No Abstract. African Health Science Vol. 8 (1) 2008: pp. 61-6

Ojara, S

Towey, RM

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African Health Sciences Vol 8 No 1 March 2008 61Practice of intensive care in rural Africa: an assessment of data fromNorthern UgandaR.M.Towey1, S.Ojara21. Consultant Anaesthetist, 2, Medical Clinical Officer, Department of Anaesthesia and Intensive Care, St.Mary’s Hospital Lacor, POBox 180, Gulu, Uganda. Email address R.M.Towey: rmtowey@tiscali.co.uk, Email: rmtowey@tiscali.co.ukIntroductionAlthough Intensive Care Units, ICUs, may be said to havestarted in 1953 in Europe1 the great majority of hospitalsin rural sub-Saharan Africa have no such facility and inthe context of working with major limitations in finan-cial and human resources the planning of a facility in thisenvironment requires careful consideration. Life expect-ancy in many parts of Africa is about  45 years and equiva-lent to the1840s in England and Wales. Medical care inAfrica predates conditions not only before ICU care inEurope but even before the discovery of anaesthesia2and in rural sub-Saharan Africa where medical care ismore limited than the urban areas the life expectancyfigures must be even worse than those published forsub-Saharan Africa as a whole. A recent review of Inten-sive Care Units in less developed countries3 noted thelack of data available upon which planning and organis-ing such a facility in the developing world could be car-ried out.MethodA collection of data was made prospectively in St.Mary’sHospital Lacor, Gulu, Uganda over a 12 month periodfrom July 2005 to July 2006 on all patients admitted tothe ICU and stored on a spreadsheet and database by theauthors. Eighteen fields of data were stored for each pa-tient.St.Mary’s Hospital Lacor is a Church supportedprevious missionary general hospital now integrated intothe Ugandan health system in a rural area which contin-ues to have a major insecurity conflict over the last 20years. As a consequence there has been considerablebreakdown in the primary health care structures in anarea of severe deprivation. It has a bed capacity of 476beds with 4 functioning operating theatres performingabout 3,500 operations per year with specialists in medi-cine, surgery, paediatrics, oral surgery, obstetrics and gy-naecology, anaesthesia, and radiology but no specialistsin thoracic, cardiac or neurosurgery. With external sup-port the hospital patient costs are 87% subsidised. AnIntensive Care Unit was set up 10 years ago in a side-room off one of the surgical wards near the operatingtheatre and was upgraded to a purpose built unit duringthe course of the study with a bed capacity of 8 beds.There were no formally agreed criteria for admission tothe unit during the study and this remains the practicenow. The senior clinicians in anaesthesia, medicine, pae-diatrics, surgery and obstetrics could admit at any timesubject to bed availability and the patient’s clinician hadultimate clinical responsibility with the physician anaes-thetist and the clinical officer anaesthetist providing asupportive role. Apart from tetanus where the anaes-thetist was given major responsibility in clinical care therewere no written protocols. During the period of study aclinical officer was appointed with clinical responsibili-ties for the ICU alone. The trained nursing ratio was ap-proximately one nurse per 4 patients, and there werealso several assistant nurses attached to the ICU. Therewas no capacity for haemodialysis or peritoneal dialysis,no infusion pumps and no capacity for sustained ino-tropic support. There was capacity for IPPV of one andsometimes 2 patients for adults or children at any onetime. Two pulse oximeters and 2 oxygen concentratorswere available and oxygen cylinders were available butnot for long periods as the logistics of replacing emptycylinders from the nearest main city involved a five hourroad journey which was limited by other demands onhospital transport. Single lumen catheter central lineswere available most of the time from donations. Crystal-loid intravenous fluids were available at all times andoccasionally a small quantity of colloid. Pethidine,diclofenac ampicillin, gentamicin, metronidazole, chlo-ramphenicol were available at all times and with a seniorclinician’s approval a small quantity of a third generationcephalosporin.  Haemoglobin and blood glucose esti-mations were available at all times but serum electro-lytes were rarely available and blood gases were neveravailable.As there was facility for oxygen therapy both inthe paediatric ward and in the medical ward using oxy-gen concentrators transfer to the ICU for oxygen therapyalone from these wards was therefore not required. Thesemain wards usually had a functioning pulse oximeter sothat rational use of oxygen could be carried out on themain wards.African Health Sciences Vol 8 No 1 March 2008 62Table 1: Gender distribution and mortalityNumber of Died Percentagepatients mortalityMale 115 (53%) 35 30Female 103 (47%) 24 23Total 218 59 27ResultsTwo hundred a eighteen patients were admitted duringthe 12 month period of which 47% were female and53% male. The overall mortality was 27%. The mortal-ity for female patients was 23% and for male was 30%.(Table1.)The age distribution and mortality of the ICUpatients is shown in Table 2. As expected the extremes oflife have the highest mortality and demographic distri-bution reflects the large percentage of younger patientsin a developing country.Table 2: Age distribution and mortality                                   Number of   Number       Percentage                                   patients        diedNeonate                      27          14                 52One month to 5yrs      35          7                   205yrs to 18                    31          0                   018yrs to 60                  115          33                 29Over 60 years              10          5                   50Total                            218          59                 27The patients were classified into 14 diagnosticgroups and the mortality of each group is shown in Table3. The commonest diagnostic group for admission wasfor general surgical post operative stabilisation whichcomprised 33% of all admissions. When patients in thecategories of burns, obstetrics and gynaecology, oral sur-gery, foreign body in bronchus, and head injury aregrouped together then this would make 83% of all ad-missions. Medical patient admissions were very few, fivepatients during the time of the study, and the mortalitywas 40%.Table 3 Diagnosis and mortalityDiagnosis Number patients Number died % MortalityPost-op stabilisation General Surgery 72 16 22Stridor 10 1 10Closed head injury 15 4 27Open head Injury 10 4 40Post-op stabilisation Obstetrics Gynae 17 6 35Eclampsia 9 0 0Adult tetanus 11 8 73Child tetanus 6 0 0Neonatal tetanus 6 5 83Post-op oral surgery 8 0 0Burns 14 6 43Foreign body bronchus 13 0 0Medical condition 5 2 40Others 22 7 32Total 218 59 27Tetanus remains a major challenge in all areasof rural Africa with a total of 23 patients admitted with anoverall mortality of 57%. We think that the use of mag-nesium has improved the mortality from previous years.4We have classified tetanus into 3 age groups, neonatal,child and adult.  During the time of the study we had nocapacity to ventilate neonates as this is a particularly de-manding on the skills and time of both nurses and clini-cians and we had no suitable ventilator. Six neonates wereadmitted with tetanus of which 5 died. All were man-aged by sedation mainly with diazepam (diazemuls topreserve venous access as generic diazepam causes lossof venous access from phlebitis in a short time). Of thesix children (over one month to 18 years) admitted withtetanus all survived among whom 4 required long termIPPV for about 3 weeks when magnesium failed to con-trol the spasms. Eleven adults were admitted with teta-nus and 8 died. No adult patient who was given IPPVwhen magnesium failed to control the spasms survived.Long term IPPV for tetanus is a major commitment ofresources and should only be embarked upon after care-ful planning of available resources but in our experiencechildren gave good outcomes. At present with our lim-ited resources we rarely start IPPV for tetanus in theolder patient.The use of a tracheostomy tube with an innerremovable tube for cleaning (Portex code 100/810)made tracheostomy tube blockage a less common oc-currence and more easily managed. This was especiallyso as we had no means of humidification besides someAfrican Health Sciences Vol 8 No 1 March 2008 63donated disposable single use filter humidifiers. Eight-een patients had tracheostomies and 4 died from theunderlying condition. No patient died from a complica-tion of tracheostomy and both trained and assistant nursesbecame skilled at managing tracheostomy care and dur-ing the study there was no major morbidity attributed totracheostomy. Ten patients had a tracheostomy for someform of upper airway obstruction and 6 for tetanus.Causes of upper airway obstruction included trauma tothe mandible, laryngeal papillomas, Ludwigs Angina,laryngotracheobronchitis, and postoperative care of pa-tients who had had thyroidectomies for giant goitres. Itwas our preference to perform a tracheostomy than leavean endotracheal tube in situ for more than one or twodays as with limited means of humidification, limitednursing care and no ward resident anaesthetist, tubeblockage of endotracheal tubes had been a major hazardprior to this study and surgeons were available to per-form tracheostomies5.Our policy was to care for all patients with atracheostomy in the ICU in order to avoid any problemswith tube blockage on the main wards where suctionmachines are not always available. Time spent in ICU istherefore extended for some patients in a low depend-ency bed whose general condition may be good but thispolicy has meant we have had few major problems withtracheostomy tube obstruction.Table 4 : Intermittent positive pressure ventilation mortalityDiagnosis Number of patients Died Percentage mortalityChild tetanus 4 0 0Adult tetanus 4 4 100Post-op general surgey 13 7 54Post-op gynae obstetrics 6 4 67Head injury 2 1 50Epilepsy 1 0 0Total 30 16 53There were 9 patients admitted with eclampsiaall of whom survived. Unlike other areas of Sub-SaharanAfrica eclampsia is an uncommon problem in the localethnic group and when present often runs a short andmild course.Twenty one percent of admissions had centrallines placed in the internal jugular vein and 22% of ad-missions had femoral vein cannulae sited. Femoral veincannulation with central lines using a Seldinger wire wasvery useful in the longer stay patients where venous ac-cess became problematic. The equipment item of pri-mary major importance we found were oxygen concen-trators, pulse oximeters and central line cannulae.Intermittent positive pressure ventilation wascarried out on 30 patients with a mortality rate of 53%(Figure 4), and the commonest group to benefit fromIPPV was the post-operative general surgical patient with13 patients of this group given IPPV with a 54% mortal-ity. The majority of these patients were ventilated for notmore than 24 hours hours. As a general policy head in-jured patients admitted to the ICU were not intubated orgiven any IPPV as our resources were limited thoughthis policy was flexible and 2 head injured patients wereventilated with one survivor where the main indicationwas for sputum retention. In general if beds were avail-able head injured patients with a Glasgow score below12 were admitted to the ICU for close monitoring, oxy-gen therapy and nursing care only.DiscussionRural African hospitals are realising that there is a con-siderable value in setting aside some area of the hospitalfor a lower patient to nurse ratio and with added equip-ment for monitoring of patients at special risk. Oxygenconcentrators and pulse oximeters are now available evenin remote areas of rural Africa and from our experienceit seems that the patients most likely to benefit would bepost-operative surgical patients in the first instance. Inplanning an ICU in this environment it would be appro-priate to place it near the operating theatre or recoveryward. A rational use of oxygen with a sustainable supplyfrom oxygen concentrators monitored with pulseoximeters should be the first requirement6, 7. It is clini-cally very difficult to assess oxygen therapy without pulseoximetry especially in African patients where cyanosis isdifficult to assess. Central venous monitoring by cannu-lating the internal jugular vein provides an importantguide to fluid therapy especially in the hours immedi-ately after surgery as well as providing secure venousaccess and non-physician clinical officers became veryskilled in the placement of central lines.The most expensive item of equipment in theICU is the ventilator. Although low cost ventilators canbe purchased most of these are driven by oxygen cylin-ders or high pressure oxygen lines. The logistic prob-lems in rural Africa necessarily mean such machines canonly be used for very short periods of a few hours asAfrican Health Sciences Vol 8 No 1 March 2008 64obtaining a regular supply of oxygen cylinders is oftennot feasible. During the course of the study oneGlostavent machine was purchased and proved very sat-isfactory as it is powered by an electrically driven oxygenconcentrator which itself drives the ventilator8 .Our elec-tricity supply from the mains or back up generator wasonly rarely interrupted.  In our experience in the ruralAfrican environment an ICU facility can make a majorimprovement to care and should be a natural develop-ment of all hospitals. The non-physician clinical officerand non-physician anaesthetists made substantial contri-butions in clinical care and placing and managing centrallines and IPPV. The overall mortality of patients givenIPPV was 53% and urban centres in Africa have had higherrates of mortality reported5, 9. A decision of whetherIPPV should be initiated has a big impact on ICU work-load and this judgement is crucial to avoid futile effortsor to identify potential survivors. It is our impressionthat our theatre and recovery ward mortality was re-duced as our non-physician anaesthetists were encour-aged to consider IPPV in postoperative cardio-respira-tory unstable patients. The nursing morale was high de-spite the heavy workload which nurses experienced com-pared with the main wards and as a policy once nurseswere trained on the unit they were not rotated to otherwards.  The high morale was attributed to their opportu-nity to increase their skills and their observation of goodpatient outcomes in critically ill patients. Surgical pa-tients are the most likely group to benefit. In Uganda theratio of rural physician anaesthetist to population is aboutone per 5 million and although this situation is a majorhurdle to medical development it should not preventwhat can still be done with current staff to develop someform of ICU facility in rural hospitals. Comparison ofoutcomes in sub-Saharan Africa with other ICU units inthe developed world is problematic as the diagnosticcase mix is so different and in the absence of reliableblood gas analysis and other laboratory results severitysickness scores such as APACHE scores cannot be per-formed10. More work is needed to develop a clinicalsickness score relevant to African conditions in order tocompare results both within and outside Africa and toevaluate changes in therapy. The work of Waters andSinclair in designing an inexpensive clinical sickness scorerelevant to Africa needs further research if outcomes areto be compared with confidence. 11, 12.At present a practice of primary surgery andprimary anaesthesia is an acceptable concept among ru-ral clinicians and extending the concept of a primaryICU unit is a logical development.References1. Berthelsen PG, Cronqvist M, The first intensive care unit inthe world: Copenhagen 1953, Acta Anesthesiol Scand 2003;47:1190–11952. United Nations Human Development Report 20053. Dunser Martin, Baelani Inipavudu, Ganbold Lundeg, Areview and analysis of intensive care medicine in the leastdeveloped countries. Critical Care Medicine 2006; 34: (4),1234-1243,4. Attygalle D, Rodrigo N. Magnesium as first line therapyin the management of tetanus: a prospective study of 40patients. Anaesthesia 2002; 57: (8), 778-8175. Anita Oji. Intensive Care in a developing country: a reviewof the first 100 cases. Ann R Coll Surg England 1986; 68(3):122-4.6. Michael Dobson. Update in Anaesthesia 1999; Issue 10.7. Kimaro E, Towey RM. Anaesthesia in Rural Tanzania. Tropi-cal Doctor 2001; 31:102-1048. R.J.Eltringham, Fan Qiu Wei. Update in Anaesthesia 2003;Issue 169. Sinclair JR, Watters DA, Davison M. Outcome of mechanicalventilation in Central Africa. Ann R Coll Surg England.1988; 70:76–7910. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Apa-che 11: a severity of disease classification system. CriticalCare Medicine 1985; 13: 818-82911. Watters DAK, Wilson IH, Sinclair JR, Ngandu N. A clinicalsickness score for the critically ill in Central Africa. Inten-sive Care Medicine 1989; 15: 467-47012. Sinclair JR, Magee PT, Gould TH, Collins CH. A comparisonof  Apache 11 and clinical sickness score. Anaesthesia 1991;46:442-446

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Practice of intensive care in rural Africa: an assessment of data from Northern Uganda

Towey, R.M.

Ojara, S.

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Practice of intensive care in rural Africa: an assessment of data from
Northern Uganda

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Practice of intensive care in rural Africa: an assessment of data from Northern Uganda

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