parallel therapy with quinoline derived antimicrobial substances leads to a preventable neuropsychiatric syndrome and suggest to find the joint pathobiochemical explanation for this condition in the l-Tryptophane-Kynurenine-Serotonine pathway. DISCUSSION: Almost all intermediary substances of the Kynurenine pathway (tryptophan, kynurenine, kynurenic acid, quinolinic acid and serotonin) are known to have neuropsychiatric properties on their own. Direct interactions between quinolines and the oxygenases of the pathway (especially with the indoleamine (2,3)-dioxygenase and kynurenine-monoxygenase) and indirect influences via the interferon-γ induced breakdown of tryptophane are discussed, as well as the modifying effect of the already existing neurotoxicity of the single quinoline related drug used. Three different mechanisms were discovered which can influence the complex, well balanced biochemical equilibrium of the kynurenine pathway. Due to the complexity of the pathway and the fact that all substances have their own, even contradictory, neuropsychiatric properties, we do not argue that through a certain type of postulated metabolism a certain drug might have a specific effect, but we do hypothesize that it is the disturbance of a well balanced equilibrium which makes a neuropsychiatric effect of the parallel antimicrobial therapy with quinolines more than probable. CONSEQUENCES: If confirmed, our hypothesis demonstrates that parallel therapy with quinoline antimicrobials constitutes an under addressed public health challenge in Africa with severe diagnostic, therapeutic and financial implications. The individual physician has to take a new entity into account for the neuropsychiatric differential diagnosis, especially in patients suffering from another neurological illness, being treated with efavirenz or belonging to high risk groups affecting the health of others like mini-bus drivers. Further direct consequences apply to physicians in the rich countries dealing with migrants, refugees, long term expats or professional groups in need of a high level of psychological stability, good judgement and fine motor skills. CONCLUSION: The hypothesis needs urgent confirmation in a randomized, prospective trial comparing levels of quinolinic acid etc., in patients on quinoline treatment versus a quinoline-naïve patients for several body fluids and ideally in the brain post-mortem.

Anesthetic management of a malnourished, 7-year-old child in Malawi undergoing a pneumonectomy.

In this report, we describe the case of a 7-year-old girl presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi, with hypoxia and respiratory distress. Investigations demonstrated an endobronchial tumor, and she underwent a radical left-sided pneumonectomy. This case highlights the challenges of anesthesia in a resource-depleted setting.

Preventing intensive care admissions for sepsis in tropical Africa (PICASTA): an extension of the international pediatric global sepsis initiative: an African perspective.

BACKGROUND: The Global Sepsis Initiative recommends prevention of sepsis through immunizations, vitamins, breast feeding, and other important interventions. In our study, we consider a second set of proposals for preventing intensive care admissions for sepsis in tropical Africa, which have been specifically designed to further prevent ICU admissions for sepsis in the group A nation hospital setting. OBJECTIVES: To reduce admissions with severe sepsis in an ICU of a group A nation through the identification of challenges leading to preventable, foreseeable, or nosocomial sepsis specific to our setting. METHODS: Malawi is one of the poorest countries in the world. Lacking the ability to comply with standard sepsis treatment, we conducted over 4 years several studies, audits, and surveys to identify challenges leading to preventable pediatric sepsis in our setting. We developed a method to identify malnourished children through a "gatekeeper" in the theaters without any equipment, tried to implement the World Health Organization's Safe Surgery Campaign checklist, evaluated our educational courses for the districts to improve the quality of referrals, looked into the extreme fasting times discovered in our hospital, trained different cadres in the districts to deal with peripartal and posttraumatic sepsis, and identified the needs in human resources to deal with pediatric sepsis in our setting. RESULTS: Six foci were identified as promising to work on in future. Focus 1: Preventing elective operations and procedures in malnourished children in the hospital and in the district: 134 of 145 nurses (92.4%) and even 25 of 31 African laymen (80.6%) were able to identify malnourished children with their own fingers. Focus 2: Preventing sepsis-related problems in emergencies through the implementation of the Safe Surgery Campaign checklist: only 100 of 689 forms (14.5%) were filled in due to challenges in ownership, communication responsibility, and time constraints. Focus 3: Preventing sepsis through the reduction of unwise referrals: our courses toward this topic reached 82-100% satisfaction of the 391 participants for relevance, presentation applicability, content, and teaching technique. Focus 4: Preventing sepsis-related problems through reduction of excessive fasting times in our hospital: necessity for action was documented by a mean fasting time of 10.2 hours (SD, 4.4 hr). Focus 5: Concentration on two extremely sepsis-relevant health challenges for children in Malawian districts, trauma and peripartal complications: numbers after our courses in the trained two districts showed a reduction in the maternal mortality rate (from 150.3 to 55 and 234.2 to 75.2), an inconclusive result for posttraumatic deaths and the identification of 44 future instructors. Focus 6: Implementation of a Master in Medicine (anesthesia and intensive care) and improvement of training in anesthesia for all cadres resulted in the first five anesthetic registrars in training and enhanced numbers in all other cadres in anesthesia dealing in own responsibility with pediatric sepsis. CONCLUSIONS: Every hospital can try to improve sepsis prevention on a local level by the Preventing Intensive Care Admissions for Sepsis in Tropical Africa approach. This will help support the promotion of the regionally adjusted Global Sepsis Initiative guidelines and the future global implementation of feasible bundles as a gold standard for resource-poor countries.