Rachs-1 system in risk stratification for congenital heart disease surgery outcome.

BACKGROUND: The Risk Adjustment in Congenital Heart Surgery (RACHS-1) system has been used as a benchmark to compare surgical results in developed countries. Its ability to stratify postoperative mortality risk has been validated in several developed countries, however, this has not been examined in a developing country. OBJECTIVES: To assess the ability of the RACHS-1 system to stratify postoperative mortality risk in a developing country. DESIGN: Retrospective study over a five year period between 1st January 2002 and 31st December 2006. SETTING: Kenyatta National Hospital, a teaching and referral hospital in Nairobi, Kenya. SUBJECTS: Three hundred and seventeen consecutive operations were performed on 313 patients aged between 0.25 and 204 months. RESULTS: Operations were performed in RACHS-1 categories 1, 2, 3 and 4 with hospital mortalities of 2.5%, 16.9%, 29.4% and 50% respectively. The difference in mortality between categories 1 and 2 was significant (p-value of 0.0003), however, the difference in mortality between categories 2 and 3 and categories 3 and 4 was not significant (p-values 0.193 and 0.67 respectively). CONCLUSIONS: The RACHS-1 system did not adequately stratify risk in a low case load setting. The use of the RACHS-1 method as a benchmark to compare surgical results of paediatric cardiac surgery services in developing countries may be limited.

Risk of conjunctival contamination from blood splashes during surgery at the Kenyatta National Hospital, Nairobi.

OBJECTIVES: To determine the utilisation rate of design specific eye protection by surgeons and to assess the risk of conjunctival contamination with blood splashes during surgery. DESIGN: Cross sectional, observational study. SETTING: The theatre suite of Kenyatta National Hospital, Nairobi SUBJECTS: Surgeons from all specialties operating in the theatre suite. RESULTS: The minority of surgeons, 5.2% utilised protective eye goggles compared to 3.5% of assistants. Prescription eye spectacles were the most common form of eye protection at 41.9 and 20.9% respectively for surgeons and their assistants. The contamination rate for provided protective eye wear was 53.1% with the average number of droplets being 2.48 per procedure for the principal surgeon. The duration of surgery and the use of power tools influenced the contamination rate. CONCLUSIONS: The utilisation rate of design specific protective eye wear is low and with a significant risk of conjunctival contamination, changes in attitudes and practices are needed to increase utilisation.

Management pathway for congenital heart disease at Kenyatta National Hospital, Nairobi.

BACKGROUND: Congenital heart disease (CHD) is a significant cause of death amongst infants. The timing of treatment in relation to the natural history of the disease correlates with the treatment outcome. OBJECTIVES: To determine the age at first suspicion of CHD, the age at confirmation of the diagnosis of CHD and the percentage follow-up at the first post diagnosis out patient clinic and to determine the influence of patient's sex, parental income and parental education have on the MP. DESIGN: A five year retrospective study. SETTING: Kenyatta National Hospital between January 1st 2000 and December 31st 2004. SUBJECTS: Two hundred and fourteen patients were studied. RESULTS: The overall mean age at referral to a paediatric cardiologist was 16.9 +/- 24.4 months [n = 102]. The mean age at which CHD was confirmed by echocardiography was 18.6 +/- 25.6 months [n = 202]. The mean age at which CHD was first suspected in patients from the province with the highest parental income was 9.5 +/- 5.1 months [n = 6]. The mean age at which CHD was first suspected in patients from a province with a significantly lower parent income was 19.1 +/- 23.2 months [n = 22], (p = 0. 046). The mean age at which CHD was confirmed in referred male patients was 16.0 +/- 17.6 months [n=48] and the mean age at which CHD was confirmed in referred female patients was 18.8 +/- 21.7 months [n = 52] (p = 0.25). CONCLUSION: The mean age at referral to a paediatric cardiologist was 16.9 months. This suggests that a significant number of patients may miss the opportunity to have optimal surgical intervention. Parental income appears to influence the MP, however, the level of parental education and patient sex did not.

Weight change post oesophagectomy for carcinoma of oesophagus.

OBJECTIVE: To determine the pattern of weight changes observed in postoperative oesophagectomy patients at the Kenyatta National Hospital and evaluate weight change with selected preoperative variables. DESIGN: A prospective analysis of post-operative weight change of patients following oesophagectomy utilising body mass index (BMI). SETTING: The cardiothoracic unit, Kenyatta National Hospital, Nairobi. SUBJECTS: All patients with oesophageal cancer, with a confirmed histological diagnosis of squamous cell carcinoma and discharged post oesophagectomy. INTERVENTION: Oesophagectomy. MAIN OUTCOME MEASURE: Changes observed in the BMI during respective clinic visits. RESULTS: Fifty nine patients were enrolled into the study with a mean preoperative weight of 50.4 kilograms and mean BMI of 19.4 kg/m2 (+/- 4.3). Sixty seven point seven percent of patients preoperatively fell into the underweight category (less than 20kg/m2); normal were 16 patients (27.1%) and overweight included six patients (10.2%). Postoperatively the majority of patients continued to loose weight and the overall average BMI at the study endpoint was calculated as 18.0 kg/m2 (+/- 3.2). This value was significantly lower compared with the preoperative value (p = 0.004). None of the selected variables showed a significant relationship to the postoperative weight change pattern observed, though the patients gaining weight postoperatively had an apparently better survival pattern compared to the others. Analysis of the selected variables versus weight change pattern (gain, stable or weight loss) showed no significant relationships. CONCLUSION: This study population presented a lower initial preoperative weight compared to similar studies from the developed world, with the majority being underweight. The majority of patients exhibited a continued postoperative weight loss with only a small number showing any weight gain. The study unfortunately was not able to demonstrate association of weight change with any of the selected variables.

Post-infarction ventricular septal defect in Nairobi: case report.

Post infarction ventricular septal defect results from perforation of the ventricular septum secondary to ischaemic injury following myocardial infarction. Ischaemic heart disease till recently was thought to be an uncommon disease in this part of the world, but now more and more cases are being seen as a result of the changes in thelife styles of the population in this country and in the developing world in general. This is a case report of the first case of post infarction ventricular septal defect presenting to surgery for repair in this country.