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The management of critical illness is especially challenging in low-resource environments, and early recognition and supportive care are essential, regardless of the ability to employ advanced or invasive therapy. In this report, we discuss two patients with Guillain-Barré syndrome who were managed successfully in the intensive care unit of a tertiary hospital in Malawi. Both patients recovered and were discharged home. The management and outcomes of these patients provide case-based lessons for improving intensive care unit medicine in low-resource contexts.

Introduction: The burden of critical illness in low- and middle-income countries (LMICs) is high; however, there is a paucity of data describing pediatric critical care outcomes in this setting., Methods: We performed a prospective observational study of the pediatric (≤18 years) intensive care population in Malawi, from August 2016 to May 2018. Data collected include patient demographics and clinical data, admission criteria and outcome. A multivariate Poisson regression was performed to determine risk factors for mortality., Results: Over the study period, 499 patients were admitted to the intensive care unit (ICU) and 105 (21.0%) were children. The average age was 10.6 ± 5.4 years. Primary indications for ICU admission were sepsis (n = 30, 30.3%) and traumatic brain injury (TBI, n = 23, 23.2%). Of those who died, sepsis (n = 18, 32.7%), acute respiratory failure (n = 11, 20.0%) and TBI (n = 11, 20.0%) were the primary admission diagnoses. Overall, ICU mortality was 54.3% (n = 57). Multivariate regression for increased ICU mortality revealed: age ≤5 years [risk ratio (RR) 1.96, 95% CI 1.10-2.26, p < 0.001], hemoglobin < 10 g/dl (RR 1.58, 95% CI 1.08-2.01, p = 0.01) and shock requiring epinephrine support (RR 2.76, 95% CI 1.80-4.23, p < 0.001)., Conclusions: Pediatric ICU mortality is high. Predictors of mortality were age ≤5 years, anemia at ICU admission and the need for epinephrine support. Training of pediatric intensive care specialists and increased blood product availability may attenuate the high mortality for critically ill children in Malawi., (© The Author(s) [2020]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: In high-income countries (HICs), the intensive care unit (ICU) bed density is approximately 20-32 beds/100 000 population compared with countries in sub-Saharan Africa, like Malawi, with an ICU bed density of 0.1 beds/100 000 population. We hypothesize that the ICU bed utilization in Malawi will be high., Methods: This is an observational study at a tertiary care center in Malawi from August 2016 to May 2018. Variables used to evaluate ICU bed utilization include ICU length of stay (LOS), bed occupancy rates (average daily ICU census/number of ICU beds), bed turnover (total number of admissions/number of ICU beds), and turnover intervals (number of ICU bed days/total number of admissions - average ICU LOS)., Results: 494 patients were admitted to the ICU during the study period. The average LOS during the study period was 4.8 ± 6.0 days. Traumatic brain injury patients had the most extended LOS (8.7 ± 6.8 days) with a 49.5% ICU mortality. The bed occupancy rate per year was 74.7%. The calculated bed turnover was 56.5 persons treated per bed per year. The average turnover interval, defined as the number of days for a vacant bed to be occupied by the successive patient admission, was 1.63 days., Conclusion: Despite the high burden of critical illness, the bed occupancy rates, turn over days, and turnover interval reveal significant underutilization of the available ICU beds. ICU bed underutilization may be attributable to the absence of an admission and discharge protocols. A lack of brain death policy further impedes appropriate ICU utilization.

This prospective cohort study evaluated the associations of day and time of admission to the Intensive Care Unit (ICU) with hospital mortality at a referral hospital in Malawi, a low-income country in sub-Saharan Africa. Patients admitted to the ICU during the day (08:00-16:00) were compared to those admitted at night (16:01-07:59); patients admitted on weekdays (Monday-Friday) were compared to admissions on weekends/holidays. The primary outcome was hospital mortality. Most patients were admitted during daytime (56%) and on weekdays (72%). There was no difference in mortality between night and day admissions (58% vs. 56%, P  = 0.8828; hazard ratio [HR] = 1.09, 95% confidence interval [CI = 0.82-1.44, P  = 0.5614) or weekend/holiday versus weekday admissions (56% vs. 57%, P  = 0.9011; HR = 0.87, 95% CI = 0.62-1.21, P  = 0.4133). No interaction between time and day was found. These results may be affected by high overall hospital mortality.

Background: Critical illness disproportionately affects people in low-income countries (LICs). Efforts to improve critical care in LICs must account for differences in demographics and infrastructure compared to high-income settings. Part of this effort includes the development and validation of intensive care unit (ICU) risk stratification models feasible for use in LICs. The purpose of this study was to validate and compare the performance of ICU mortality models developed for use in sub-Saharan Africa., Materials and Methods: This was a prospective, observational cohort study of ICU patients in a referral hospital in Malawi. Models were selected for comparison based on a Medline search for studies which developed ICU mortality models based on cohorts in sub-Saharan Africa. Model discrimination was evaluated using the area under the curve with 95% confidence intervals (CI)., Results: During the study, 499 patients were admitted to the study ICU, and after exclusions, there were 319 patients. The cohort was 62% female, with the mean age 31 years (IQR: 23-41), and 74% had surgery preceding ICU admission. Discrimination for hospital mortality ranged from 0.54 (95% CI 0.48, 0.60) for the Universal Vital Assessment (UVA) to 0.72 (95% CI 0.66, 0.78) for the Malawi Intensive care Mortality Evaluation (MIME). After tenfold cross-validation, these results were unchanged., Conclusions: The MIME outperformed other models in this prospective study. Most ICU models developed for LICs had poor to modest discrimination for hospital mortality. Future research may contribute to a better risk stratification model for LICs by refining and enhancing the MIME.

Introduction: Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed., Methods: This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve., Results: Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76)., Conclusions: The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility., (Copyright © 2018. Published by Elsevier Ltd.)

Background: The provision of critical care services is essential to healthcare systems and increasingly a global health focus, but many hospitals in sub-Saharan Africa are unable to meet this need. Intensive care unit (ICU) mortality in this region is high, but studies describing the provision of critical care services are scarce., Methods: This was a retrospective cohort study of all patients admitted to the ICU at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, between September 1, 2013, and October 17, 2014. We summarized demographics, clinical characteristics, and outcomes, and analyzed factors associated with mortality., Results: Of 390 patients admitted to ICU during the study, 44.9 % of patients were male, and the median age was 22 years (IQR 6-35) years. Although most patients (73.1 %) were admitted with surgical diagnoses, the highest mortality was among patients admitted with sepsis (59.3 %), or obstetric (44.7 %) or medical (40.0 %) diagnoses. Overall ICU mortality was high (23.6 %)., Conclusions: There is a shortage of data describing critical care in low-resource settings, particularly in sub-Saharan Africa. Surgical disease comprises the majority of ICU utilization in this study site, but medical and obstetric illness carried higher ICU mortality. These data may guide strategies for improving critical care in the region.

Purpose: High-dependency care units (HDUs) are a focus of research to optimize critical care resource allocation. HDUs provide a level of care between the general ward and the intensive care unit (ICU). However, few data report on the case mix and outcomes of patients in these units., Methods: Retrospective observational cohort study of patients admitted to 11 stand-alone HDUs in the UK from 2008 to 2011. We stratified patients by location prior to HDU admission and location on discharge from HDU, and we summarized the case mix, transitions of care, and mortality., Results: Of 9008 patients admitted to 11 stand-alone HDUs, 56.5% were male and the mean age was 62.7 ± 17.9 years. The majority of patients admitted to HDUs were non-surgical (59.3%), with 22.4 and 20.1% admitted from the ICU and general ward, respectively; 41.3% were admitted from the operating room or recovery suite. The median length of stay in HDU was 1.8 days (IQR 0.9-3.5) and in-HDU mortality was 5.1%. Among HDU survivors (n = 8551), 8.5% were discharged to an ICU, 80.9% to a general ward, and 10.6% to other care areas. For patients admitted to HDU from an ICU, only 5.8% were readmitted to ICU. Hospital mortality for the HDU population was 14.8%; for patients discharged to an ICU, hospital mortality was 43.6%., Conclusions: In a sample of 11 stand-alone HDUs in the UK, patients are from many different hospital locations. Hospital mortality for patients requiring HDU care is high, particularly for patients who require transfer to an ICU.

Background: Anemia is associated with intensive care unit (ICU) outcomes, but data describing this association in sub-Saharan Africa are scarce. Patients in this region are at risk for anemia due to endemic conditions like malaria and because transfusion services are limited.Methods: This was a prospective cohort study of ICU patients at Kamuzu Central Hospital (KCH) in Malawi. Exclusion criteria included age <5 years, pregnancy, ICU readmission, or admission for head injury. Cumulative incidence functions and Fine-Gray competing risk models were used to evaluate hemoglobin (Hgb) at ICU admission and hospital mortality.Results: Of 499 patients admitted to ICU, 359 were included. The median age was 28 years (interquartile ranges (IQRs) 20-40) and 37.5% were men. Median Hgb at ICU admission was 9.9 g/dL (IQR 7.5-11.4 g/dL; range 1.8-18.1 g/dL). There were 61 (19%) patients with Hgb < 7.0 g/dL, 59 (19%) with Hgb 7.0-8.9 g/dL, and 195 (62%) with Hgb ≥ 9.0 g/dL. Hospital mortality was 51%, 59%, and 54%, respectively. In adjusted analyses, anemia was associated with hospital mortality but was not statistically significant.Conclusions: This study provides preliminary evidence that anemia at ICU admission may be an independent predictor of hospital mortality in Malawi. Larger studies are needed to confirm this association. [ABSTRACT FROM AUTHOR]

See the reply by Martini et al [ABSTRACT FROM AUTHOR]

Background: Traumatic injury is a leading cause of morbidity and mortality worldwide, but epidemiologic data about trauma patients who require intensive care unit (ICU) admission are scant. This study aimed to describe the annual incidence of ICU admission for adult trauma patients, including an assessment of risk factors for hospital complications and mortality in this population. Methods: This was a retrospective study of adults hospitalized at Level 1 and Level 2 trauma centers after trauma and recorded in the National Trauma Data Bank in 2013. Multiple logistic regression analyses were performed to determine predictors of hospital complications and hospital mortality for those who required ICU admission. Results: There were an estimated total of 1.03 million ICU admissions for trauma at Level 1 and Level 2 trauma centers in the United States in 2013, yielding an annual incidence of 3.3 per 1000 population. The annual incidence was highest in men (4.6 versus 1.9 per 100,000 for women), those aged 80 years or older (7.8 versus 3.6-4.3 per 100,000 in other age groups), and residents in the Western US Census region (3.9 versus 2.7 to 3.6 per 100,000 in other regions). The most common complications in patients admitted to the ICU were pneumonia (10.9 %), urinary tract infection (4.7 %), and acute respiratory distress syndrome (4.4 %). Hospital mortality was significantly higher for ICU patients who developed one or more complications (16.9 % versus 10.7 % for those who did not develop any complications, p < 0.001). Conclusions: Admission to the ICU after traumatic injury is common, and almost a quarter of these patients experience hospital complications. Hospital complications are associated with significantly increased risk of mortality. [ABSTRACT FROM AUTHOR]