Summary Appropriate and sustainable intensive care practice is possible even in the resource‐limited locations of sub‐Saharan Africa. Data from seven sub‐Saharan African countries indicates that the majority of patients served are surgical. Comparison between intensive care units is difficult due to lack of laboratory support, which precludes the severity sickness scores used internationally. Hospital mortality can be reduced by increasing nurse/patient ratios, adequate monitoring and initiating postoperative intermittent positive pressure ventilation when required. Equipment should include appropriate technology, for instance using oxygen concentrators and a ventilator not dependent on compressed gases or disposable circuits. The clinical officer anaesthetist has a major role to play in the intensive care team.
Summary We undertook an audit in a rural Ugandan hospital that describes the epidemiology and mortality of 5147 patients admitted to the intensive care unit. The most frequent admission diagnoses were postoperative state (including following trauma) (2014/5147; 39.1%), medical conditions (709; 13.8%) and traumatic brain injury (629; 12.2%). Intensive care unit mortality was 27.8%, differing between age groups (p < 0.001). Intensive care unit mortality was highest for neonatal tetanus (29/37; 78.4%) and lowest for foreign body aspiration (4/204; 2.0%). Intensive care unit admission following surgery (333/1431; 23.3%), medical conditions (327/1431; 22.9%) and traumatic brain injury (233/1431; 16.3%) caused the highest number of deaths. Of all deaths in the hospital, (1431/11,357; 12.6%) occurred in the intensive care unit. Although the proportion of hospitalised patients admitted to the intensive care unit increased over time, from 0.7% in 2005/6 to 2.8% in 2013/4 (p < 0.001), overall hospital mortality decreased (2005/6, 4.8%; 2013/14, 4.0%; p < 0.001). The proportion of intensive care patients whose lungs were mechanically ventilated was 18.7% (961/5147). This subgroup of patients did not change over time (2006, 16%; 2015, 18.4%; p = 0.12), but their mortality decreased (2006, 59.5%; 2015, 44.3%; p < 0.001).
A survey of the anaesthetic services in rural Tanzania was carried out in an area of 67500 km2 and population of 4 million in order to assess the quality of anaesthesia and the major obstacles to good practice. Lack of draw-over vaporizers, Ayre's T-pieces, and a supply of oxygen were found to be the major obstacles to safe practice in this area of Africa.
Approximately 5.4 million people are bitten by snakes annually, with up to half of these victims experiencing signs of envenomation. This results in an estimated 138 000 deaths per year. [1] Only limited data exist on the long-term morbidity of snakebites, but one study suggested that between 5 900 and 14 600 amputations per year may be attributed to snakebites in sub-Saharan Africa (sSA) alone. [2] However, accuracy of epidemiological data is limited owing to under-reporting, patients' poor access to healthcare facilities and many victims attending traditional healers rather than health centres or hospitals. [1][2][3] The burden of snakebites is unevenly distributed across the globe, with 95% of cases encountered in low-and middle-income countries in Africa and Asia. [4,5] Even in those areas, the health effects of snakebites are disproportional, with the poorest of the poor generally experiencing poor outcomes. [6,7] Rural sSA is specifically vulnerable owing to limited availability of healthcare services. In 2017, the World Health Organization (WHO) recognised snakebite envenoming as a neglected tropical disease. [7] Accordingly, snakebite antivenoms are included in the WHO's list of essential medicines. [8] Common acute medical conditions arising from snakebites depend on the species, but include neurotoxicity, coagulation failure accompanied by shock or organ dysfunction, and local tissue destruction. [9] Multiple factors, including delayed presentation to healthcare facilities, adversely affect the management and outcome of snakebite victims. [2] Inadequate regulatory frameworks that result in ineffective or unsafe antivenom products being available, restricted access and high costs are crucial challenges limiting the use of antivenoms, particularly in sSA. [10,11] Supportive measures are often the only therapeutic options for patients presenting with snakebite envenoming in sSA.In this study, we report the intensive care unit (ICU) management and outcomes of 174 snakebite victims who were treated mainly with basic intensive-care interventions (e.g. mechanical ventilation) in a rural sSA hospital where adequate doses of antivenom were not available.
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