Acid-Base disorders as predictors of early outcomes in major Trauma in a resource limited setting: An observational prospective study

Introduction: Mortality from trauma remains a major challenge despite recent substantial improvements in acute trauma care. In trauma care patient resuscitation to correct hypotension from volume loss still  majorly relies on use of physiological parameters such as blood pressure, pulse rate, respiratory rate,  urine output and oxygen saturation. In resource limited settings these methods may not be sufficient to detect occult tissue hypoxia and the accompanying metabolic derangements. Methods: A prospective observational study carried out at a level I urban Trauma centre; Accident and Emergency unit. Major trauma patients were consecutively recruited into the study. Venous blood samples were drawn for analysis of serum electrolytes, serum PH and anion gap. The venous blood gas findings were correlated with patients' clinical outcome at two weeks. Ethical approval was obtained.Results: Ninety three major trauma patients were recruited, patients' age ranged from 12 months to 50 years. Forty nine patients (53%) were acidotic (PH less than 7.32), 39 patients (42%) had low bicarbonate (bicarbonate level less than 21 mmol), 54 patients (58%) had high  corrected anion gap (anion gap corrected of 16 or more). Fourteen patients (15%) developed secondary organ  failure and 32 (34%) patients died. Conclusion: Metabolic acidosis is common among major trauma patients, its severity may be related to delay in initiating care. Acid base derangements were predictors of mortality among major trauma patients in this resource limited setting

Feasibility of the modified sequential organ function assessment score in a resource-constrained setting: a prospective observational study.

BackgroundSub-Saharan Africa has a great burden of critical illness with limited health care resources. We evaluated the feasibility and utility of the modified Sequential Organ Function Assessment (mSOFA) score in assessing morbidity and mortality in the National Referral Hospital's intensive care unit (ICU) for one year.MethodsWe conducted a prospective, observational cohort study on patients above 12 years of age admitted to the ICU at Mulago Hospital (Kampala, Uganda). All SOFA scores were determined at admission and at 48 h. We modified the SOFA score by replacing the PaO2/FiO2 ratio with SPO2/FiO2. The primary outcome was ICU mortality.ResultsThis ICU cohort of 118 patients had a mean age of 37 years and an ICU mortality rate of 46.6%. Non-survivors had higher initial (7.7 SD 3.8 vs. 5.5 SD 3.3; p = 0.007), mean (8.1 SD 3.9 vs 4.7 SD 2.6; p < 0.001) and highest mSOFA scores (9.4 SD 4.2 vs. 5.8 SD 3.2; p < 0.001), with an increase of 1.0 (SD 3.1) mSOFA on average after 48 h when compared to survivors (p < 0.001). The area under the receiver operating characteristic curves for each mSOFA category was: initial-0.68, mean-0.76, highest-0.76 and delta mSOFA-0.74. Multivariate logistic regression analysis showed no significant association between mSOFA scores and mortality.ConclusionOur results confirm that calculation of the mSOFA score is feasible for an ICU population in a resource-limited country. More data are needed to test for an association between mSOFA and mortality

Effect of low-dose ketamine on post-operative serum IL-6 production among elective surgical patients: a randomized clinical trial

Background: Surgery and Anesthesia cause an excessive pro-inflammatory response. Mulago Hospital is faced with staff shortage making post-operative pain management difficult.Interleukin-6 (IL-6) drives inflammatory pain, endothelial cell dysfunction and fibrogenesis. Ketamine is cheap and, readily available. We hypothesized that its attenuation of serum IL-6 was a surrogate for clinical benefit.Materials and methods: Institutional Review Board’s approval was sought and RCT was registered at clinical trials.gov (identifier number: NCT01339065). Consenting patients were randomized to receive pre-incision intravenous ketamine - 0.5mg/kg or 0.9% saline placebo in weighted dosing. Blood samples were collected and laboratory analyzed at baseline, post-operatively in PACU, 24 and 48 hours respectively.Results: We recruited 39 patients of whom 18 were randomized to the ketamine arm and 21 in the placebo arm with follow up at 24 and 48 hours. Serum IL-6 and IL-1β levels were analyzed using ELIZA assay of pre-coated micro wells. Ketamine suppressed serum IL-6 at PACU with reduced increase at 24 hours. There was no reaction in 98% of IL-1β assayed.Conclusion: Low-dose ketamine attenuated early serum IL-6 levels due to surgical response with reduced 24 hour increase, but the difference was not statistically significant and we recommend more studies.Keywords: Ketamine, post-operative inflammation, interleukin 6, interleukin 1-

Recommendations for sepsis management in resource-limited settings

PURPOSE: To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis. METHODS: The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings. RESULTS: Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included. CONCLUSION: Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries

Achieving the Recommended Endotracheal Tube Cuff Pressure: A Randomized Control Study Comparing Loss of Resistance Syringe to Pilot Balloon Palpation

Background. Both under- and overinflation of endotracheal tube cuffs can result in significant harm to the patient. The optimal technique for establishing and maintaining safe cuff pressures (20–30 cmH2O) is the cuff pressure manometer, but this is not widely available, especially in resource-limited settings where its use is limited by cost of acquisition and maintenance. Therefore, anesthesia providers commonly rely on subjective methods to estimate safe endotracheal cuff pressure. This study set out to determine the efficacy of the loss of resistance syringe method at estimating endotracheal cuff pressures. Methods. This was a randomized clinical trial. We enrolled adult patients scheduled to undergo general anesthesia for elective surgery at Mulago Hospital, Uganda. Study participants were randomized to have their endotracheal cuff pressures estimated by either loss of resistance syringe or pilot balloon palpation. The pressures measured were recorded. Results. One hundred seventy-eight patients were analyzed. 66.3% (59/89) of patients in the loss of resistance group had cuff pressures in the recommended range compared with 22.5% (20/89) from the pilot balloon palpation method. This was statistically significant. Conclusion. The loss of resistance syringe method was superior to pilot balloon palpation at administering pressures in the recommended range. This method provides a viable option to cuff inflation

Acute hypoxaemic respiratory failure in a low-income country: a prospective observational study of hospital prevalence and mortality.

INTRODUCTION: Limited data exist on the epidemiology of acute hypoxaemic respiratory failure (AHRF) in low-income countries (LICs). We sought to determine the prevalence of AHRF in critically ill adult patients admitted to a Ugandan tertiary referral hospital; determine clinical and treatment characteristics as well as assess factors associated with mortality. MATERIALS AND METHODS: We conducted a prospective observational study at the Mulago National Referral and Teaching Hospital in Uganda. Critically ill adults who were hospitalised at the emergency department and met the criteria for AHRF (acute shortness of breath for less than a week) were enrolled and followed up for 90 days. Multivariable analyses were conducted to determine the risk factors for death. RESULTS: A total of 7300 patients was screened. Of these, 327 (4.5%) presented with AHRF. The majority (60 %) was male and the median age was 38 years (IQR 27-52). The mean plethysmographic oxygen saturation (SpO2) was 77.6% (SD 12.7); mean SpO2/FiO2 ratio 194 (SD 32) and the mean Lung Injury Prediction Score (LIPS) 6.7 (SD 0.8). Pneumonia (80%) was the most common diagnosis. Only 6% of the patients received mechanical ventilatory support. In-hospital mortality was 77% with an average length of hospital stay of 9.2 days (SD 7). At 90 days after enrolment, the mortality increased to 85%. Factors associated with mortality were severity of hypoxaemia (risk ratio (RR) 1.29 (95% CI 1.15 to 1.54), p=0.01); a high LIPS (RR 1.79 (95% CI 1.79 1.14 to 2.83), p=0.01); thrombocytopenia (RR 1.23 (95% CI 1.11 to 1.38), p=0.01); anaemia (RR 1.15 (95% CI 1.01 to 1.31), p=0.03) ; HIV co-infection (RR 0.84 (95% CI 0.72 to 0.97), p=0.019) and male gender (RR 1.15 (95% CI 1.01 to 1.31) p=0.04). CONCLUSIONS: The prevalence of AHRF among emergency department patients in a tertiary hospital in an LIC was low but was associated with very high mortality. Pneumonia was the most common cause of AHRF. Mortality was associated with higher severity of hypoxaemia, high LIPS, anaemia, HIV co-infection, thrombocytopenia and being male

Effect of low-dose ketamine on post-operative serum IL-6 production among elective surgical patients: a randomized clinical trial.

Background: Surgery and Anesthesia cause an excessive pro-inflammatory response. Mulago Hospital is faced with staff shortage making post-operative pain management difficult.Interleukin-6 (IL-6) drives inflammatory pain, endothelial cell dysfunction and fibrogenesis. Ketamine is cheap and, readily available. We hypothesized that its attenuation of serum IL-6 was a surrogate for clinical benefit. Materials and methods: Institutional Review Board\u2019s approval was sought and RCT was registered at clinical trials.gov (identifier number: NCT01339065). Consenting patients were randomized to receive pre-incision intravenous ketamine - 0.5mg/kg or 0.9% saline placebo in weighted dosing. Blood samples were collected and laboratory analyzed at baseline, post-operatively in PACU, 24 and 48 hours respectively. Results: We recruited 39 patients of whom 18 were randomized to the ketamine arm and 21 in the placebo arm with follow up at 24 and 48 hours. Serum IL-6 and IL-1\u3b2 levels were analyzed using ELIZA assay of pre-coated micro wells. Ketamine suppressed serum IL-6 at PACU with reduced increase at 24 hours. There was no reaction in 98% of IL-1\u3b2 assayed. Conclusion: Low-dose ketamine attenuated early serum IL-6 levels due to surgical response with reduced 24 hour increase, but the difference was not statistically significant and we recommend more studies

Intra-operative low-dose ketamine does not reduce the cost of post-operative pain management after surgery: a randomized controlled trial in a low-income country

Background: In developing countries, post-operative pain remains underestimated and undertreated due to economic constraints, lack of awareness and limited resources. In contrast, ketamine is an effective, readily available, easy to use and inexpensive drug frequently used in poor settings. Objectives: The aim of this study was to explore the overall reduction in the medication treatment cost of acute post-operative pain by adding intra-operative low-dose ketamine to traditional intravenous morphine for surgery in a low-income country. Methods: A double blind randomized controlled trial with placebo-controlled parallel group was performed in Mulago National Hospital (Uganda). Consenting adults scheduled for elective surgery were randomized into two study arms: Group K received ketamine 0.15mg/kg bolus at induction and a continuous infusion of 0.12 mg/kg/hour till start of skin closure; Group C (control) received normal saline. Both groups received Morphine 0.1 mg/kg IV at debulking. The total medication cost was registered. NRS pain scores and other measurements such vital signs and incidence of major and minor side effects were also recorded. Results: A total of 46 patients were included. Patients\u2019 baseline characteristics were comparable in both groups. No statistically significant difference was found between the groups concerning the overall medication cost of post-operative pain management. Pain scores, patients\u2019 satisfaction in the first 24 hours after surgery and hospital length of stay were similar in both groups. Conclusion: Our results do not support the utilization of intra-operative low dose ketamine as a cost-saving post-operative pain treatment strategy for all types of surgery in low-resource settings