Outcome in Children Admitted to the First PICU in Malawi

Abstract

Objectives: Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality.

Design: Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models.

Setting: A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi.

Patients: Children admitted to PICU between August 1, 2017, and July 31, 2019.

Interventions: None.

Measurement and main results: Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality.

Conclusions: In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.

Figure 1.

Main diagnoses at admission and corresponding mortality rates. N/A = not available.

Figure 2.

Unadjusted odds ratios of mortality stratified for older children and neonates. Definitions: Age: Neonatal age less than 28 d, older children greater than or equal to 28 d; underweight: z score weight for age less than –2; post-cardiac arrest: cardiopulmonary resuscitation (CPR) prior to PICU admission/CPR reason for PICU admission; hypothermia: axillary temperature less than 36 degrees Celsius; severe tachycardia: age-dependent cutoff; severe hypotension: age-dependent cutoff; decreased saturation: oxygen saturation less than 90; decreased mental status: Blantyre Coma Score less than 5 (out of 5) or Glasgow Coma Score less than 15 (out of 15 or score less than Alert on AVPU score); acidosis: pH less than 7.2; lactatemia: lactate greater than 5 mmol/L; severe anemia: hemoglobin less than 6 g/dL; leukopenia: WBC less than 2.0 × 10^9/L; thrombocytopenia: platelet count less than 150 × 10^9/L; and hypoglycemia: glucose less than 2.5 mmol/L.