The Southern African journal of critical care : the official journal of the Critical Care Society最新文献

Background: The use of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scoring system to predict mortality in the intensive care unit (ICU) has not been validated for use in the coronavirus-19 (COVID-19) pandemic in the South African context.

Objectives: To provide data on the outcomes and clinical characteristics of ICU patients in a regional hospital diagnosed with COVID-19. The primary objective was to measure the validity of the APACHE-II scoring system in predicting mortality in these patients. Secondary objectives included the description of clinical characteristics, potential risk factors for mortality and length of ICU stay.

Methods: This study was a single-centre, retrospective, observational cohort study conducted from 2020 to 2022. Data were obtained from electronic databases and patient records to determine diagnosis of COVID-19, demographics, comorbidities, history, clinical parameters and patient outcome. A receiver operating characteristic (ROC) analysis was performed to assess the discriminative power of the APACHE-II score in predicting mortality.

Results: A total of 96 patients with confirmed COVID-19 diagnoses had sufficient data to calculate the APACHE-II score. The observed in-hospital mortality was 57.3%, while the APACHE-II score predicted a mortality of 25%. An ROC analysis showed poor discrimination (area under the ROC curve 0.58). Patients who had increased odds of death were those with increased age: odds ratio (OR) 1.01 (confidence interval (CI) 1.00 - 1.02), and those who were peripartum: OR 4.35 (CI 1.06 - 29.30). Other factors were not significantly associated with mortality. The median (interquartile range) length of hospital stay was 5.00 (4.00 - 9.25) days.

Conclusion: The APACHE-II scoring system is a poor discriminator between death and survival in this cohort of COVID-19 ICU patients. ICU patients who were diagnosed with COVID-19 were more likely to die despite a relatively low APACHE-II score. Information regarding clinical characteristics of these ICU patients and their outcomes provides some insight into the nature of the COVID-19 pandemic.

Contribution of the study: While mortality prediction models such as the APACHE-II score are valuable in general ICU populations, their applicability to novel diseases may be limited, as evidenced during the COVID-19 pandemic. Our findings highlight the limitations of these generalized prognostic tools when applied to future emerging diseases.

Background: Strengthening emergency care at the primary healthcare (PHC) level has been identified as a strategy for improving the emergency care system, which should include the private sector as well. As the National Health Insurance Act will soon come into effect, more non-medical aid users are expected to access private healthcare facilities. There is a great need for further assessment of the emergency care capacity at private primary healthcare facilities.

Objectives: To use a standardised facility-based assessment tool to assess if private PHC facilities in Gauteng have the capacity to deliver emergency care services using the Hospital Emergency Unit Assessment Tool (HEAT).

Methods: The HEAT - a standardised tool - was used for quantitative description of the critical functions and structure of an emergency unit (EU) at any facility level of PHC facilities in a private healthcare group.

Results: More than half (n/N=10/19) of the facilities participated in the study. Facilities demonstrated adequate equipment, resources and staffing for basic emergency care despite a lack of specific skills and specialised protocols.

Conclusion: All private primary healthcare facilities met the listed infrastructure and essential equipment requirements for emergency care, including a resuscitation area; however, none of the facilities had an area specifically for triage. Common barriers to performing emergency care procedures across most facilities were due to a lack of training in emergency protocols and procedures.

Contribution of the study: This study assessed the emergency care capacity of private primary healthcare facilities in Gauteng, South Africa, finding that while facilities had adequate infrastructure and equipment for basic emergency care, they lacked specialised triage areas and staff training in emergency protocols, highlighting gaps that need addressing as more patients are expected to access private healthcare under the National Health Insurance Act.

Background: Early mobilisation (EM) is safe and feasible with positive patient outcomes in various settings. However, data from Namibia in southern Africa are lacking, and the status of intensive care unit (ICU)-based mobilisation is unknown.

Objectives: To describe the mobility practices and profiles of critically ill patients in ICUs in Windhoek, Namibia.

Methods: A retrospective, descriptive record review was conducted in two private hospitals in Windhoek. Data were extracted using a self-designed electronic data abstraction form. The primary outcomes were the profile of ICU patients and documented mobility practices. Secondary outcomes included the timing and frequency of mobilisation, physiotherapy techniques used, and adverse events during physiotherapy. Patients with incomplete datasets or illegible records were excluded.

Results: The review included charts of 870 adult patients admitted to the participating ICUs between January and December 2016. Patients were predominantly male (61.8%; n=538), with a mean (standard deviation (SD)) age of 56 (14.9) years. Most admissions were planned (66.3%; n=577), mainly for coronary angiograms (20.6%; n=179), cardiac conditions (13.0%; n=113) and cardiac surgery (10.3%; n=90). The mean (SD) length of ICU stay was 3.41 (3.3) days, and the mean duration of mechanical ventilation was 0.7 (2.1) days. The overall ICU mortality rate was 5.2% (n=45). Of the 870 patients, 352 (40.5%) received physiotherapy, with 345 of these (98.0%) being mobilised. The median (interquartile range) length of ICU stay for mobilised patients was 3 (2 - 5) days, compared with 2 (2 - 3) days for non-mobilised patients (p<0.0001). Adverse events during physiotherapy were rare, occurring in only 5 patients (1.4%).

Conclusion: EM is often implemented as part of physiotherapy practice in Windhoek ICUs; however, fewer than half of the patients in this study received physiotherapy, highlighting the need for improved implementation of EM protocols and screening for readiness to mobilise.

Contribution of the study: This study provides insights into intensive care unit (ICU) patient profiles and physiotherapy mobility practices in Windhoek, Namibia, demonstrating that early mobilisation is feasible and can be integrated into routine care. It highlights areas for improvement, including increasing physiotherapy referrals and implementing mobilisation screening. These findings can inform the development of more comprehensive, evidence-based ICU care protocols.

Background: Reduced vertical transmission of HIV has led to an increased proportion of HIV-exposed uninfected children (HEU) in South Africa. Increased infective morbidity and mortality creates a need to better understand outcomes and morbidity in this population.

Objectives: To describe and compare critical care outcomes in terms of survival and disease severity between HIV-unexposed children (HUU), HIV-exposed infected children (HEI) and HEU.

Methods: A retrospective analytical cohort study was carried out from 1 January 2017 to 31 December 2021. Paediatric intensive care unit admissions of children aged 1 month - 5 years were included. Outcomes for HEU and HEI were compared with those of HUU, with a significance threshold set at p=0.05. Multivariate logistic regression analysis was conducted.

Results: Of 1 015 children, 633 (62.4%) were HUU, 318 (31.3%) were HEU and 64 (6.3%) were HEI. Mortality was higher in HEU (15.8%; p=0.1) and HEI (17.2%; p=0.4) compared with HUU (11.4%), but this was not statistically significant. HEU and HEI were younger (p<0.001) and more frequently underweight (p<0.001). HEU (and HEI) had an increased risk of acute kidney injury (AKI) (odds ratio 1.19; 95% confidence interval 1.07 - 1.81; p=0.014) and a lower minimum estimated glomerular filtration rate (p<0.001) compared with HUU. Septic shock was more frequent in HEU (28.6%; p=0.001) and HEI (43.8%; p<0.001) compared with HUU (20.1%). HEI had more frequent mechanical ventilation (p=0.003), more prolonged mechanical ventilation (p<0.001) and lower admission haemoglobin concentrations (p<0.001) than HUU.

Conclusion: Compared with HUU, both HEU and HEI demonstrated a trend towards increased mortality, but this was not statistically significant. HEU and HEI experienced increased AKI and other morbidity.

Contribution of the study: This study provides the largest report of outcomes in HIV-exposed uninfected children (HEU) to date. The study provides new data suggesting that HEU may be at increased risk of acute kidney injury.

Background: Shock, characterised by circulatory hypoperfusion and cellular hypoxia, represents a critical medical condition requiring immediate attention. Despite its significance, there are limited data on shock incidence and outcomes, particularly within the context of Thailand.

Objectives: This retrospective observational study aimed to investigate the incidence, management and outcomes of shock patients admitted to the internal medicine department of Siriraj Hospital, a referral university hospital in Bangkok, Thailand. Additionally, the study sought to identify factors associated with mortality among these patients.

Methods: Medical records of patients admitted were reviewed. Shock cases were identified based on specific diagnostic criteria, and demographic and clinical data were extracted for analysis.

Results: A total of 125 patients were included in the study, with septic shock being the most prevalent condition (40.0%), followed by cardiogenic shock (39.2%), hypovolaemic shock (18.4%) and obstructive shock (2.4%). The overall intensive care unit (ICU) admission rate was 46.7%, varying among shock types, with cardiogenic shock patients exhibiting the highest rate. The overall 28-day mortality rate was 23.7%, with septic shock patients admitted to the ICU demonstrating the highest mortality rate (50.0%). The multivariate analysis identified factors associated with mortality, including colloid resuscitation (adjusted odds ratio (aOR) 3.10 (1.08 - 8.9), p=0.036); vasopressor dose of more than 0.2 µg/kg/min (aOR 4.38 (1.39 - 13.74), p=0.011); and renal replacement therapy (aOR 3.43 (1.04 - 11.28), p=0.043).

Conclusion: This study provides significant insights into shock incidence, management and outcomes in a tertiary referral hospital in Thailand. It also highlights challenges related to ICU bed availability and identifies predictors of mortality. Early recognition and tailored interventions are crucial for improving outcomes in shock patients.

Contribution of the study: This study provides the comprehensive evaluation of shock incidence, management and outcomes among internal medicine patients. By identifying critical care resource limitations and key predictors of mortality, the findings offer valuable insights for improving early recognition and tailored interventions in resource-constrained settings.

Background: Supervised machine learning models (SMLMs) are likely to be a prevalent approach in the literature on medical machine learning. These models have considerable potential to improve clinical decision-making through enhanced prediction and classification. In this review, we present an overview of SMLMs. We provide a discussion of the conceptual domains relevant to machine learning, model development, validation, and model explanation. This discussion is accompanied by clinical examples to illustrate key concepts.

Contribution of the study: This conceptual review provides an overview and guide to the interpretation of SMLMs in the medical literature.

Background: Procalcitonin (PCT) is used in the diagnosis of sepsis. Its capability as a prognostic marker is unclear. The association between PCT and paediatric intensive care unit (PICU) outcomes has not been investigated in the South African setting.

Objectives: To determine the association between admission PCT, and trends within 72 hours of admission, and outcomes of patients admitted to the PICU at two tertiary academic hospitals.

Methods: The study was a two-year, double centre, retrospective, analytical cross-sectional medical record review.

Results: A total of 381 participants were included in the study; 55 died and 220 required mechanical ventilation. Non-survivors had a higher median admission PCT than survivors (p<0.0001, 95% confidence interval (CI) 1.28 - 15.12). Non-survivors had a higher median PCT at 48 - 72 hours than survivors (p<0.0001, 95% CI 2.50 - 21.72). Non-survivors had less of a median decrease in PCT than survivors (p=0.22, 95% CI -0.59 - 4.72). The area under the receiver operating characteristics curve (AUROCC) for admission PCT to discriminate for mortality was 0.6702 and for the 48 - 72 hour PCT it was 0.7369. There was a positive correlation between PCT and number of ventilator days (Spearman correlation co-efficient =0.1477, p=0.0138). There was no correlation between the length of PICU stay and admission PCT (p=0.7579) or PCT change (p=0.2034).

Conclusion: Single PCT measurements display some ability to discriminate for PICU mortality. Serial PCT measurements provide greater prognostic information. Non-survivors had a significantly greater median admission PCT, median PCT at 48 - 72 hours and a lower median PCT decrease than survivors.

Contribution of the study: This study clarifies the role and limitations of procalcitonin measurements and trends in PICU outcomes.

Background: Bordetella pertussis is a highly infectious disease associated with increased mortality in young infants. Critical pertussis is defined as pertussis disease resulting in paediatric intensive care unit admission or death.

Objectives: This study describes the clinical profile, morbidity, mortality and management of children with critical pertussis admitted to a South African paediatric intensive care unit (PICU).

Study design: A retrospective analysis of children with critical pertussis admitted to the PICU over 1 year (January 2022 - December 2022).

Results: There were 1 273 PICU admissions during the study period, of which 101 (7.9%) were tested and 19 (1.5%) tested positive for B. pertussis. Of those, 13 (68.4%) were completely unimmunised, mainly owing to young age (n=9). The median (interquartile range) total duration of ventilation was 7.0 (3.0 - 21.0) days, with a maximum of 35 days. Mortality was 36.8% (n=7) in those with B. pertussis; with more deaths in HIV-exposed patients (n=3/7,42.9% v. n=3/12, 25%; p<0.001) and preterm infants (n=4/7,57.1% v. n=4/12, 33.3%; p<0.001), as well as those with septic shock (n=7/7, 100% v. n=4/7, 33.3%; p = 0.02) and acute kidney injury (n=6/7, 85.7% v. n=2/12, 16.7%; p<0.001). The maximum white cell count was significantly lower in survivors (27.75 v. 76.32; p<0.001). None of the variables was independently associated with mortality on multivariable regression.

Conclusion: Critical B. pertussis infection is associated with significant morbidity and mortality in this setting. The low rate of vaccination is a concern, and advocacy is needed to promote access to vaccination during the third trimester of pregnancy as well as strengthening current immunisation programmes. Further research is required to identify the prevalence of critical pertussis and risk factors for poor outcomes in resource-limited settings.

Contribution of the study: This study demonstrated high mortality rates in infants with critical pertussis under the age of 3 months, especially in infants who are unimmunized or partially immunized. We therefore recommend vaccination against Bordetella pertussis in the third trimester of pregnancy and stress the importance of strengthening current immunization programmes. Our study highlights the importance of describing the markers of disease severity, such as hyperleukocytosis, especially in resource constrained settings, in order to ensure timeous transfer to PICU. We recommend further research regarding these markers of disease severity as well as therapies offered such as leukoreduction or exchange transfusion.

Background: Evidence for implementation of evidence-based protocols (EBPs) in resource-constrained intensive care units (ICUs) is sparse.

Objectives: To evaluate a tailored best-practice multifaceted strategy for implementation of a validated physiotherapy EBP for the management of surgical ICU (SICU) patients. Also, to explore the physiotherapists' perceptions regarding the implementation process and factors affecting protocol adherence, guided by the Consolidated Framework for Implementation Research.

Methods: A type 2 hybrid implementation study design was applied, including all adult patients admitted over 16 months to two (control and experimental) SICUs in Western Cape Province, South Africa. The physiotherapists eligible to participate in the qualitative study (N=17) were those who participated in the implementation process and worked in the experimental SICU. The Therapeutic Index Scoring System-28 (TISS-28) and four process of care indicators (POCIs) were the primary and secondary outcomes, respectively, both analysed in Stata version 15. Thematic content analysis of textual data generated physiotherapists' perceptions of the implementation process.

Results: The intervention strategy did not result in protocol adherence, with no significant difference (p>0.05) in TISS-28 and POCI outcomes during and after implementation in the experimental unit and all phases of the control. Physiotherapists (71%; n=12/17) perceived that the process affected their thinking and clinical decision-making, but not the organisation of physiotherapy services, except for a more multidisciplinary approach to care in the experimental unit. Organisational factors (time constraints, workload/flow barriers) affected adherence, explaining the lack of practice change.

Conclusion: The importance of organisational change and support of the physiotherapy departments providing services to ICUs while also addressing the healthcare needs of a diverse group of hospitalised patients is highlighted.

Contribution of the study: The study provides insights for rehabilitation implementation in resource-constrained intensive care settings. It highlights the importance of taking the next step towards implementation in complex environments and a new approach to facilitating the uptake of evidence and ensuring sustainable change through addressing the structural and organisational aspects of physiotherapy service delivery and care, and the inclusion of a multidisciplinary team approach to the implementation of any discipline-specific evidence-based protocols in the intensive care setting.

Background: Traditionally, it was understood that children universally show greater ventilation of the non-dependent lung. Recent studies have questioned the understanding of ventilation distribution patterns in the paediatric population. There are no studies examining the effect of body position in mechanically ventilated infants/children.

Objectives: To determine the effect of body position on regional ventilation distribution in mechanically ventilated children.

Methods: Thoracic electrical impedance tomography (EIT) measurements were taken in left- and right-side lying, supine and prone positions in mechanically ventilated infants/children. Functional EIT images were produced, and regional relative tidal impedance (ΔZ) in the left, right, ventral and dorsal lung regions was calculated. The proportion of ventilation occurring in large lung regions and regional filling were also calculated.

Results: Seventeen children (n=8; 47% male) aged 6 months - 6 years are presented. Many of the children (n=8; 47%) consistently showed greater ventilation in the right lung in both side-lying positions, and in the dorsal lung region (n=6; 35%) in both the supine and prone positions. Regional filling was similar between lung regions in the different body positions.

Conclusion: Ventilation distribution in mechanically ventilated infants/children with mild lung disease is variable and similar to that of healthy spontaneously breathing infants/children.

Contribution of the study: Ventilation distribution in mechanically ventilated children with mild disease is not dissimilar to that in healthy infants and children. Positioning to optimise ventilation should be tailored to each child's responses. This study provides exploratory data describing ventilation distribution in mechanically ventilated infants and children. These data can be used to inform further research study design.