Nigerian Journal of Paediatrics

Paediatric critical care needs assessment in a tertiary facility in a developing country

Niger J Paediatr 2018; 45 (1): 10 - 14

ORIGINAL

Akindolire AE

CC – BY Paediatric critical care needs

Tongo OO

assessment in a tertiary facility in

a developing country

DOI:http://dx.doi.org/10.4314/njp.v45i1.3

Accepted: 7th March 2018

Abstract : Introduction and Aim:

paediatric assessment triangle

There is a great burden of criti-

(PAT) were documented.

Akindolire AE (

)

cally ill children in developing

Results: There were 391 admis-

Tongo OO

countries where paediatric critical

sions during the study period, of

Department of Paediatrics,

care is still in its early stages. The

which 130 were critically ill. They

University College Hospital, Ibadan

actual burden of critically ill chil-

had one or more of the following;

Email: abimbola_12@yahoo.com

dren is necessary for healthcare

respiratory distress 93(28.3%),

planning however, in Nigeria the

respiratory failure 35 (19.0%),

magnitude is unknown. In order to

shock 65(50%), central nervous

provide the basic paediatric inten-

system/metabolic derangements 64

sive care services which will

(49.2%). Eighty-nine (68.5%) of

likely reduce mortality and im-

the critically ill were under-5s. The

prove patient outcomes, the spe-

diagnoses commonly associated

cific burden and need for various

with critical illness were malaria,

aspects of paediatric critical care

59 (45.4%), septicaemia, 18,

services must be quantified.

(13.8%) and meningitis 17 (13.

This study set out to determine the

1%). Four of the critically ill chil-

volume, specific critical care

dren (2.8%) were admitted into the

needs and outcomes of critically

general ICU and 33 (25.4%) died

ill paediatric emergencies in the

within 48hours of presentation.

UCH.

Conclusion: There is a huge bur-

Methods: It was a prospective

den of critical care needs among

study of all consecutive patients

children presenting to the chil-

admitted into the children’s emer-

dren’s emergency ward, which

gency ward over a three-month

remains largely unmet. There is an

period. Data on clinical state on

urgent need to address paediatric

admission and the need or other-

critical care services in order to

wise for critical care using the

improve child survival.

Introduction

on the exact magnitude of critically ill children in Nige-

ria and their specific needs are not available rather most

Paediatric critical care consists of identification of chil-

studies only show mortalities which are used as esti-

dren at risk of dying or having adverse outcomes, inten-

mates of critical illness in children. Specific information

sive monitoring and provision of appropriate interven-

on burden of critical illness is required for appropriate

tions. It is a high technology discipline requiring equip-

healthcare planning that will make judicious use of

ment for cardiorespiratory monitoring and support such

scarce resources. This study therefore set out to evaluate

as mechanical ventilators and high flow oxygen as well

the burden of critical illness and the critical care needs

as circulatory support medications. Such services usu-

of children presenting at a busy paediatric emergency

ally require specifically trained and highly skilled staff.

room in Nigeria.

Nigeria still has a high under 5 mortality rate, UNICEF

estimates that over 700,000 children under 5 years die

Aim

annually in Nigeria, majority of the cause of mortality is

from pneumonia, malaria and diarrhoeal diseases. In

To determine the volume, specific critical care needs

developing countries like Nigeria, majority of mortali-

and outcomes of critically ill paediatric emergencies in

ties occur due to infectious diseases which are treatable

the University College Hospital, Ibadan, Nigeria.

and have potential for full recovery if appropriate defini-

tive care as well as intensive care is given to those who

come critically ill.

2,3

Materials and Methods

However, paediatric critical care services are largely

unavailable in most developing countries.

4,5

Information

It was a prospective study of all consecutive admissions

into the children’s emergency ward of the University

Burden of critically ill children

College Hospital Ibadan over a three-month period from

April to June 2016.

Using the PAT classification, 130 (33.2%) out of 391

The children’s emergency room annually receives ap-

admissions had one or more feature of critical illness as

proximately 1,600 sick children excluding neonates and

shown in Table 2, below. Eighty-nine of these (68.5%)

trauma cases for triage, resuscitation or stabilisation and

were under 5 years with a mean ± SD age of 4.4 ±3.4

are then transferred to appropriate units, wards or when

and a male: female ratio of 1(one). One hundred and

indicated, the general intensive care unit (ICU). The

twelve (86.2%) of the critically ill required ICU admis-

patients are triaged immediately on arrival into one of

sion based on need for mechanical ventilation, airway

the seven pathophysiologic groups using the Paediatric

support or circulatory support having failed to respond

assessment triangle see Table 1. The hospital has no

to fluid management as shown in Table 4.

paediatric intensive care unit and in view of the limited

Definition of respiratory failure under the PAT includes

spaces for paediatric patients in the general ICU, not all

those with severe respiratory distress and abnormal ap-

critically ill children are able to get into the ICU. In the

pearance.

hospital, point of care user fees are charged for all ser-

Using the WHO criteria 165(42.4%) were critically ill,

vices except those on the National Health Insurance

with some having more than one deranged parameter.

Scheme.

Eighty-eight (53.3%) had airway/ breathing problem,

129(78.2%) circulation problem while 82(49.7%) had

Data on clinical state on admission and classification

either unconsciousness or seizures.

based on the paediatric assessment triangle (PAT) and

the World Health Organisation (WHO) definition of

Table 2: Criteria defining critical illness among the paediatric

critical illness were obtained with a structured question-

emergencies using the Paediatric Assessment Triangle

naire. The need or otherwise for critical care was deter-

PAT Classification

Number of patients in each PAT

mined based on the PAT and the outcome at 48 hours

class n (%) N=391

documented.

Stable

178(45.5)

Respiratory distress only

93(23.8)

The PAT assesses appearance, work of breathing and

Respiratory failure

35(19.0)

circulation to the skin and uses these to classify a patient

Compensated shock

18(4.6)

as stable if all three parameters are normal or into one of

Decompensated shock

47(12.0)

6 categories namely respiratory distress, respiratory fail-

CNS/ Metabolic

64(16.4)

ure, compensated shock, decompensated shock, CNS/

metabolic dysfunction or cardiopulmonary failure.

PAT- Paediatric assessment triangle; *Some patients had mul-

tiple features of critical illness

Results

Clinical diagnoses of the critically ill children

General characteristics

Ninety seven percent of patients who were critically ill

There were 391 medical emergencies admitted during

were as a result of infections. None had genetic disor-

the study period, 201 (51.4%) males and 190 (48.6%)

ders or congenital malformations that were potentially

females, aged between one month and 16 years with a

untreatable. The clinical diagnoses are as shown in

mean ±SD age of 4.4±4.2 years. One hundred and ninety

Table 3.

six (50.1%) of the patients, were referred from various

health facilities while 195(49.9) came straight from

Table 3: Clinical diagnoses of the critically ill

home.

Clinical diagnosis

n(%) N=130

One hundred and ninety five (49.9%) received poten-

Malaria

59(45.4)

tially life-saving interventions like intravenous fluids 95

Meningitis

21(16.2)

(48.5%), oxygen 24 (12.2%) and anticonvulsants 18

Septicaemia

18(13.8)

(9.2). Hydrocortisone 6(3.1). One hundred and thirty

Acute diarrhoeal disease

13(10.0)

(66.3%) had received antibiotics and 71(36.2%) had

Pneumonia

12(9.2)

received anti-malaria drugs prior to presentation.

Epilepsy

2(1.5)

Dengue fever

2(1.5)

Table 1: Components of the Paediatric Assessment Triangle

Kerosene poisoning

2(1.5)

Component

Appearance

Work of

Circulation

Croup

1(0.8)

breathing

to skin

Critical care needs

Stable

Normal

Respiratory Distress

Normal

Abnormal

Normal

Respiratory Failure

Abnormal

Normal/

Specific critical care needs of the 130 patients who were

Abnormal

critically ill are as shown in Table 4. Critical care man-

Compensated Shock

Normal

Abnormal

agement for comatose patients and cardiovascular sys-

Decompensated Shock

Abnormal

Normal/

Abnormal

tem (CVS) monitoring were the most frequent needs.

CNS/Metabolic Dysfunc-

Abnormal

Normal

Thirty patients (23.1%) required mechanical ventilation.

tion

Some had more than one specific critical care need.

Cardiopulmonary Failure

Abnormal

Care received and Outcomes

Among all the critically ill, there was significantly

higher mortality among those whose critical care needs

Of the 130 who were critically ill, only 4 (3.1%) were

were unmet except manual monitoring and daily electro-

able to get into the general ICU. Of the 4, 3 were me-

lytes and urea as shown in Table 7.

chanically ventilated, one was admitted for intensive

monitoring others could not be admitted due to lack of

Table 7: Percentage mortality among all critically ill subjects

space and/or financial constraints. The other critical care

whose critical care needs were met and those unmet

needs met and unmet are as shown in Table 5. Of the

Critical care need

% mortality

total number of critical care requirements identified,

unmet

in those

met

among those

whose

whose needs

only 14.4% were met due to inadequate staffing and/or

needs were

were met

financial constraints.

unmet

^ICU admission

108

29.6

4(3.6)

25.0

Table 4: Type of critical care needed

Mechanical ventila-

88.9

33.3

Type of care required

n (%); N-130

tion

(10.0)

Critical care management for comatose patients

71(54.6)

Continuous elec-

64.0

4(8.0)

25.0

tronic *CVS moni-

Continuous electronic *CVS monitoring (Non

50(38.5)

toring (Non-

invasive)

Hourly TPR moni-

Circulatory support

41(31.7)

112

20.5

55.5

Mechanical ventilation

30(23.1)

toring by nurses

(13.8)

Sedation for intractable seizures

12(9.2)

Hourly input/ output

116

23.2

42.3

(10.8)

High flow oxygen

12(9.2)

Daily electrolytes

14.6

48.8

*CVS- cardiovascular system

and urea

(31.5)

Table 5: Critical care needs met and unmet

Critical care need

Number

Number met

needed N 130

Discussion

^ICU admission

112

4(3.6)

Mechanical ventilation

3(10.0)

This study shows that the burden of critically ill children

Continuous electronic *CVS

4(8.0)

is very high in this setting, constituting about a third of

monitoring (Non-invasive)

paediatric medical emergencies seen in the UCH, major-

Hourly TPR monitoring by

130

18(13.8)

ity of whom were under-5. The mean age of critically ill

nurses

Hourly input/ output

130

14(10.8)

children was 4.4±4.2 which is comparable to 4.9±4.4

reported by Hariharan et al in Barbados. This burden of

Daily electrolytes and urea

130

41(31.5)

Total

582

84(14.4)

critical illness among under-5s underscores the vulner-

ability of this age group to critical illness and conse-

^- intensive care unit;*- cardiovascular system monitoring;

quently death. It is therefore essential to provide ade-

- temperature, pulse and respiration

quate facilities to cater for this group of children or bet-

ter still prevent diseases that may lead to such states.

Thirty-three (25.4%) of those who were critically ill died

Critical illness scores from resource rich countries are

within 48hours of admission, 13(39.4%) from septicae-

not easily translatable to resource poor countries due to

mia, 12(36.4%) from malaria, 4(12.1%) from meningi-

the presence of parameters not readily available in most

tis, 3(9.1%) from pneumonia and 1(3.0) from dengue

hospital settings in resource poor countries. The PAT

fever. Only one (0.4%) patient out of the 261 who were

however is a simple tool, which utilises basic signs in

not critically ill at admission died within 48 hours.

triaging critically ill children for prompt attention espe-

Of these mortalities, all required ICU admission and

cially in a busy and under staffed emergency room in a

monitoring of which only 3.6% were met, other critical

resource poor setting like ours. This tool had been re-

care needs of the patients who died are as shown in

cently introduced in the children’s emergency room

Table 6.

prior to conduct of the study as the primary tool in sort-

ing out medical emergencies. The introduction of a tri-

Table 6: The critical care needs of the 33 patients who died

age tool such as the PAT, suited for the local setting,

Critical care need

Number

Number met

which will promptly and correctly identify critically ill

needed

n(%)

children has been shown to reduce mortality and provide

^ICU admission

4(3.6)

better outcomes. Similar guidelines would include the

Mechanical ventilation

3(10.0)

Continuous electronic *CVS

4(8.0)

WHO parameters for definition of critical illness which

monitoring (Non-invasive)

in this study also identified a similar proportion of criti-

Hourly TPR monitoring by

18(13.8)

cally ill children, though the objective of this study was

nurses

not to compare both tools.

Hourly input/ output

14(10.8)

Daily electrolytes and urea

41(31.5)

Critically ill children require comprehensive care that

^- intensive care unit;*- cardiovascular system monitoring; -

begins with pre hospital care and appropriate transport

temperature, pulse and respiration

to the hospital to improve outcomes. Less than half of

the patients who were referred from other hospitals had

potential lifesaving care such as intravenous fluids and

The types of critical care required by patients in this

oxygen prior to referral. Oxygen is particularly impor-

study included high flow oxygen and cardiovascular

tant in this environment because a considerable number

monitoring and circulatory support, which should not be

of under 5 deaths are from acute respiratory illnesses.

beyond the reach of most secondary and tertiary hospi-

As observed in the current study a significant proportion

tals even in the face of limited financial resources and

of the critical illness had respiratory component and as

high technology prior to establishment of definitive

such oxygen therapy was vital. However, only few of

PICUs. Such facilities are available in high dependency

the patients in this study who were referred were given

units of even small hospitals in developed countries like

the UK.

oxygen prior to or during referral. It is not known

whether this was due to non availability or non recogni-

tion of the need, but studies and interventions to

Despite the fact that the type of critical care required

strengthen pre hospital care including transport of criti-

were not high tech, majority of those needs were unmet

cally ill patients are urgently needed in order to improve

mostly due to understaffing, limited resources and point

outcomes in this group of patients. Oxygen is therefore

of care fees. The care of critically ill children should not

one of the essential elements that must be available in

depend on the financial capability of the family. This

health facilities especially since it has reported to be

makes it imperative for appropriate policies and provi-

cheap in Nigeria.

sions based on proper healthcare planning to be put in

place, however this requires that the actual burden be

In this study of paediatric emergencies, majority of the

known. Multicentre studies quantifying such needs in

critically ill patients had infections with prospects for

resource limited countries like Nigeria are recom-

full recovery, this makes it cost effective to make avail-

mended.

able paediatric critical care services which includes ade-

quate number of trained personnel in recognition and

The first 48 hours of admission is the most crucial pe-

management of such children as well as the basic equip-

riod in the care of critically ill children as mortality is

highest in this period.

2,3,14

ment and supplies needed. In a study of PICU admis-

In this study, 25.2% of the

sions from Brazil, it was reported that critically ill pa-

critically ill patients died within 48 hours of admission.

tients admitted from the wards were more likely to die

Studies have shown that mortality is three fold higher in

than those from the emergency room probably because

patients who required ICU care but did not get it and

the ward patients had more of diseases associated with

this may be one of the factors responsible for the high

poor prognosis like oncologic diagnosis. For this rea-

early mortality observed in this study as only 3.6% of

those who required ICU admission got it.

son, recognition of critical illness and provision of nec-

Even other

essary interventions to paediatric emergency cases is

aspects of critical care such as cardiovascular monitor-

expedient. That infections were responsible for most of

ing were not met due to inadequate staffing, equipment

the critical illness in this study, is similar to other reports

and bed space.

which have shown that infectious disease is both a com-

mon precipitant and final common pathway to critical

While it may not be immediately feasible to set up

illness in the developing world and as such there is a

proper paediatric intensive care units as obtained in de-

good chance of full recovery if timely critical care is

veloped countries, the principles of prevention, recogni-

given.

3,11

This is unlike in the developed countries where

tion appropriate triaging and management of critical

infections account for less than 20% of reasons for ICU

illness as appropriate for low income countries ought to

admissions.

While interventions targeting prevention

be given priority. This is to ensure progress towards

of these diseases need to be strengthened it is also essen-

reduction in child mortality in order to meet the Sustain-

tial to be adequately equipped for those whose illness

able development goals. In implementing such princi-

gets to this critical level.

ples in low income countries specific clinical evidence,

standards of care and quality improvement should be the

focus.

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