Performance of Point-of-Care Diagnostics for Glucose, Lactate, and Hemoglobin in the Management of Severe Malaria in a Resource-Constrained Hospital in Uganda

Hawkes, Michael; Conroy, Andrea L.; Opoka, Robert O.; Namasopo, Sophie; Liles, W. Conrad; John, Chandy C.; Kain, Kevin C.

doi:10.4269/ajtmh.13-0689

Cited by 16 publications

(52 citation statements)

References 21 publications

(23 reference statements)

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“…Median [IQR] for non-normally distributed variables. Number (%) for categorical variables b Lactate was assessed using LactateScout in the fever cohort and i-STAT in the iNO trial as previously described [52] c Positive by microscopy or RDT (HRP2/pLDH or pLDH) d Severe anemia defined as hemoglobin less than 5 g/dL (hospital laboratory) or pallor by clinical assessment in the fever cohort and Hb <5 g/dL (reference laboratory) in the iNO trial cohort …”

Section: Resultsmentioning

confidence: 99%

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Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial

et al. 2016

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BackgroundExposure of red blood cells to oxidants increases production of methemoglobin (MHb) resulting in impaired oxygen delivery to tissues. There are no reliable estimates of methemoglobinemia in low resource clinical settings. Our objectives were to: i) evaluate risk factors for methemoglobinemia in Ugandan children hospitalized with fever (study 1); and ii) investigate MHb responses in critically ill Ugandan children with severe malaria treated with inhaled nitric oxide (iNO), an oxidant that induces MHb in a dose-dependent manner (study 2).MethodsTwo prospective studies were conducted at Jinja Regional Referral Hospital in Uganda between 2011 and 2013. Study 1, a prospective cohort study of children admitted to hospital with fever (fever cohort, n = 2089 children 2 months to 5 years). Study 2, a randomized double-blind placebo-controlled parallel arm trial of room air placebo vs. 80 ppm iNO as an adjunctive therapy for children with severe malaria (RCT, n = 180 children 1–10 years receiving intravenous artesunate and 72 h of study gas). The primary outcomes were: i) masimo pulse co-oximetry elevated MHb levels at admission (>2 %, fever cohort); ii) four hourly MHb levels in the RCT.ResultsIn the fever cohort, 34 % of children admitted with fever had elevated MHb at admission. Children with a history of vomiting, delayed capillary refill, elevated lactate, severe anemia, malaria, or hemoglobinopathies had increased odds of methemoglobinemia (p < 0.05 in a multivariate model). MHb levels at admission were higher in children who died (n = 89) compared to those who survived (n = 1964), p = 0.008. Among children enrolled in the iNO RCT, MHb levels typically plateaued within 12–24 h of starting study gas. MHb levels were higher in children receiving iNO compared to placebo, and MHb > 10 % occurred in 5.7 % of children receiving iNO. There were no differences in rates of study gas discontinuation between trial arms.ConclusionsHospitalized children with evidence of impaired oxygen delivery, metabolic acidosis, anemia, or malaria were at risk of methemoglobinemia. However, we demonstrated high-dose iNO could be safely administered to critically ill children with severe malaria with appropriate MHb monitoring.Trial registrationClinicalTrials.gov Identifier: NCT01255215 (Date registered: December 5, 2010).

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Section: Resultsmentioning

confidence: 99%

“…b Lactate was assessed using LactateScout in the fever cohort and i-STAT in the iNO trial as previously described [52]…”

Section: Resultsmentioning

confidence: 99%

Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial

et al. 2016

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“…Although there is little evidence that dangerous hyperglycaemia or poor outcomes result from treating hypoglycaemia, hyperglycaemia, as well as recurrent hypoglycaemia, may be common after dextrose infusions [34]. Considering the imperfect performance of point-of-care glucose testing, an upward adjustment of the treatment threshold could be merited due to the risk of instrument bias [35]. …”

Section: Discussionmentioning

confidence: 99%

‘We just dilute sugar and give’ health workers’ reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

Lindsjö

Chirambo

Langton

et al. 2018

Global Health Action

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Background: Acutely sick children in resource-constrained settings who present with hypoglycaemia have poor outcomes. Studies have questioned the current hypoglycaemia treatment cut-off level of 2.5 mmol/l. Improved knowledge about health workers’ attitudes towards and management of hypoglycaemia is needed to understand the potential effects of a raised cut-off level. Objective: This research explored health workers’ perceptions about managing acutely ill children with hypoglycaemia in a Malawian referral hospital. A secondary objective was to explore health workers’ opinions about a potential increase in the hypoglycaemia cut-off level. Methods: We used a qualitative design with semi-structured individual interviews performed with health workers in the Paediatric Accident and Emergency Unit at Queen Elizabeth Central Hospital, Malawi, in October 2016. Data were analysed using latent content analysis. Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee P.01/16/1852. Results: Four themes were formed that described the responses. The first, ‘Critical and difficult cases need easy treatment’, showed that health workers perceived hypoglycaemia as a severe condition that was easily manageable. The second, ‘Health system issues’, revealed challenges relating to staffing and resource availability. The third, ‘From parental reluctance to demand’, described a change in parents’ attitudes regarding intravenous treatments. The fourth, ‘Positive about the change but need more information’, exposed health workers’ concerns about potential risks of a raised cut-off level for hypoglycaemia treatment, as well as benefits for the patients. Conclusions: Health workers perceived hypoglycaemia as a severe condition that is easy to manage when the required equipment and supplies are available. Due to the common lack of test equipment and dextrose supplies, health workers have adopted alternative strategies to diagnose and manage hypoglycaemia. A change to the hypoglycaemia treatment cut-off level raised concerns about potential risks, but was also thought to be of benefit for some patients.

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“…Recently, Michael Hawkes and colleagues 1 reported the performance of point-of-care (POC) tests to guide the management of 179 children with severe malaria in a resource-limited Ugandan hospital. They paired measurements of glucose using i-STAT and OneTouch Ultra glucometer and other measurements for lactate and hemoglobin.…”

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confidence: 99%

“…Newborn hypoglycemia is probably underestimated completely as a result of the lack of safe and reliable POC diagnostic tests in maternity wards in resource-limited countries. 1 Despite considerable interest recently in neonate mortality in *Address correspondence to Hubert Barennes, Agence Nationale de Recherche sur le VIH et Hé patite, Phnom Penh, Cambodia. E-mail: barenneshub@yahoo.fr the new world, neonate hypoglycemia has been rarely documented in the tropics.…”

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Improving the Management of Dysglycemia in Children in the Developing World

Hubert¹,

Pussard²

2015

The American Society of Tropical Medicine and Hygiene

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Abstract. Improving the availability of point-of-care (POC) diagnostics for glucose is crucial in resource-constrained settings (RCS). Both hypo and hyperglycemia have an appreciable frequency in the tropics and have been associated with increased risk of deaths in pediatrics units. However, causes of dysglycemia, including hyperglycemia, are numerous and insufficiently documented in RCS. Effective glycemic control with glucose infusion and/or intensive insulin therapy can improve clinical outcomes in western settings. A non-invasive way for insulin administration is not yet available for hyperglycemia. We documented a few causes and developed simple POC treatment of hypoglycemia in RCS. We showed the efficacy of sublingual sugar in two clinical trials. Dextrose gel has been recently tested for neonate mortality. This represents an interesting alternative that should be compared with sublingual sugar in RCS. New studies had to be done to document dysglycemia mechanism, frequency and morbid-mortality, and safe POC treatment in the tropics.Recently, Michael Hawkes and colleagues 1 reported the performance of point-of-care (POC) tests to guide the management of 179 children with severe malaria in a resource-limited Ugandan hospital. They paired measurements of glucose using i-STAT and OneTouch Ultra glucometer and other measurements for lactate and hemoglobin. Despite the small sample size of children with hypoglycemia and the lack of gold standard methods, they concluded that diagnostic tools, although imperfect, may expedite clinical decision-making in the management of critically ill children in resource-constrained settings (RCS). We completely agree with the crucial need for improving the availability of point-of-care diagnostics for glucose, particularly in RCS where hypoglycemia is a common and underdiagnosed cause of death.2-4 However, the sole diagnosis of dysglycemia is not sufficient if an access to effective therapy is not feasible, especially in the field for comatose children.For this purpose, we assessed the frequency of dysglycemia in sick children in non-malaria areas.2 In the pediatric ward of a referral hospital in Madagascar, an appreciable frequency (10.9%) (95% confidence interval [CI], 8.1-14.3) of hyperglycemic children at admission carried an increased risk of death (risk ratio [RR]: 2.2, 95% CI: 1-4.7).2 This association of hyperglycemia and increased mortality was described in rural Kenya and in a tertiary care hospital in India. 5,6 However, data on hyperglycemia frequency, causes, and mortality remains scarce in the tropics. 7,8 In the same study, we also found a 3.0% (95% CI, 1.6-5.2) prevalence of hypoglycemia among 420 consecutive children.2 Hypoglycemia was associated with increased risk of deaths (RR: 19.4, 95% CI: 5.0-74.7) after multivariate analyses. The rate of hypoglycemia was consistent with reports from Tanzania 9 but lower than rates reported in malaria areas. [5][6][7]10,11 Hypoglycemia is a common and serious complication in children with severe malaria, and it also is in...

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Performance of Point-of-Care Diagnostics for Glucose, Lactate, and Hemoglobin in the Management of Severe Malaria in a Resource-Constrained Hospital in Uganda

Cited by 16 publications

References 21 publications

Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial

Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial

‘We just dilute sugar and give’ health workers’ reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

Improving the Management of Dysglycemia in Children in the Developing World

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