Tétanos de l'enfant au Centre Hospitalier Universitaire Mère­Enfant de Libreville, Gabon / Child tetanus at the Mother and Child University Hospital Center, Libreville, Gabon

L'objectif de cette étude était de déterminer les aspects épidémiologique, clinique, thérapeutique et évolutif du tétanos de l'enfant au service de réanimation du Centre Hospitalier Universitaire Mère-Enfant de Libreville, au Gabon. Méthodes : Etude rétrospective de type descriptif menée du 1er janvier 2019 au 31 décembre 2022. Les dossiers des enfants âgés de 0 à 16 ans, admis en réanimation pour tétanos, ont constitué la base des données. Les variables étudiées étaient épidémiologiques, cliniques, thérapeutiques et évolutives. Résultats : Parmi les 561 enfants hospitalisés en réanimation durant la période, il y'avait 12 cas de tétanos, soit une prévalence de 2,1%. Le sexe ratio était de 2. Les enfants âgés de 10 ans et plus représentaient la moitié de l'effectif (n=6). La porte d'entrée la plus retrouvée était une plaie du pied soit 50%, suivie d'une plaie céphalique dans 25% des cas. Tous les enfants avaient un état vaccinal incorrect, un trismus et des troubles d'alimentation. Le score pronostique de Dakar était à 2 chez six enfants (50%) et de 3 chez les 6 autres. Les molécules les plus utilisées étaient le Midazolam (92%), le Métronidazole (100%), le sérum et vaccin antitétanique (100%). Cinq patients (42%) ont bénéficié d'une ventilation assistée. La durée moyenne de séjour était de 13,6 jours ±9,9 et la létalité de 42%. Conclusion : le tétanos prédomine chez le grand enfant n'ayant pas de couverture vaccinale. Des mesures de sensibilisation des populations sur la vaccination antitétanique sont indispensables pour baisser la létalité.

Predictors of poor prognosis requiring intubation in COVID-19 patients admitted in Intensive Care Unit: a Congolese observational study Facteurs prédictifs de mauvais pronostic nécessitant une intubation chez les patients COVID-19 admis en unité de soins intensifs: une étude observationnelle congolaise

Context and objective In intensive care units (ICU), clinicians have little information to identify COVID-19 patients at high risk of poor prognosis requiring intubation. Considering the clinical and biological parameters of the patients during their admission to ICU, we determined the incidence of a pejorative evolution requiring intubation, and secondarily we searched among the starting parameters, which were predictors of the intubation during follow-up Methods We conducted a monocentric retrospective cohort study of adult patients admitted for moderate, severe or critical COVID-19/WHO clinical classification, during the first two waves of the pandemic in Kinshasa/DR Congo. Our primary end point was the incidence of intubation. Potential predictors of intubation were determined by the Cox regression analysis. The relative risk of death was assessed according to treatment with mechanical ventilation. (intubation) Results We included 219 patients (average age of 56.8 ±15.2 years; 75 % men), respectively 37 % in the 1st and 63 % in the 2nd wave of the pandemic.Cumulative incidence of intubation was 24% (1stwave: 26% vs 2nd wave: 24%). One-third of intubations were performed on the first 3 days versus two-thirds beyond the third day. The Cox's regression model showed that among data from the 1st day of ICU admission, those predicting intubation were: age (Hazard ratio: 1.025, CI 95%: 1.005-1.044), obesity (HR: 4.808; CI 95%: 2.660-8.696), corticosteroid therapy (HR: 0.313, CI 95%: 0.102-0.965), ROX index < 4.88 (HR: 2.024, CI 95 %: 1.003-4.080) and black race (HR: 0.502, CI 95%: 0.272-0.928). In total, 54 deaths (25 % of patients) were recorded with a higher relative risk (18.8) in intubated patients. Conclusion A quarter of COVID-19 patients admitted to ICU could worsen and be intubated. The majority of intubations were performed after the third day of admission and mortality was high. The predictors of intubation that have been identified can help anticipate management by being proactive

Éclampsie en réanimation polyvalente: facteurs déterminants du décès / Eclampsia in polyvalent intensive care unit: determinants of death

Contexte et objectif . L'éclampsie étant une cause majeure de mortalité maternelle, notre objectif était de décrire l'évolution et identifi er les facteurs prono stics des éclampsies admises en réanimation. Méthodes. Etude rétrospective, analytique portant sur les cas d'éclampsie admis du 01 janvier 2015 au 31 décembre 2019. Les données étudiées étaient d'ordres épidémio-clinique, thérapeutique et évolutif. L'analyse a été réalisée à l'aide du test de Fisher au seuil de signifi cativité 5%. Résultats. Soixante-douze (72) dossiers ont été retenus et la prévalence était de 5,46%. L'âge moyen était de 23,87 ans ± 1,52. Les crises étaient survenues en anté partum à 52,78%. Une césarienne a été réalisée dans 65,28% des cas. Les anticonvulsivants les plus utilisés étaient le phénobarbital (51,39%), le sulfate de magnésium (38,89%) et le diazépam (26,39%). La ventilation mécanique a été indiquée dans certains cas : 38,89%. Nous avons observé des complications dans 59,72% des cas dont les plus fréquentes étaient le syndrome d'hémolyse, de cytolyse hépatique et de thrombopénie (30,56%), l'état de mal convulsif (25%) et l'insuffi sance rénale aigüe (19,44%). La mortalité était de 12,5%. Les facteurs de mauvais pronostic étaient la ventilation mécanique et la présence de certaines complications. Les facteurs améliorant le pronostic étaient l'éclampsie du post partum et le sulfate de magnésium. Conclusion. Les complications étaient fréquentes, la mortalité élevée et les facteurs pronostics concernaient la période de survenue des convulsions, le type de complications associées et les moyens de prise en charge

Context and objective. Eclampsia being a major cause of maternal mortality, our objective was to describe the evolution and identify the prognostic factors of eclampsia admitted to intensive care. Methods. R0etrospective, analytical study of cases of eclampsia admitted from January 1, 2015 to December 31, 2019. The data studied were epidemiologicalclinical, therapeutic and evolutionary. The analysis was carried out using Fisher's test at the 5% signifi cance level. Results. 72 fi les were retained and the prevalence was 5.46%. The mean age was 23.87 years ± 1.52. The seizures had occurred antepartum in 52.78%. A caesarean section was performed in 65.28% of cases. The most used anticonvulsants were phenobarbital (51.39%), magnesium sulphate (38.89%) and diazepam (26.39%). Mechanical ventilation was indicated in some cases: 38.89%. We observed complications in 59.72% of cases, the most frequent of which were hemolysis syndrome, hepatic cytolysis and thrombocytopenia (30.56%), convulsive status epilepticus (25%) and insufficiency acute renal (19.44%). Mortality was 12.5%. The poor prognostic factors were mechanical ventilation and the presence of certain complications. The factors improving the prognosis were postpartum eclampsia and magnesium sulphate. Conclusion. Complications were frequent, mortality high and the prognostic factors concerned the period of onset of the seizures, the type of associated complications and the means of management.

Test positivity and clinical presentation of COVID-19 in Mozambican infants hospitalized during the second wave of the pandemic in 2021

Introduction: during the second wave of the COVID-19 pandemic in Mozambique, there was a surge in pediatric hospitalizations at a time when there was relatively little evidence, but significant concern about clinical outcomes in African children, particularly in higher-risk infants requiring, and health system capacity to respond. Methods: a retrospective cohort study was conducted for patients 1-12 months of age admitted to the Breastfeeding ward at Hospital Central de Maputo from January-February 2021. All had routine SARS-CoV-2 PCR testing performed. For patients with positive results, hospital charts were retrospectively reviewed. Descriptive analyses were performed. Results: of 209 patients that had SARS-CoV-2 PCR testing performed, 102 (48.8%) received results, of which 37 (36.3%) were positive. Positive results were received prior to discharge for 14 patients (37.8%). Median duration of hospitalization was 3 days. There were two deaths in COVID-positive patients (5.4%), both with complex comorbidities. For the 35 COVID-19 positive patients whose charts were located, the principal admission diagnosis was respiratory for 22 (62.9%), and 14 (40.0%) had oxygen saturation <94% at admission. The white blood cell count was >12.0 x 103cells/mL in 10 patients (28.6%) and the most common abnormal finding on chest radiograph was peribronchial thickening (38.5% of patients with results). Oxygen therapy was needed for 20 patients (57.1%). Conclusion: the majority of infants with COVID-19 had a mild, short-duration respiratory illness that did not exceed ward capacity for care, including oxygen treatment. Laboratory capacity for PCR testing was overwhelmed, delaying the return of results and complicating inpatient infection control measures.

Intensive care unit deaths among neurosurgery patients in a tertiary hospital in South Western Nigeria

Neurosurgical patients are the most critical ICU admissions. While advancements in neurosurgical ICUs (NICU) have improved outcomes of care globally, ICU mortality remains a major clinical issue in developing nations. This study evaluates ICU mortalities of neurosurgical patients in a general ICU setting at the UNIOSUN Teaching Hospital, Osogbo, Nigeria. Method: Case records of neurosurgery patients who died in the ICU of UNIOSUN Teaching Hospital, Osogbo, South-Western, Nigeria from June 2012 to May 2022 were reviewed. Simple descriptive statistics of data on demographics, clinical diagnoses, management and outcome were done. Results: Mortality rate was 38.9% (84 of 216 admissions). Males were 67(79.8%) and the mean age was 41.5years (Range: 2-85years). The average duration of ICU stay was 3.5days (Range: 30minutes-20days). Most patients had severe traumatic brain injury (TBI) (62, 73.8%). This was followed by cerebrovascular diseases (12, 14.3%) and brain tumours (6, 7.1%). Two had brain abscess. One patient each had mixed subacute/chronic subdural haematoma and severe cervical spondylotic myelopathy. Of the 69 whose case files were found, 7(10.1%) had a diagnosis of brainstem death before eventual 'final' death after an average of 13.5 additional hours on mechanical life support. The identified secondary causes of death included raised ICP, sepsis, primary surgical haemorrhage, seizures, acute kidney injury, malignant hypertension, poor glycaemic control and aggressive blood pressure lowering. Only 1 patient had autopsy. Conclusion: Most ICU mortalities among neurosurgical patients were from severe TBI. The establishment of NICU is necessary to improve outcome of care of neurosurgical patients

Causes de décès en milieu de réanimation polyvalente au Centre Hospitalier Universitaire Analakininina, Madagascar / Causes of death in the intensive care unit Of the Analakininina teaching hospital, Madagascar

Background: Intensive Care Unit unit is taking care the serious patients whose vital prognosis is engaged. Death remains the main fear of those patients who are admitted to intensive care. The main objective of our study was to identify the causes of death in the intensive care unit at the Analakininina teaching hospital, Toamasina, madagascar. Methods: This was a descriptive, retrospective study carried out from January 1, 2019 to June 30, 2019. Results: We had identified 110 cases of death with a high male prevalence and a sex ratio of 1.75. The average age was 48.73 +/- 17.60 years. The main reason for admission was disturbance of consciousness in 63.64% of cases with 24.45% of severe coma. Regarding the causes of death, a total of 25 diagnosis were made. The shock states represented 30% of the causes of death of which 69% were septic, 18% cardiogenic and 15.15% hypovolemic. Next, stroke accounted for 28%, cerebral malaria 7.27% and diabetic coma accounted for 5.45% of causes of death. The average length of hospital stay was 1.91 days. Conclusion: Our study provides a better understanding of the causes of death of patients in the intensive care unit. These data can point towards initiatives to improve the quality of care

HIV exposure and its association with paediatric ICU outcomes in children admitted with severe pneumonia at Chris Hani Baragwanath Academic Hospital, South Africa

Background. Pneumonia is one of the leading causes of under-5 death in South Africa and accounts for a substantial burden of paediatric intensive care unit (PICU) admissions. However, little is known about PICU outcomes in HIV-exposed uninfected (HIV-EU) children with pneumonia, despite the growing size of this vulnerable population. Objectives. To determine whether HIV exposure without infection is an independent risk factor for mortality and morbidity in children admitted to PICU with pneumonia. Methods. This retrospective review included all patients with pneumonia admitted to the PICU at Chris Hani Baragwanath Academic Hospital between 1 January 2013 and 31 December 2014. Patients were classified as HIV-unexposed (HIV-U), HIV-EU and HIV-infected. Medical records were reviewed to determine survival to PICU discharge, duration of PICU admission and duration of mechanical ventilation. Survival analysis was used to determine the association between HIV infection/exposure with mortality, and linear regression was used to examine the association with length of stay and duration of mechanical ventilation. This study included 107 patients: 54 were HIV-U; 28 were HIV-EU; 23 HIV-positive; and 2 had an unknown HIV status. Results. Overall, 84% (n=90) survived to PICU discharge, with no difference in survival based on HIV infection or exposure. Both HIV-EU and HIV-U children had significantly shorter PICU admissions and fewer days of mechanical ventilation compared with HIV-infected children (p=0.011 and p=0.004, respectively). Conclusion. HIV-EU children behaved similarly to HIV-U children in terms of mortality, duration of PICU admission and length of mechanical ventilation. HIV infection was associated with prolonged length of mechanical ventilation and ICU stay but not increased mortality.

Knowledge and Practice about Glasgow Coma Scale Assessment among Nurses Working in Adult Intensive Care Units of Federal Public Hospitals in Addis Ababa, Ethiopia: A Cross-Sectional Study

The Glasgow Coma Scale is a dependable and objective neurological assessment instrument used for determining and recording a patient's level of consciousness. Therefore, the knowledge, practice, and factors affecting Glasgow coma scale evaluation among nurses working in adult intensive care units of federally administered hospitals in Addis Ababa, Ethiopia, were investigated. METHODS: From April 4 to 24, 2020, 121 Adult Intensive Care Unit nurses at Ethiopian federal hospitals participated in an institutional-based cross-sectional survey with a standardized selfadministered questionnaire. The information was entered into Epidata version 3.1 and then exported to SPSS version 25.0 for analysis. Bivariable and multivariable logistic regressions were used to examine the relationships between independent and dependent variables. RESULT: According to this study, nurses working in the Adult Intensive Care Unit of federal hospitals in Addis Ababa, Ethiopia, had poor knowledge (51.2%) and poor practice (62%) of the Glasgow Coma Scale's basic theoretical notions and competencies. Furthermore, the education and gender of nurses were linked to their level of knowledge and clinical practice. Being a male and having a master's degree were both significantly linked with knowledge (AOR = 4.13, 95% CI: (1.87­9.1)), (AOR=7.4, 95% CI: (1.4-38)) and practice (AOR = 2.7, 95% CI: (1.2­6)), (AOR = 10.4, 95% CI: (2.0­53)) respectively. CONCLUSION: The findings from this study showed that nurses had poor knowledge and application of practice-related clinical scenarios on the Glasgow Coma Scale

The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa

Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce. Objective. To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases. Methods. A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated. Results. Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes. Conclusion. The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study

Strategies to enhance resilience to cope with workplace adversities post-COVID-19 among ICU nurses

Background: It is critical for intensive care unit (ICU) nurses to develop resilient coping strategies to cope with workplace adversities. The coping strategies will mitigate the development of maladaptive psychological disorders prone to working in a stressful environment. Objectives: The aim of this study is to analyse previous literature conducted on strategies that enhance resilience in ICU nurses to cope with workplace adversities beyond the coronavirus disease 2019 (COVID-19) pandemic. The study was conducted by examining all available global literature in the context of the aim of the study. Method: An integrative literature review was chosen for the study. Purposive sampling method was used to select the relevant databases to answer the review question, namely Google Scholar, EBSCOhost, Medline and Nursing/Academic Edition. The search terms used were 'strategies', 'resilience', 'intensive care unit nurses', 'coping', 'workplace adversities', 'beyond COVID-19' and post 'COVID-19'. Results: Three themes emerged from the study, namely promoting personal attributes, effective relational support and active psychological support. Conclusion: Enhancing resilience among ICU nurses requires both intentional individualised care from the ICU nurses and a systematic approach by nursing management that will meet the psychological needs of ICU nurses when working in a stressful ICU environment.Contribution: The findings of the review have highlighted specific strategies of improving resilience in ICU nurses, which can ultimately create a safe working environment in the ICU.

In-hospital interventions to promote relational practice with families in acute care settings: A scoping review

Relational practice is characterised by genuine interaction between families and healthcare professionals that promotes trust and empowerment. Positive clinical outcomes have been associated with relational practice. To assess and examine in-hospital interventions designed to promote relational practice with families in acute care settings of emergency departments, intensive care units and high care units. The preferred reporting Items for Systematic Reviews and Meta-Analyses guidelines informed the design of this scoping review. To identify relevant studies, databases (Academic Search Complete; CINAHL; PubMed; PsyInfo) and the search engine Google Scholar were searched using terms for core elements of relational practice and family engagement. Of the 117 articles retrieved, eight interventional studies met the search criteria. The interventions focused on relational practice elements of collaborating with and creating safe environments for families, whilst only one addressed healthcare professionals being respectful of families' needs and differences. In relation to the nature of engagement of families in interventions, the focus was mainly on improving family functioning. Family engagement in the interventions was focused on involving families in decision-making. The scoping review revealed a limited number of in-hospital interventions designed to promote relational practice with families in acute care settings. Further research is encouraged to develop such interventions. Contribution: The scoping review has highlighted specific elements of relational practice that have been overlooked in the mapped interventions. This provides guidance on where future interventional research may be focused.

An evaluation of challenges with the South African PMTCT HIV programme seen from the perspective of HIV-positive children admitted to the PICU

Background. Mother-to-child transmissions (MTCT) accounts for 90% of the 370 000 new HIV-positive children, globally. Despite progress in the prevention of mother-to-child transmission (PMTCT) of HIV, children still acquire HIV infection. Objective. To identify and describe the prevalence of maternal, infant and/or health system-related risk factors gleaned from the literature for HIV transmission in HIV-positive children admitted to the paediatric intensive care unit (PICU) at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa. Method. A retrospective electronic chart review identifying all HIV-positive children under 2 years admitted to the PICU at IALCH between January 2017 and December 2019 was undertaken. Individual patient records were analysed using a standardised template. Results. Of the 80 mothers and children with HIV enrolled in the present study, 38.8% (n=31/80) of mothers were diagnosed prior to pregnancy, 42.5% (n=34/80) were diagnosed during pregnancy (unsure when exactly transmission occurred), and 18.8% (n=15/80) of mothers were diagnosed after delivery. The median (range) time of antiretroviral treatment (ART) was 225 (30 - 365) days for mothers. More than half of mothers (56.3%, n=45/80) whose babies became HIV-positive had poor adherence to antiretroviral drugs (HIV viral load >1 000 copies/mL). An HIV-positive diagnosis in the children of these mothers occurred throughout infancy and early childhood, especially in the first 6 months (87.5%, n=70/80). A third of mothers practised mixed feeding. Health system deficiency, mainly via cancellation of tests without notifying healthcare workers, was typical in infants (33%; n=26/80) and mothers (68.8%, n=55/80). All others (100%) were not counselled about the importance of PMTCT and 93.8% of mothers were not counselled about the importance of follow-up. Almost all HIV-positive infants (95%, n=76) presented with severe respiratory illness, mainly severe acute respiratory distress syndrome (62.5%, n=50/80) and pneumonia with hypoxic respiratory failure (32.5%, n=26/80). The overall mortality of the cohort was 22.5% (n=18/80), and most deaths were associated with cytomegalovirus (CMV), Pneumocystis jirovecii pneumonia (PJP) or both (61.1%, n=11/18). Conclusion. This present study confirmed that a new diagnosis of HIV positivity occurs throughout pregnancy and early childhood in infants. Poor adherence to ART in mothers and their infants, poor counselling, failure to attend antenatal and postnatal care, mixed feeding, and challenged laboratory services were common modifiable factors that need addressing.

The impact of government- and institution-implemented COVID-19 control measures on tertiary- and regional- level intensive care units in Pietermaritzburg, KwaZulu-Natal Province, South Africa

Background. The COVID-19 pandemic has had a significant impact on healthcare systems globally as most countries were not equipped to deal with the outbreak. To avoid complete collapse of intensive care units (ICUs) and health systems as a whole, containment measures had to be instituted. In South Africa (SA), the biggest intervention was the government-regulated national lockdown instituted in March 2020. Objective. To evaluate the effects of the implemented lockdown and institutional guidelines on the admission rate and profile of non-COVID-19 patients in a regional and tertiary level ICU in Pietermaritzburg, KwaZulu-Natal Province, SA. Methods. A retrospective analysis of all non-COVID-19 admissions to Harry Gwala and Greys hospitals was performed over an 8-month period (1 December 2019 - 31 July 2020), which included 4 months prior to lockdown implementation and 4 months post lockdown. Results. There were a total of 678 non-COVID-19 admissions over the 8-month period. The majority of the admissions were at Greys Hospital (52.4%; n=355) and the rest at Harry Gwala Hospital (47.6%; n=323). A change in spectrum of patients admitted was noted, with a significant decrease in trauma and burns admissions post lockdown implementation (from 34.2 - 24.6%; p=0.006). Conversely, there was a notable increase in non-COVID-19 medical admissions after lockdown regulations were implemented (20.1 - 31.3%; p<0.001). We hypothesized that this was due to the gap left by trauma patients in an already overburdened system. Conclusions. Despite the implementation of a national lockdown and multiple institutional directives, there was no significant decrease in the total number of non-COVID-19 admissions to ICUs. There was, however, a notable change in spectrum of patients admitted, which may reflect a bias towards trauma admissions in the pre COVID-19 era

Pharmacological management of post-traumatic seizures in a South African paediatric intensive care unit

Background. Traumatic brain injury (TBI) is a common cause of paediatric intensive care unit (PICU) admissions in South Africa. Optimal care of these patients includes the prevention and control of post-traumatic seizures (PTS) in order to minimise secondary brain injury. Objectives. To describe the demographics of children admitted to a South African PICU, to describe the characteristics of PTS, and to describe the prophylactic and therapeutic management of PTS within the unit. Method. A 3-year retrospective chart review was conducted at the PICU of the Chris Hani Baragwanath Academic Hospital (CHBAH) in Soweto, Johannesburg, from 1 July 2015 to 30 June 2018. Results. Seventy-eight patients were admitted to the PICU, all with severe TBI. A total of 66 patient files were available for analysis. The median age of admission was 6 years (interquartile range (IQR) 4 - 9) with the majority of trauma secondary to mechanical injury (89%). Prophylactic anti-epileptic drugs (AEDs) were initiated in 44 (79%) patients. Early PTS occurred in 11 (25%) patients who received prophylaxis and 4 (33%) who did not. Three (5%) patients developed late PTS, resulting in an overall incidence of PTS of 43%. The most common seizure type was generalised tonic clonic (82%). Children diagnosed with PTS were a median of 2 years younger than those without PTS, with increased prevalence of seizures (83% v. 38%) in children below 2 years of age. Maintenance therapy was initiated in all patients consistent with recommended dosages. Of the total 167 anti-epileptic levels taken during maintenance, only 56% were within target range. Of the initial 78 patients, 8 died (10%). The median length of stay was 7 (IQR 5 - 12) and 8 (IQR 8 - 24) days longer in ICU and hospital respectively, in children with PTS. Conclusion. PTS is a frequent complication of severe TBI in children. There was considerable variation in the approach to both prophylaxis and maintenance therapy of PTS in terms of choice of agent, dosage, frequency of drug monitoring and approach to subtherapeutic levels. It is clear that more high-level studies are required in order to better inform these practices

COVID-19 in pregnant women in South Africa: A retrospective review

Background. The majority of maternal deaths in South Africa (SA) occur as a result of non-pregnancy-related infections (NPRI). Pregnancy is a known risk factor in severe COVID-19, increasing the burden of NPRI in SA. In this study, we describe the prevalence, profile and clinical outcomes of pregnant women with COVID-19 admitted to a tertiary facility.Objectives. To describe the prevalence, profile and clinical outcomes of pregnant women with COVID-19 admitted to a tertiary facility in Gauteng, SA.Methods. We performed a retrospective review of all pregnant women with COVID-19 admitted to Charlotte Maxeke Johannesburg Academic Hospital between 6 March and 30 August 2020. Data collected included demographics, medical history, obstetric history, clinical findings and laboratory variables. Outcomes assessed were mortality, admission to intensive care unit (ICU), symptomatic v. asymptomatic disease, maternal and fetal outcome and mode of delivery.Results. A total of 204 pregnant women were included in the study. Of these, 33 (16.2%) women were critically ill, with 21 (10.3%) admitted to the ICU and 3 (1.5%) deaths related to COVID-19. The median gestational age was 37 weeks and median birthweight 2 940 g. Sixty-seven women (33%) were HIV-positive, in keeping with national statistics regarding HIV in pregnancy. Caesarean section was the most common mode of delivery (n=105, 60%). However, no women underwent caesarean section for indications related to COVID-19. Conclusion. COVID-19-related mortality in our cohort was higher than that seen internationally, likely due to differences in background maternal mortality rates and difficulty in accessing care.

Risk factors and outcomes of sepsis-associated acute kidney injury in intensive care units in Johannesburg, South Africa

Background. Sepsis-associated acute kidney injury (SA-AKI) has been shown to be a significant contributor to morbidity and mortality in both children and adults with critical illness. In sub-Saharan Africa, there is a lack of information on factors associated with development of SA-AKI and outcomes after intensive care unit (ICU) admission. Objectives. To assess the rate of SA-AKI, factors associated with its development, and predictors of mortality at 90 days in critically ill patients admitted to the ICU with sepsis. Methods. This was a prospective observational study conducted at two of the biggest teaching hospitals in Johannesburg, South Africa, from 15 February 2016 to 15 February 2020. The study included consecutive patients with confirmed sepsis who were admitted to the ICU within 24 hours of admission to hospital. The primary outcome of the study was development of SA-AKI (defined according to Kidney Disease Improving Global Outcome (KDIGO) criteria), and secondary outcomes were risk factors for SA-AKI and predictors of mortality at 90 days. Multivariate logistic regression analysis was employed to determine the factors associated with SA-AKI and 90-day mortality. Results. In total, 327 critically ill patients with sepsis admitted to the ICUs were included in the study. The median (interquartile range) age was 39 (30 - 52) years, and 185 patients (56.6%) developed SA-AKI. Of these patients, blacks and whites comprised 91.0% and 6.1%, respectively, and the prevalent comorbidities were HIV/AIDS (19.3%), hypertension (14.2%) and diabetes mellitus (10.1%). Patients with SA-AKI were likely to be older and of male gender, and to have cardiovascular disease, malignancies, hypotension and a low serum albumin level. In multivariate analysis, the predictors of SA-AKI were age ≥55 years (odds ratio (OR) 2.43; 95% confidence interval (CI) 1.27 - 4.65), inotropic support (OR 3.61; 95% CI 2.18 - 5.96) and a low serum albumin level (OR 2.93; 95% CI 1.40 - 6.13). SA-AKI and need for inotropic support were respectively associated with 1.9-fold and 1.7-fold increased mortality at 90 days after ICU admission. Conclusion. SA-AKI was found to be frequent in this study in two tertiary hospital ICUs in Johannesburg, and the need for inotropic support predicted mortality after ICU admission.

The organisational response of a hospital critical care service to the COVID-19 pandemic: The Groote Schuur Hospital experience

Background. There are limited data about the coronavirus disease-19 (COVID-19)-related organisational responses and the challenges of expanding a critical care service in a resource-limited setting.Objectives. To describe the ICU organisational response to the pandemic and the main outcomes of the intensive care service of a large state teaching hospital in South Africa.Methods. Data were extracted from administrative records and a prospective patient database with ethical approval. An ICU expansion plan was developed, and resource constraints identified. A triage tool was distributed to referring wards and hospitals. Intensive care was reserved for patients who required invasive mechanical ventilation (IMV). The total number of ICU beds was increased from 25 to 54 at peak periods, with additional non-COVID ICU capacity required during the second wave. The availability of nursing staff was the main factor limiting expansion. A ward-based high flow nasal oxygen (HFNO) service reduced the need for ICU admission of patients who failed conventional oxygen therapy. A team was established to intubate and transfer patients requiring ICU admission but was only available for the first wave. Results. We admitted 461 COVID-19 patients to the ICU over a 13-month period from 5 April 2020 to 5 May 2021 spanning two waves of admissions. The median age was 50 years and duration of ICU stay was 9 days. More than a third of the patients (35%; n=161) survived to hospital discharge. Conclusions. Pre-planning, leadership, teamwork, flexibility and good communication were essential elements for an effective response. A shortage of nurses was the main constraint on ICU expansion. HFNO may have reduced the requirement for ICU admission, but patients intubated after failing HFNO had a poor prognosis.

Evaluation de la prise en charge des cas graves de COVID-19 aux soins intensifs dans un environnement à ressources limitées: expérience du centre de traitement des épidemies (CTE) d'Allada / NA

Introduction : Dans sa politique de riposte contre la pandémie liée à l'infection au SARS-COV2, le Bénin a opté pour la construction d'Hôpitaux dédiés exclusivement à la prise en charge des COVID19. Pendant la première vague de la pandémie en Afrique, les systèmes de santé n'étaient pas encore bien outillés pour faire face à cette pandémie. Nous vous rapportons l'expérience des soins intensifs du Centre de traitement des épidémies (CTE) d'ALLADA. Objectifs : évaluer la prise en charges des cas graves de COVID19 à l'USI du CTE ALLADA. Matériels et méthode : Il s'est agi d'une étude prospective, descriptive et analytique, réalisée aux soins intensifs du centre de traitement des épidémies d'ALLADA, du 1er juin au 31 Août 2020. Résultats : Quatre-vingt-quatorze malades étaient éligibles pour notre étude. L'âge moyen des malades était de 58,41 ans, le sex-ratio 1,61. Les comorbidités les plus représentatives étaient l'hypertension artérielle (70,21%), le diabète (31,91%), l'obésité morbide (21,28%) et l'asthme (15,96%). Selon le score de gravité adopté au Bénin, trente-six malades (38,30%) étaient classés cas graves grade3 et ont bénéficié d'une ventilation mécanique. La VNI était la technique de ventilation la plus utilisée (75% des cas). Le plateau technique était limité et les ressources humaines qualifiées insuffisantes. Les associations chloroquine/azithromycine ou lopinavir/ritonavir/ribavirine étaient les traitements spécifiques utilisés. La mortalité était de 27,66%. Conclusion : Malgré les conditions de travail difficiles, notamment le plateau technique limité et les ressources humaines qualifiées insuffisantes, les résultats obtenus après traitement des cas graves de COVID19 à l'USI du CTE ALLADA étaient encourageants

Introduction: To respond to the pandemic linked to the SARS-COV-2 infection, Benin has opted for the construction of hospitals dedicated exclusively to the treatment of COVID-19. During the first wave of the pandemic in Africa, health systems were not yet well equipped to deal with this pandemic. We here report the Intensive CareUnit (ICU) experience of the Epidemic Treatment Center of ALLADA (ETCA). Purpose: To assess the management of serious cases of COVID-19 in the ICU of ETCA. Materials and method: This was a prospective, descriptive and analytical study, carried out in the ICU of ETCA, from June 1 to August 31, 2020. Results: Ninety-four patients were eligible for our study. The average age of the patients was 58.41 years with a sex ratio of 1.61. The most representative comorbidities were arterial hypertension (70.21%), diabetes (31.91%), morbid obesity (21.28%) and asthma (15.96%). According to the severity score adopted in Benin, thirty-six patients (38.30%) were classified as severe grade III cases and received mechanical ventilation. Non-Invasive Ventilation (NIV) was the most used ventilation technique (75% of cases). The technical platform was limited and the qualified human resources were insufficient. Chloroquine/azithromycin or lopinavir / ritonavir/ribavirine were the specific treatments used. Mortality was 27.66%. Conclusion: Despite the difficult working conditions, especially the limited technical platform and insufficient qualified human resources, the results obtained after treatment of serious cases of COVID-19 at the ICU of ETCA were encouraging

Risk factors and interventions associated with mortality or survival in adult COVID-19 patients admitted to critical care: a systematic review and meta-analysis

Patients with confirmed COVID-19 admitted to intensive care units have a high mortality rate, which appears to be associated with increasing age, male sex, smoking history, hypertension and diabetes mellitus. Methods: A systematic review to determine risk factors and interventions associated with mortality/survival in adult patients admitted to an intensive care unit (ICU) with confirmed COVID-19/SARS-CoV-2 infection. The protocol was registered with PROSPERO (CRD42020181185).Results: The search identified 483 abstracts between 1 January and 7 April 2020, of which nine studies were included in the final review. Only one study was of low bias. Advanced age (odds ratio [OR] 11.99, 95% confidence interval [CI] 5.35­18.62) and a history of hypertension were associated with mortality (OR 4.17, 95% CI 2.90­5.99). Sex was not associated with mortality. There was insufficient data to assess the association between other comorbidities, laboratory results or critical care risk indices and mortality.The critical care interventions of mechanical ventilation (OR 6.25, 95% CI 0.75­51.93), prone positioning during ventilation (OR 2.06, 95% CI 0.20­21.72), and extracorporeal membrane oxygenation (ECMO) (OR 8.00, 95% CI 0.69, 92.33) were not associated with mortality. The sample size was insufficient to conclusively determine the association between these interventions and ICUmortality. The need for inotropes or vasopressors was associated with mortality (OR 6.36, 95% CI 1.89­21.36). Conclusion: The studies provided little granular data to inform risk stratification or prognostication of patients requiring intensive