Prospective cohort study of referred Malawian children and their survival by hypoxaemia and hypoglycaemia status

Objective To investigate survival in children referred from primary care in Malawi, with a focus on hypoglycaemia and hypoxaemia progression. Methods The study involved a prospective cohort of children aged 12 years or under referred from primary health-care facilities in Mchinji district, Malawi in 2019 and 2020. Peripheral blood oxygen saturation (SpO2) and blood glucose were measured at recruitment and on arrival at a subsequent health-care facility (i.e. four hospitals and 14 primary health-care facilities). Children were followed up 2 weeks after discharge or their last clinical visit. The primary study outcome was the case fatality ratio at 2 weeks. Associations between SpO2 and blood glucose levels and death were evaluated using Cox proportional hazards models and the treatment effect of hospitalization was assessed using propensity score matching. Findings Of 826 children recruited, 784 (94.9%) completed follow-up. At presentation, hypoxaemia was moderate (SpO2: 90­93%) in 13.1% (108/826) and severe (SpO2: < 90%) in 8.6% (71/826) and hypoglycaemia was moderate (blood glucose: 2.5­4.0 mmol/L) in 9.0% (74/826) and severe (blood glucose: < 2.5 mmol/L) in 2.3% (19/826). The case fatality ratio was 3.7% (29/784) overall but 26.3% (5/19) in severely hypoglycaemic children and 12.7% (9/71) in severely hypoxaemic children. Neither moderate hypoglycaemia nor moderate hypoxaemia was associated with mortality. Conclusion Presumptive pre-referral glucose treatment and better management of hypoglycaemia could reduce the high case fatality ratio observed in children with severe hypoglycaemia. The morbidity and mortality burden of severe hypoxaemia was high; ways of improving hypoxaemia identification and management are needed.

Is intravenous long-acting opioid (morphine) associated with more postoperative hypoxemia than short-acting opioid (fentanyl) after non-cardiac surgery?

Background: morphine is a potent analgesic in decreasing postoperative pain; however its use is accompanied by many complications especially respiratory one. On the other side, fentanyl titration may cause less postoperative respiratory complications. Objective: To compare between intravenous long-acting opioid (Morphine), and short-acting opioid (Fentanyl) regarding postoperative hypoxemia after non-cardiac surgery. Patients and methods: A prospective randomized clinical study done on 52 patients, they were divided equally into two groups: Group M (Morphine) received (0.1mg/kg), and Group F (Fentanyl) received (1ug/kg) on induction, and supplemented by effective rescue analgesia. When postoperative VAS score ≥4 , patients in Group M received 5mg morphine as bolus ,and re-assess pain every 5 min to give another bolus ( the total allowed dose was 15mg/3-4h).For Group F 50ug fentanyl was given as a bolus ,and could be repeated (total allowed dose was 100 ug/1-2h.). Result(s): There were no significant difference between two groups as regard respiratory rate (RR) nor peripheral O2 saturation (SPO2) (P value0.05). Conclusion: Intravenous morphine as effective rescue analgesic is not associated with more postoperative hypoxemia, or respiratory depression than fentanyl

Hypoxaemia on Arrival in a Multidisciplinary Intensive Care Unit

BACKGROUND:Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is; however; potentially preventable.OBJECTIVE:To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication.METHOD:A retrospective observational study was conducted at King Edward VIII Hospital; Durban; South Africa; from May 2013 to February 2014.RESULTS:Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (petlt;0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring; transfer by an intern as opposed to other medical/paramedical staff; and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02).CONCLUSION: Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring

Prevalence and predictors of hypoxaemia in hospitalised children at the emergency unit of a resource constrained centre

Background: Hypoxaemia is often poorly detected and treated in emergently-ill children in resource-poor centres because of the non-availability of pulse oximeters and similar facilities to detect it. This study sets out to determine the prevalence and simple predictors of hypoxaemia among children with or without respiratory features at the emergency unit of the Wesley Guild Hospital, Ilesa, Nigeria.Methods: Children aged one month to 14 years were consecutively recruited and prospectively studied over an eight month period. All the children had their peripheral oxygen saturation (SpO2) measured at presentation using a portable pulse oximeter (Nellcor(R) N-200, USA) and hypoxaemia was defined as SpO2 < 90%. Relevant history and examination findings were compared among hypoxaemic and nonhypoxaemic children. Multivariate analysis was used to predict the presence of hypoxaemia.Results: Four hundred and two children were recruited with male to female ratio of 1.3:1 and105 (26.1) presented with respiratory features. Eighty three (20.6%) were hypoxaemic including 40 (38.1%) of those with respiratory features at admission. Infancy, chest in-drawing, cyanosis and grunting were associated with hypoxaemia (p < 0.05) among those with respiratory features, while infancy, pallor and tachycardia were significant among those with no respiratory features. Grunting (OR = 7.875; 95% CI=1.029- 15.797; p = 0.045) and Cyanosis (OR =13.579; 95% CI = 1.360- 14.379; p = 0.009) independently predict hypoxaemia among the children with respiratory features.Conclusion: Hypoxaemia occurred in approximately one out of five ill children admitted to the emergency unit of the WGH, Ilesa and was significantly associated with mortality. Emergently ill children with cyanosis and grunting especially infants should preferentially be placed on oxygen therapy even when hypoxaemia cannot be confirmed

Assessment of Clinical Features and Haematocrit Levels in Detection of Hypoxaemia in Sick Children

This cross-sectional study was to determine the prevalence of hypoxaemia among sick children in EnuguState University Teaching Hospital, Enugu, Nigeria and correlate it with clinical features and haematocrit levels.Ninety-two (92) sick children aged 2­48 months hospitalised at the teaching hospital were recruited after obtaining consent from their carers.The prevalence of hypoxaemia in this study, defined by oxygen saturation of less than 90%, was 13%, and was not dependent on age or sex. A higher proportion of subjects with hypoxaemia had tachypnoea (81.8%),compared with those without (18.2%) (χ² = 1.69; p=0.19).The sensitivity of using tachypnoea alone to predict hypoxaemia was 18.4% while the specificity was 92.3%.The presence of hypoxaemia predicted poor outcome 66.7% of those that died had hypoxaemia. The difference was statistically significant (χ2= 17.9; p=0.00).Tachypnoea had a poor sensitivity although good specificity in predicting hypoxaemia. Presence of hypoxaemia connotes poor prognosis. We recommend that finger pulse oximeters, which are cost effective,should be routinely available at hospitals in developing countries, so that hypoxaemia can be detected earlier and more intensive management instituted

Effect of Chronic High Altitude Hypoxia on Foetal and Maternal Juxta-Alveolar Distal Pulmonary Smooth Muscle Cells Actin and Calponin Organisation and Growth Profiles

BACKGROUND: The effect of chronic high altitude hypoxia (CHAH) in the juxta-alveolar region near the air-blood interface is unknown because of the experimental inaccessibility of this region. OBJECTIVE: To examine primary cultures of digested juxtaalveolar smooth muscle cells for hypoxia-induced changes. METHODS: Smooth Muscle Cells (SMCs) obtained by dispase digestion of the extreme lung parenchyma were used to study the effect of CHAH in the juxta-alveolar region and foetal and maternal cells were compared. Pulmonary venous SMCs were also obtained from dissected 5th to 7th generation levels pulmonary veins (0.5 mm). Fluorescence tagged antibodies against alpha smooth muscle actin (alpha SMA) and calponin respectively were used as markers to identify cellular structural differences by routine immunohistochemistry. Comparison of the functional integrity of the cells was made using their growth profiles obtained by radiolabeled thymidine incorporation and liquid scintillation counting. RESULTS: Marked differences were seen in juxta-alveolar SMCs obtained by digestion of extreme lung parenchyma of hypoxic sheep. Hypoxic adult sheep cells showed increased filamentation. Hypoxic foetal sheep cells showed internal restructuring and disorganization of both alpha-SMA and calponin filaments. The growth profiles of juxta-alveolar SMCs showed that the hypoxia-affected cells of both the foetus and adult sheep had a fast initial growth rate peaking at 48h while their normoxic equivalents had a steadier growth rate peaking at 72h. Hypoxia-affected cells showed contact inhibition at ~50subconfluence and apoptosis by 48h. CONCLUSION: Chronic high altitude hypoxia causes both phenotypical and functional changes in pulmonary smooth muscle cells near the air/blood interface

Reversible Cortical Blindness Following Successful Surgical Repair of Two Wounds in the Heart

This report describes a case of cortical blindness that followed successful surgical repair of two stab wounds in the heart in a 29-year old Libyan man. The patient presented in a state of pre cardiac arrest (shock and low cardiac output status); following multiple chest stab wounds. Chest tube was immediately inserted. Surgery was urgently performed suturing the two wounds; in the root of the aorta and in the left ventricle; and haemostasis was secured. Cardiac arrest was successfully prevented. The patient recovered smoothly; but 24 hours later he declared total blindness. Ophtalmic and neurological examinations and investigations that included fundoscopy; Electroencephalograms (EEGs) and Computed Tomography Scans revealed no abnormalities; apart from absence of alpha waves in the EEGs. We diagnosed the case as cortical blindness and continued caring for the patient conservatively. Three days later; the patient regained his vision gradually and was discharged on the 7th postoperative day without any remarks