The utilization of procedural sedation and analgesia at the University Teaching Hospital of Kigali, Rwanda

Introduction: In the Emergency Department (ED), safe and effective Procedural Sedation and Analgesia (PSA) is essential. The professional performing procedural sedation has to be prepared to handle any potential adverse effects. Medications are used according to their availability and based on the physician’s experience and preference. Despite the common occurrence of procedural sedation in the ED, it has not previously been studied in Rwanda. The study aimed to describe procedural sedation and analgesia utilization and common adverse events at Rwanda's University Teaching Hospital of Kigali (UTH-K) ED.Methods: This study is a prospective observational study of procedural sedations done at UTH-KED. The effectiveness of sedation was evaluated using the Richmond Agitation Sedation Score (RASS) during sedation. The pain scale was assessed before and after the procedure. Categorical data were analyzed for significant differences using Chi-squared (X) tests and continuous data with Mann-Whitney (MW) tests.Results: Two hundred fifty-one patients were recruited. Seventy-two percent (72%) of patients were male with a median age of 32 years (IQR 23to 40). The most commonly used analgesics included morphine (78%) and tramadol (17%), with ketamine least used (1%). A common adverse event was hypoxia (36%), followed by hallucination (8%). No adverse events were observed in 47% of procedures. Conclusion: Our study findings suggest that although sedation in our low-resource setting did not result in serious adverse outcomes for patients, there was a much higher incidence of minor adverse events (especially hypoxia) than in higher-resource settings

Mid-arm circumference can be used to estimate children's weights

Introduction Accurate measurement of children's weight is rarely possible in paediatric resuscitation, and rapid estimates are made to ensure appropriate drug and fluid doses and equipment selection. Weight is commonly estimated from formulae based on children's age, or from their height using the Broselow tape. Foot-length and mid-arm circumference have also been suggested as the basis of weight-estimation formulae. Objectives To determine which of age, height, foot-length or mid-arm circumference had the strongest relationship with weight in healthy children, to derive a simple weight-estimation formula from the strongest correlate, and to compare its performance with existing weight-estimation tools. Methods This was a population-based prospective observational study of Hong Kong Chinese children aged 1–11 years old last birthday. Weight was measured to the nearest 0.2 kg; height, foot-length and mid-arm circumference to the nearest 0.1 cm. Multiple regression analysis was used to determine the strongest independent relationships with weight, and linear regression analysis derived a weight-estimation formula. Accuracy and precision of this formula were compared with standard age-based and height-based weight-estimation methods. Results Mid-arm circumference had the strongest relationship with weight, and this relationship grew stronger with age. The formula, weight [kg] = (mid-arm circumference [cm] − 10) × 3, was at least as accurate and precise as the Broselow method and outperformed the age-based rule in school-age children, but was inadequate in pre-school children. Conclusion This weight-estimation formula based on mid-arm circumference is reliable for use in school-age children, and an arm-tape could be considered as an alternative to the Broselow tape in this population

Validation of the APLS age-based vital signs reference ranges in a Chinese population

Reference ranges for vital signs may differ significantly among children of different ethnic origins. Aim (1) To validate the Advanced Paediatric Life Support (APLS) age-based vital signs reference ranges in Chinese children in Hong Kong. (2) To derive age-based centile curves for systolic blood pressure, heart rate and respiratory rate for Chinese children. (3) To summarize the reference ranges in a table format appropriate for applying APLS to ethnic Chinese patients. Method A cross-sectional study was performed on a population of healthy Chinese children recruited from 8 kindergartens and 6 primary schools in Hong Kong. Trained operators visit the sites to obtain measurements. Age-groups: small toddlers (12–23 months); pre-school (24–59 months); and school (60–143 months). Z-test was used to assess statistical significance for proportions of each parameter falling outside the APLS reference range. One-sample t-test was used for comparison with APLS means according to age-groups. LMS Chartmaker Pro v2.3 software was used to describe the data in centile curves. Results A total of 1353 patients (55.1% boys) were included. For heart rate, systolic blood pressure and respiratory rate respectively, 34.1%, 55.9% and 55.7% of corresponding measurements were outside the APLS age-based reference ranges. In the ‘pre-school’ and ‘school’ age-groups, the mean value for blood pressure is significantly higher, and the mean values for heart rate and respiratory rate significantly lower, in comparison to APLS mean values. Conclusion Independently derived vital signs reference ranges are more appropriate for use when applying APLS to Chinese patients in Hong Kong

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: A multicentre, prospective cohort study

Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome. Objectives To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong. Methods Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS ≥ 9 and aged ≥ 18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome. Results Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18–106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N = 177) and surviving non-responders (N = 163). However, there were significant differences between these groups and the group of patients who died (N = 60). Only 16/400 (4%) cases reported a GOSE ≥ 7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE ≥ 7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age > 65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26–40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97). Conclusion For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury < 1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score ≥ Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is ≥ Hong Kong norm