Intensive Care Unit Capacity Strain and Outcomes of Critical Illness in a Resource-Limited Setting: A 2-Hospital Study in South Africa.

OBJECTIVE: To measure the association of intensive care unit (ICU) capacity strain with processes of care and outcomes of critical illness in a resource-limited setting. METHODS: We performed a retrospective cohort study of 5332 patients referred to the ICUs at 2 public hospitals in South Africa using the country's first published multicenter electronic critical care database. We assessed the association between multiple ICU capacity strain metrics (ICU occupancy, turnover, census acuity, and referral burden) at different exposure time points (ICU referral, admission, and/or discharge) with clinical and process of care outcomes. The association of ICU capacity strain at the time of ICU admission with ICU length of stay (LOS), the primary outcome, was analyzed with a multivariable Cox proportional hazard model. Secondary outcomes of ICU triage decision (with strain at ICU referral), ICU mortality (with strain at ICU admission), and ICU LOS (with strain at ICU discharge), were analyzed with linear and logistic multivariable regression. RESULTS: No measure of ICU capacity strain at the time of ICU admission was associated with ICU LOS, the primary outcome. The ICU occupancy at the time of ICU admission was associated with increased odds of ICU mortality (odds ratio = 1.07, 95% confidence interval: 1.02-1.11; P = .004), a secondary outcome, such that a 10% increase in ICU occupancy would be associated with a 7% increase in the odds of ICU mortality. CONCLUSIONS: In a resource-limited setting in South Africa, ICU capacity strain at the time of ICU admission was not associated with ICU LOS. In secondary analyses, higher ICU occupancy at the time of ICU admission, but not other measures of capacity strain, was associated with increased odds of ICU mortality.

Prophylactic Phenylephrine Infusions to Reduce Severe Spinal Anesthesia Hypotension During Cesarean Delivery in a Resource-Constrained Environment.

Phenylephrine infusions are considered as standard management for obstetric spinal hypotension, but there remains reluctance to implement them in resource-limited contexts. This prospective, alternating intervention study of patients undergoing elective or urgent cesarean delivery under spinal anesthesia compared a vasopressor bolus strategy to fixed-rate, low-dose prophylactic phenylephrine infusion with supplemental boluses. The primary outcome was the incidence of severe hypotension (mean arterial pressure <70% baseline or systolic blood pressure <80 mm Hg). Fewer patients receiving prophylactic phenylephrine infusions had severe hypotension (47.4% [n = 120/253] vs 62.1% [n = 157/253], P = .001, estimated relative risk 0.84, 95% confidence interval, 0.69-1.02), with no significant difference in the rate of hypertension (15% [n = 39/253] vs 11% [n = 27/253], P = .11, estimated relative risk 1.39, confidence interval 0.87-2.20). Guidelines for resource-constrained settings should consider a fixed, low-dose phenylephrine infusion in combination with rescue vasopressor bolus therapy.

An audit of paediatric pain prevalence, intensity, and treatment at a South African tertiary hospital.

INTRODUCTION: Pain in paediatric inpatients is common, underrecognised, and undertreated in resource-rich countries. Little is known about the status of paediatric pain prevention and treatment in low- and middle-income countries. OBJECTIVES: This audit aimed to describe the prevalence and severity of pain in paediatric patients at a tertiary hospital in South Africa. METHOD: A single-day prospective observational cross-sectional survey and medical chart review of paediatric inpatients at Grey's Hospital, Pietermaritzburg, South Africa. RESULTS: Sixty-three children were included, and mean patient age was 9.7 years (SD 6.17). Most patients (87%) had pain during admission, with 29% reporting preexisting (possibly chronic) pain. At the time of the study, 25% had pain (median pain score 6/10). The worst pain reported was from needle procedures, including blood draws, injections, and venous cannulation (34%), followed by surgery (22%), acute illness/infection (18%), and other procedures (14%). Pharmacological treatments included WHO step 1 (paracetamol and ibuprofen) and step 2 (tramadol, tilidine, and morphine) analgesics. The most effective integrative interventions were distraction, swaddling, and caregiver participation. Although a pain narrative was present in the majority of charts, only 16% had documented pain intensity scores. CONCLUSION: The prevalence of pain in hospitalised children in a large South African Hospital was high and pain assessment inadequately documented. There is an urgent need for pain education and development of guidelines and protocols, to achieve better pain outcomes for children. This audit will be repeated as part of a quality-improvement initiative.

Priority areas for cannabis and cannabinoid product research in South Africa.

No abstract available.