Resuscitation, 4, 39-43
A paediatric
respiratory
intensive care unit in Lagos
J. 0. SODIPO College ofMedicine,
Universiry of Lagos, P.M.B. 12003, Lagos, Nigeria
Summary The respiratory Intensive Care Unit was created at the Lagos University Teaching Hospital in 1963. Experience shows that mortality has been highest in neonates who had congenital anomalies, as well as in children under 2 years of age. The predominant cause of death was preventable respiratory failure. The incidence of mortality was 43%. This was related to several factors: (i) the severity of illness, types of illness and antecedent period of neglect; (ii) lack of a critical care medicine programme; (iii) insufficient skilled full-time intensive care personnel, including physicians, nurses, physiotherapists and paramedical specialists; (iv) the high incidence of infection in the Intensive Care Unit. Introduction In September, 1963, a pilot unit of four beds was set aside in an open 32-bed ward in the Lagos University Teaching Hospital to deal with acute respiratory emergencies. This was later converted into an Intensive Care Unit dealing with cases needing intensive therapy. The floor space was only 8.26 square metres (89.2 sq.ft). The medical staff consisted of the anaesthesiologist on call for the day, and a paediatrician who joined the team for consultation purposes only. The nursing personnel consisted of two staff nurses per shift. They had received no previous training for intensive care, and were not permanently employed in the unit. There ware no full-time intensive care unit personnel. A very slow build-up of essential monitoring equipment has taken place in the unit. Although still grossly deficient, this equipment now includes: an arterial blood pressure monitor; a venous pressure monitor; an electrocardiograph; a blood gas analyser; an eightchannel Beckman recorder and ventilators. There was no acute laboratory facilities adjacent to the unit to deal with day to day analyses. The analyses were performed in the central laboratory, and the results were not immediately available for controlling the treatment. Ideally, there should be an acute laboratory adjacent to the intensive care unit. Clinical material
This paper summarizes our experiences in a 10 year period (1963-1973) during which 288 paediatric patients were managed in the Respiratory Intensive Care Unit by nonpermanent personnel. Their case notes are reviewed in the following respects: age of the patients, the primary cause of the respiratory problems, active measures used to support ventilation, the cause of death and the rate of mortality. 39
40
J. 0. SODIPO
Table 1. Analysis of main conditions present in children admitted to the Intensive Care Unit (19631973).
No. of cases
Percentage of total
Severe tetanus Respiratory diseases Miscellaneous Post-surgical Trauma
104 95 39 35 15
36.1 33.0 13.4 12.2 5.3
Total
288
100.0
Table 2. Clinical conditions associated with the 123 deaths in 288 patients admitted to the Intensive Care Unit. No. of cases
Mortality (%)
No. of deaths
Severe tetanus Respiratory diseases MisceRaneous Post-surgical Trauma
104 95 39 35 15
47 38 20
45.2 40.2 51.2 25.9 60.0
Total
288
123
42.7
Table 3. Patients with acute respiratory failure requiring endotracheal intubation, intermittent positive pressure ventilation (IPPV).
No. of cases Severe tetanus Respiratory obstruction Bronchopneumonia Respiratory distress syndrome Post-operative Trauma
104 45 35 :: 15
tracheotomy
or
No. requiring intubation or tracheotomy
No. given IPPV
No. of deaths
94 45 20 15 35 I5
51 25 15 15 6 10
47 20 10 : 9
The reason for the patients’ admissions are presented in Table 1. A large proportion, 104 patients (36.1%), had severe tetanus. Trauma and miscellaneous causes accounted for the highest mortality in this series (Table 2). The variety of conditions in which acute respiratory failure required active measures to support ventilation in addition to the specific therapy is shown in Table 3. Severe tetanus accounted for 104 cases. Of these, 94 required endotracheal intubation or tracheotomy and 51 had intermittent positive pressure ventilation. There were 47 deaths. Upper respiratory obstruction was present in 45 cases: an endotracheal tube was needed in 39 and the remaining six patients had tracheotomies. In the series, 20 patients died.
PAEDIATRIC RESPIRATORY CARE Table 4. Analysis of the conditions of the 39 patients who required endotracheal intubation, positive pressure ventilation (IPPV).
41
tracheotomy
or intermittent
Bulbar poliomyelitis Coma (from various medical causes) Laryngeal papilloma Meningitis Rabies Drug poisoning Acute myelitis (Gillian Barre type)
Table 5. Age distribution
1 to 28 days 1 month to 2 years 2 years to 5 years 6 years to 10 years 11 years to 14 years
No. of cases
No. requiring intubation or tracheotomy
No. given IPPV
No. of deaths
10 10
10 10
I 5
5 4
I 5 3 2 2
7 5 3 2 2
4 3 _
4 2 3 0 2
2
and percentage mortality of the patients.
No. of cases (and percentage)
No. of deaths (and percentage)
46 113 50 37 42
26 46 18 15 18
(39.3%) (39.3%) (17.4%) (12.8%) (14.6%)
(56.5%) (40.7%) (36.0%) (40.5%) (42.8%)
Of the 35 cases of bronchopneumonia, 20 needed an endotracheal tube or tracheotomy, 15 had artificial ventilation and 10 succumbed. All the 15 cases of respiratory distress syndrome required an endotracheal tube and eight patients died. There were 35 post-operative cases, of which 20 needed endotracheal tubes, six were artificially ventilated and nine died. Fifteen of the patients who required endotracheal intubation had severe trauma; nine of these died and 10 in the group had to be given intermittent positive pressure ventilation. The 39 miscellaneous cases who required endotracheal intubation or tracheotomy with or without intermittent positive pressure ventilation are listed in Table 4. Bulbar poliomyelitis accounted for 10 cases, all of whom required tracheotomy and artificial ventilation, and five of whom died. All of the 10 patients in coma from various medical causes were intubated or had tracheotomies: five required artificial ventilation and four died. Out of the seven cases of laryngeal papilloma, four succumbed, mainly from uncontrolled haemorrhage. Rabies presented the most challenging problem. All three patients died within 4 days of admission to the unit, as did two cases of acute myelitis of the Gillian Barre type (Table 4). Discussion The overall mortality in our unit in Lagos was abnormally high (42.7%). Mortality was highest in neonates who had congenital anomalies. The mortality among neonates and
42
J. 0. SODIPO
children under 2 years of age accounted for more than 50% of the overall mortality (Table 5). While the predominant cause of death was preventable respiratory failure, including 45 patients with bronchopneumonia, 15 with aspiration pneumonia, I 5 with lower airway obstruction from inspissated mucus, seven accidents during weaning from controlled ventilation, five instances of ventilation disconnection and two of tracheal stenosis. Other causes of death were intractable cardiovascular failure after trauma, severe tetanus, septic shock and brain damage. Cross-infection was a serious and challenging problem in our unit as also has been reported in many intensive care units (Rountree & Beard, 1968; Harris, Orwin, Colquhoun & Schroeder, 1969; Colquhoun & Harris, 197 1). Pulmonary sepsis was common, and patients maintained for prolonged periods on intermittent positive pressure ventilation were particularly susceptible; Gram-negative organisms were commonly responsible. These findings are similar to those of other investigators (Bridge, 1960; Phillips, 1967; Tinne, Gordon, Bain & Mackey, 1967; Lowbury, Thorn, Lilly, Baab & Whittall, 1970). All our tracheotomy wounds were found to be heavily infected as judged by serial cultures of swabs of the wounds. Urinary tract infection was regarded as inevitable among our patients and attributed to the in-dwelling urethral catheters retained to monitor the urinary output. Infection of incision wounds was recorded in many cases. All these led to the long stays in the unit, ranging from 3 days to 93 days. The high incidence of sepsis was probably due to the extreme proximity of the four beds in our unit; the beds were approximately 1.1 metres apart side to side and 1.7 metres apart end to end, which defeated the most stringent aseptic precautions in the handling of tracheotomies. Besides, the ventilation in our open ward cannot be regarded as adequate to dilute the bacterial concentration of the environment to safe levels. Some of the essential monitoring equipment, laboratory facilities and competent technologists were not available in our unit. Despite the limitations of this study it is possible to draw some tentative conclusions. There is no doubt that the undesirable deficiencies highlighted in this paper were contributory factors to the high mortality in our unit. These can occur in any intensive care unit unless it is carefully planned to conform with certain standards (Kampschulte & Safar, 1973; Safar & Grenvik, 1971; Society of Critical Care Medicine, 1973). Theunique features of a paediatric intensive care unit should include; special paediatric life-support, monitoring techniques and special personnel such as physicians and paediatric nurses with training in critical care medicine. Most respiratory catastrophies and iatrogenic infections are preventable. Provision of a full-time intensive care unit physician and trainees helps to decrease mortality (Kampschulte & Safar, 1973). The lessons learnt in the Paediatric Respiratory Intensrve Care Unit of the Lagos University Teaching Hospital are being applied to a new ultra-modem ten-bed unit now under construction. It is hoped that in the future it will be possibie to present a progress report, in which the results from the new unit can be compared gainfully with those of this report.
References Bridge, C. J. (1960) Sequelae of tracheobronchial aspirations. Laryngoscope, 70,318-325. Colquhoun, J. & Harris, D. M. (1971) Problems of infection in an intensive care unit&x. Roy. Sot. Med., 64,1281-1283.
PAEDIATRIC RESPIRATORY CARE
43
Harris, D. M., Orwin, J. M., Colquhoun, J. & Schroeder, H. G. (1969) Control of cross-infection in an intensive care unit. J. Hygiene, 67,525-532. Kampschulte, S. & Safar, P. (1973) Development of a multidisciplinary paediatric intensive care unit. Critical Care Medicine, 1, 305-308. Lowbury, E. J. L., Thorn, B. T., Lilly, H. A., Babb, J. R. & Whittall, K. (1970) Series of infection with Pseudomonas aeruginosa in patients with tracheostomy. J. Med. Microbial., 3,39-56. Phillips, I. (1967) Pseudomonas aeruginosu respiratory tract infections in patients receiving mechanical ventilation. J. Hygiene, 65,229-235. Rountree, P. M. & Beard, M. A. (1968) Sources of infection in an intensive care unit. Med. J. Aust., 1, 511-582. Safar, P. & Grenvik, A. (1971) Critical care units. Chest, 59,535-547. Society of critical care medicine (1973) Guidelines for training of physicians in critical care medicine. Critical Care Medicine, 1,39-42. Tinne, J. E., Gordon, A. M., Bain, W. H. & Mackey, W. A. (1967) Cross infection by Pseudomonas aeruginosa as a hazard of intensive therapy. Bit. Med. J., iv, 313-315.
A paediatric
respiratory
intensive care unit in Lagos
J. 0. SODIPO College ofMedicine,
Universiry of Lagos, P.M.B. 12003, Lagos, Nigeria
Summary The respiratory Intensive Care Unit was created at the Lagos University Teaching Hospital in 1963. Experience shows that mortality has been highest in neonates who had congenital anomalies, as well as in children under 2 years of age. The predominant cause of death was preventable respiratory failure. The incidence of mortality was 43%. This was related to several factors: (i) the severity of illness, types of illness and antecedent period of neglect; (ii) lack of a critical care medicine programme; (iii) insufficient skilled full-time intensive care personnel, including physicians, nurses, physiotherapists and paramedical specialists; (iv) the high incidence of infection in the Intensive Care Unit. Introduction In September, 1963, a pilot unit of four beds was set aside in an open 32-bed ward in the Lagos University Teaching Hospital to deal with acute respiratory emergencies. This was later converted into an Intensive Care Unit dealing with cases needing intensive therapy. The floor space was only 8.26 square metres (89.2 sq.ft). The medical staff consisted of the anaesthesiologist on call for the day, and a paediatrician who joined the team for consultation purposes only. The nursing personnel consisted of two staff nurses per shift. They had received no previous training for intensive care, and were not permanently employed in the unit. There ware no full-time intensive care unit personnel. A very slow build-up of essential monitoring equipment has taken place in the unit. Although still grossly deficient, this equipment now includes: an arterial blood pressure monitor; a venous pressure monitor; an electrocardiograph; a blood gas analyser; an eightchannel Beckman recorder and ventilators. There was no acute laboratory facilities adjacent to the unit to deal with day to day analyses. The analyses were performed in the central laboratory, and the results were not immediately available for controlling the treatment. Ideally, there should be an acute laboratory adjacent to the intensive care unit. Clinical material
This paper summarizes our experiences in a 10 year period (1963-1973) during which 288 paediatric patients were managed in the Respiratory Intensive Care Unit by nonpermanent personnel. Their case notes are reviewed in the following respects: age of the patients, the primary cause of the respiratory problems, active measures used to support ventilation, the cause of death and the rate of mortality. 39
40
J. 0. SODIPO
Table 1. Analysis of main conditions present in children admitted to the Intensive Care Unit (19631973).
No. of cases
Percentage of total
Severe tetanus Respiratory diseases Miscellaneous Post-surgical Trauma
104 95 39 35 15
36.1 33.0 13.4 12.2 5.3
Total
288
100.0
Table 2. Clinical conditions associated with the 123 deaths in 288 patients admitted to the Intensive Care Unit. No. of cases
Mortality (%)
No. of deaths
Severe tetanus Respiratory diseases MisceRaneous Post-surgical Trauma
104 95 39 35 15
47 38 20
45.2 40.2 51.2 25.9 60.0
Total
288
123
42.7
Table 3. Patients with acute respiratory failure requiring endotracheal intubation, intermittent positive pressure ventilation (IPPV).
No. of cases Severe tetanus Respiratory obstruction Bronchopneumonia Respiratory distress syndrome Post-operative Trauma
104 45 35 :: 15
tracheotomy
or
No. requiring intubation or tracheotomy
No. given IPPV
No. of deaths
94 45 20 15 35 I5
51 25 15 15 6 10
47 20 10 : 9
The reason for the patients’ admissions are presented in Table 1. A large proportion, 104 patients (36.1%), had severe tetanus. Trauma and miscellaneous causes accounted for the highest mortality in this series (Table 2). The variety of conditions in which acute respiratory failure required active measures to support ventilation in addition to the specific therapy is shown in Table 3. Severe tetanus accounted for 104 cases. Of these, 94 required endotracheal intubation or tracheotomy and 51 had intermittent positive pressure ventilation. There were 47 deaths. Upper respiratory obstruction was present in 45 cases: an endotracheal tube was needed in 39 and the remaining six patients had tracheotomies. In the series, 20 patients died.
PAEDIATRIC RESPIRATORY CARE Table 4. Analysis of the conditions of the 39 patients who required endotracheal intubation, positive pressure ventilation (IPPV).
41
tracheotomy
or intermittent
Bulbar poliomyelitis Coma (from various medical causes) Laryngeal papilloma Meningitis Rabies Drug poisoning Acute myelitis (Gillian Barre type)
Table 5. Age distribution
1 to 28 days 1 month to 2 years 2 years to 5 years 6 years to 10 years 11 years to 14 years
No. of cases
No. requiring intubation or tracheotomy
No. given IPPV
No. of deaths
10 10
10 10
I 5
5 4
I 5 3 2 2
7 5 3 2 2
4 3 _
4 2 3 0 2
2
and percentage mortality of the patients.
No. of cases (and percentage)
No. of deaths (and percentage)
46 113 50 37 42
26 46 18 15 18
(39.3%) (39.3%) (17.4%) (12.8%) (14.6%)
(56.5%) (40.7%) (36.0%) (40.5%) (42.8%)
Of the 35 cases of bronchopneumonia, 20 needed an endotracheal tube or tracheotomy, 15 had artificial ventilation and 10 succumbed. All the 15 cases of respiratory distress syndrome required an endotracheal tube and eight patients died. There were 35 post-operative cases, of which 20 needed endotracheal tubes, six were artificially ventilated and nine died. Fifteen of the patients who required endotracheal intubation had severe trauma; nine of these died and 10 in the group had to be given intermittent positive pressure ventilation. The 39 miscellaneous cases who required endotracheal intubation or tracheotomy with or without intermittent positive pressure ventilation are listed in Table 4. Bulbar poliomyelitis accounted for 10 cases, all of whom required tracheotomy and artificial ventilation, and five of whom died. All of the 10 patients in coma from various medical causes were intubated or had tracheotomies: five required artificial ventilation and four died. Out of the seven cases of laryngeal papilloma, four succumbed, mainly from uncontrolled haemorrhage. Rabies presented the most challenging problem. All three patients died within 4 days of admission to the unit, as did two cases of acute myelitis of the Gillian Barre type (Table 4). Discussion The overall mortality in our unit in Lagos was abnormally high (42.7%). Mortality was highest in neonates who had congenital anomalies. The mortality among neonates and
42
J. 0. SODIPO
children under 2 years of age accounted for more than 50% of the overall mortality (Table 5). While the predominant cause of death was preventable respiratory failure, including 45 patients with bronchopneumonia, 15 with aspiration pneumonia, I 5 with lower airway obstruction from inspissated mucus, seven accidents during weaning from controlled ventilation, five instances of ventilation disconnection and two of tracheal stenosis. Other causes of death were intractable cardiovascular failure after trauma, severe tetanus, septic shock and brain damage. Cross-infection was a serious and challenging problem in our unit as also has been reported in many intensive care units (Rountree & Beard, 1968; Harris, Orwin, Colquhoun & Schroeder, 1969; Colquhoun & Harris, 197 1). Pulmonary sepsis was common, and patients maintained for prolonged periods on intermittent positive pressure ventilation were particularly susceptible; Gram-negative organisms were commonly responsible. These findings are similar to those of other investigators (Bridge, 1960; Phillips, 1967; Tinne, Gordon, Bain & Mackey, 1967; Lowbury, Thorn, Lilly, Baab & Whittall, 1970). All our tracheotomy wounds were found to be heavily infected as judged by serial cultures of swabs of the wounds. Urinary tract infection was regarded as inevitable among our patients and attributed to the in-dwelling urethral catheters retained to monitor the urinary output. Infection of incision wounds was recorded in many cases. All these led to the long stays in the unit, ranging from 3 days to 93 days. The high incidence of sepsis was probably due to the extreme proximity of the four beds in our unit; the beds were approximately 1.1 metres apart side to side and 1.7 metres apart end to end, which defeated the most stringent aseptic precautions in the handling of tracheotomies. Besides, the ventilation in our open ward cannot be regarded as adequate to dilute the bacterial concentration of the environment to safe levels. Some of the essential monitoring equipment, laboratory facilities and competent technologists were not available in our unit. Despite the limitations of this study it is possible to draw some tentative conclusions. There is no doubt that the undesirable deficiencies highlighted in this paper were contributory factors to the high mortality in our unit. These can occur in any intensive care unit unless it is carefully planned to conform with certain standards (Kampschulte & Safar, 1973; Safar & Grenvik, 1971; Society of Critical Care Medicine, 1973). Theunique features of a paediatric intensive care unit should include; special paediatric life-support, monitoring techniques and special personnel such as physicians and paediatric nurses with training in critical care medicine. Most respiratory catastrophies and iatrogenic infections are preventable. Provision of a full-time intensive care unit physician and trainees helps to decrease mortality (Kampschulte & Safar, 1973). The lessons learnt in the Paediatric Respiratory Intensrve Care Unit of the Lagos University Teaching Hospital are being applied to a new ultra-modem ten-bed unit now under construction. It is hoped that in the future it will be possibie to present a progress report, in which the results from the new unit can be compared gainfully with those of this report.
References Bridge, C. J. (1960) Sequelae of tracheobronchial aspirations. Laryngoscope, 70,318-325. Colquhoun, J. & Harris, D. M. (1971) Problems of infection in an intensive care unit&x. Roy. Sot. Med., 64,1281-1283.
PAEDIATRIC RESPIRATORY CARE
43
Harris, D. M., Orwin, J. M., Colquhoun, J. & Schroeder, H. G. (1969) Control of cross-infection in an intensive care unit. J. Hygiene, 67,525-532. Kampschulte, S. & Safar, P. (1973) Development of a multidisciplinary paediatric intensive care unit. Critical Care Medicine, 1, 305-308. Lowbury, E. J. L., Thorn, B. T., Lilly, H. A., Babb, J. R. & Whittall, K. (1970) Series of infection with Pseudomonas aeruginosa in patients with tracheostomy. J. Med. Microbial., 3,39-56. Phillips, I. (1967) Pseudomonas aeruginosu respiratory tract infections in patients receiving mechanical ventilation. J. Hygiene, 65,229-235. Rountree, P. M. & Beard, M. A. (1968) Sources of infection in an intensive care unit. Med. J. Aust., 1, 511-582. Safar, P. & Grenvik, A. (1971) Critical care units. Chest, 59,535-547. Society of critical care medicine (1973) Guidelines for training of physicians in critical care medicine. Critical Care Medicine, 1,39-42. Tinne, J. E., Gordon, A. M., Bain, W. H. & Mackey, W. A. (1967) Cross infection by Pseudomonas aeruginosa as a hazard of intensive therapy. Bit. Med. J., iv, 313-315.
