Browsing by Author "Argent, Andrew"

Now showing 1 - 14 of 14
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    Acinetobacter baumannii infections in the paediatric intensive care unit of a tertiary hospital in South Africa
    (2014) Reddy, Deveshnee; Argent, Andrew; Morrow, Brenda M
    Acinetobacter baumannii (A. baumannii) is now increasingly recognised as an important cause of nosocomial infections in paediatric intensive care unit (PICU) patients, particularly in developing countries, where it contributes significantly to morbidity and mortality. Furthermore, it has been documented that emerging antimicrobial resistance patterns complicate antibiotic choice in these patients. At present, more paediatric data is needed regarding these infections. This is a retrospective case-control study that aims to document the demographic data and relevant clinical details of patients in whom A. baumannii was cultured, either from blood or respiratory specimens (thus including both infections and colonisation), in the PICU at Red Cross War Memorial Children's Hospital (RCWMCH) during 2010. Secondary objectives include comparing these patients with those in whom A. baumannii was not cultured and determining which isolates were causing infection and which were colonisers. In addition; of the isolates regarded as infections, documenting the antimicrobial sensitivities and resistance of the organisms cultured, determining whether infections were late or early onset and determining whether specific bed numbers were consistently involved.
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    Acquired infections in paediatric patients after cardiac surgery
    (2015) Appel, Ilse Nadine; Argent, Andrew; Morrow, Brenda
    Introduction: Hospital acquired infections (HAIs) are an important cause of morbidity and mortality following paediatric cardiac surgery. Aim: To determine the incidence, risk factors for and outcome of postoperative HAIs in the Paediatric Intensive Care Unit (PICU) of the Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town. Methods: A prospective observational study of all postoperative cardiac patients admitted to PICU from September 2011 to March 2012. The definitions of laboratory confirmed blood stream infections (BSI), urinary tract infections (UTI), and surgical site infections were based on the Centres of Disease Control criteria. Ventilator associated pneumonia (VAP) was diagnosed using a modification of the Clinical Pulmonary Infection Score (CPIS). Results: 110 patients (median age 19 months; 43% male) undergoing 126 surgical procedures were enrolled. Sixty HAIs occurred in 43 (39%) patients (68.3% pulmonary; 13.3% blood; 11.7% wound; 3.3% urine; 3.3% tissue). Nine (8.2%) patients died and their deaths were not related to HAIs.
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    Cardiac arrest in children preceding PICU admission: Aetiology and outcome in a developing country
    (2015) Appiah, John Adabie; Argent, Andrew; Salie, Shamiel
    Objective: To describe the characteristics and outcomes of children admitted to PICU following cardiac arrest between January 2010 and December 2011. Methods: Retrospective descriptive study of routinely collected data. Results: Of 2501 PICU admissions, 110 (4.4%; 58.7% male) had preceding cardiac arrest, 80.6% of which occurred in hospital. Median (IQR) age was 7.2 (2.5 - 21.6) months; 30.8% had chronic underlying disease. Children presented most commonly with respiratory (n=28, 27.2%), cardiovascular (n= 22, 21.4%), and gastrointestinal disease (n= 20, 19.4%). Twenty-eight (27.2%) arrested while undergoing a procedure. Cardiopulmonary resuscitation (CPR) was given for median (IQR) 10 (5 - 20) minutes. Thirty-five (34%) patients received no adrenaline, 44 (42.7%) received up to 3 doses of adrenaline, and 24 (23.3%) received more than 3 doses of adrenaline during resuscitation. Duration of CPR and number of adrenaline doses did not significantly influence patient outcome. Survival to PICU discharge was 63 (61.2%), 57 (55.3%) survived to hospital discharge with half the deaths in PICU occurred within 24 hours of PICU admission. Out of 51 survivors whose neurological status were assessed 32 were normal, 6 had mild disability, 7 had moderate disability and 6 had severe disability. Standardized mortality ratio (actual/mean predicted) was 0.7. The median (IQR) length of stay in PICU and hospital were 3 (1 - 8) and 27 (9 -52) days respectively. Pediatric risk of mortality (PIM2) score was the only variable independently associated with mortality on multiple logistic regression (adjusted OR 1.05; 95% CI 1.02 - 1.07; p=0.0009).
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    Clinical features and outcome of patients with severe lower respiratory tract infection admitted to a Paediatric Intensive Care Unit in the Western Cape, South Africa
    (2016) Hutton, Hayley; Zar, Heather J; Argent, Andrew
    Objective: Acute lower respiratory tract infection (ALRTI) remains an important cause of childhood morbidity and mortality in low and middle income countries (LMIC). This study aims to describe the clinical features of children admitted to a Pediatric Intensive Care Unit (PICU) with severe ALRTI and to investigate risk factors, clinical course and in-hospital outcome. Design: Retrospective cohort study Setting: Red Cross War Memorial Children's Hospital, Cape Town, South Africa Patients: 265 children (0-12years) admitted to the PICU during 2012 with a primary diagnosis of ALRTI. Intervention: None. Measurements and main results: 265 patients [median (interquartile range, IQR) age 4 months (2-12months)] were admitted with ALRTI, 157(59.3%) were male. Co-morbid disease was present in 102(38.5%) including cardiac disease in 42(15.9%) or tuberculosis in 7(6.4%) . While only 27(10.2%) were HIV infected, 87(32.8%) children were HIV exposed. The in-hospital mortality was 34(12.8%); 24(9.1%) died in PICU and a further 10 in the medical wards following discharge from PICU. The median duration of ICU and hospital stay was 4.0 days (2.0-8.0) and 12.5 days (7.9-28.0) respectively. Most [192 (72.5%)] children required invasive ventilatory support, while 42 (15.8%) patients required cardiac inotropic support. Risk factors for mortality included severe malnutrition (Odds ratio (OR) 8.25; 95% CI 1.47- 46.21); informal housing without access to piped water and/or electricity (OR11.87; CI 1.89- 20.81); or need for inotropic support (OR 44.35; CI 8.20-239.92). HIV exposure or infection was associated with a significantly longer duration of hospital stay (p=0.002). Conclusion: Severe ALRTI occurs predominantly in young infants and is associated with a high mortality. Several sociodemographic risk factors impact on the risk of severe disease and poorer outcome.
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    Developing a patient-centred care pathway for paediatric critical care in the Western Cape
    (2015) Hodkinson, Peter William; Wallis, Lee; Argent, Andrew
    Background: Emergency care of critically ill or injured children requires prompt identification, high quality treatment and rapid referral. This study examines the critical care pathways in a health system to identify preventable care failures by evaluating the entire pathway to care, the quality of care at each step along the referral pathway, and the impact on patient outcomes. Methods: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation until paediatric intensive care unit admission or emergency centre death, using a modified confidential enquiry process of expert panel review and caregiver interview. Outcomes were expert panel assessment of quality of care, avoidability of death or PICU admission and severity at PICU admission, identification of modifiable factors, adherence to consensus standards of care, as well as time delays and objective measures of severity and outcome. Results: The study enrolled 282 children: 85% medical and 15% trauma cases (252 emergency admissions, and 30 children who died at referring health facilities). Global quality of care was graded poor in 57(20%) of all cases and 141(50%) had at least one major impact modifiable factor. Key modifiable factors related to access and identification of the critically ill, assessment of severity, inadequate resuscitation, delays in decision making and referral, and access to paediatric intensive care. Standards compliance increased with increasing level of healthcare facility, as did caregiver satisfaction. Children presented primarily to primary health care (54%), largely after hours (65%), and were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 74% of children, indicating room for improvement. Conclusions and Relevance: The study presents a novel methodology, examining the quality of paediatric critical care across a health system in a middle income country. The findings highlight the complexity of the care pathway and focus attention on specific issues, many amenable to suggested interventions that could reduce mortality and morbidity, and optimize scarce critical care resources; as well as demonstrating the importance of continuity and quality of care throughout the referral pathway.
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    Disease profile and outcomes of neonates admitted to the paediatric intensive care unit at Red Cross War Memorial Children's hospital in Cape Town, South Africa
    (2023) Riemer, Linda; Argent, Andrew; Morrow Brenda
    Aim Neonatal healthcare is an area of focus in reducing global child mortality. Unwell neonates are usually managed in neonatal intensive care (NICU) but sometimes are admitted into paediatric units (PICU). This study aimed to describe the profile of neonates admitted to a South African PICU and to identify risk factors associated with mortality. Methods Patients with a post-menstrual age of <44 weeks, admitted to the PICU between November 2018 and October 2019, were included in a prospective observational study. Associations with mortality were evaluated with univariate and multivariable logistic regression analyses. Results 266 neonates (median birthweight 2210g (IQR 1397 – 2995g); chronological and post-menstrual age at admission 11 days (IQR 2 – 28) and 38 weeks (35 – 40) respectively were included, accounting for 18.4% of PICU admissions. The largest referral source were tertiary NICUs. Surgical admissions accounted for most patients. Congenital abnormalities occurred in 50.4% of the cohort. Neonatal mortality at ICU discharge was 10.9% compared to 3.8% in older patients (OR 3.08. CI 1.89 – 5.02; p = <0.001). Congenital abnormalities were the most common group of conditions associated with mortality, followed by NEC and infections. After logistic regression analysis the only variables independently associated with death/palliation were oscillatory ventilation, TPN and feeds received. Conclusion We describe a cohort of predominantly term and normal birth weight neonates but also includes expremature babies. Closer analysis of neonatal referral pathways can build on this study. All of this data can help policymakers and unit managers improve neonatal care.
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    An investigation into nonbronchoscopic bronchoalveolar lavage and endotracheal suctioning in critically ill infants and children
    (2005) Morrow, Brenda May; Argent, Andrew; Futter, Merle
    This thesis investigated the effects on critically ill, mechanically ventilated paediatric patients of two related, frequently performed physiotherapy procedures: nonbronchoscopic bronchoalveolar lavage (NB-BAL) and endotracheal (ET) suctioning. General aims: To investigate un- or poody-documented complications of paediatric NBBAL and ET suctioning, and to test a method for each procedure of reducing the incidence and/or severity of these complications.
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    Leaving the party - withdrawal of South African essential medicines
    (2005) Wilmshurst, Jo M; Blockman, Marc; Argent, Andrew; Gordon-Graham, Eugenie; Thomas, Jenny; Whitelaw, Andrew; McCulloch, Mignon; Ramiah, Malitha; Dyeshana, H; Ireland, Joe
    In August 2004 pharmacies and drug depots were advised that the sole supplier of parenteral phenobarbitone in South Africa, essential for the management of status epilepticus in children, was stopping production at the end of the same year. Alternative protocols for the management of status epilepticus resulted in more children requiring intensive care intervention (N = 9) at the Red Cross Children’s Hospital, over a 2-month period, than had occurred in any 12-month period since 2000 (2000 N = 3, 2001 N = 1, 2002 N = 1, 2003 N = 2, 2004 N = 7). Other agents that have suffered or are at risk of the same fate are sodium nitroprusside, labetalol and esmolol. Sodium nitroprusside is used extensively in the peri-operative period in cardiac patients requiring after-load reduction. There are no other nitrates with equivalent efficacy. Supply was stopped in 2005 and only reinstated after the pharmaceutical company was contacted directly. Supply of labetalol and esmolol was stopped without warning. Without access to these products it is necessary to resort to agents that are not appropriate for paediatric use. Acetylcysteine (Parvolex), used in the management of acetaminophen overdose, also became unavailable and the supply was re-established only after direct communication with the pharmaceutical company.
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    Optimising stabilisation of the critical ill child in the medical emergency unit at the Red Cross War Memorial Children's Hospital : an enthnographic study
    (2013) Bonaconsa, Candice Hilda; Coetzee, Minette; Argent, Andrew
    Includes abstract. Includes bibliographical references.
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    Outcomes following admission to paediatric intensive care: A systematic review
    (2020) Procter, Claire; Argent, Andrew; Morrow, Brenda
    Introduction Paediatric Intensive Care has developed rapidly in recent years with a dramatic increase in survival rates. However, there are increasing concerns regarding the impact that admission to a Paediatric Intensive Care Unit (PICU) has on both the child and their family. Following discharge from PICU, children may be living with complex medical problems as well as dealing with the psychosocial impact that their illness has had on them and their family. Objectives To describe the long-term health outcomes of children admitted to a paediatric intensive care unit (PICU). Methods A full literature search was conducted including the databases; MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, (CENTRAL), Scopus, Web of Science, CINAHL, ERIC, Health Source Nursing/Academic, APA PsycInfo. All studies including children under 18 admitted to a PICU were included. Primary outcome was short- and longerterm mortality. Secondary outcomes were neurodevelopment/cognition/school performance; physical function, psychological function/behaviour impact, quality of life outcomes and social/family implications. Studies focused on Neonatal Intensive Care Admission and articles with no English translation were excluded. Results One hundred and five articles were included in the analysis. Mortality in PICU ranged from 1.3% to 50%. Mortality in high income countries reduced over time but the data did not show the same trend for low- and middle-income countries. Higher income countries were found to have lower Standardised Mortality Rates (SMRs) than low- and middle-income countries. Children had an ongoing risk of death for up to 10 years following PICU admission. Children admitted to PICU also have more ongoing morbidity than their healthy counterparts with more cognitive/developmental problems, more functional health issues, poorer quality of life as well as increased psychological problems. Their parents also have an increased risk of Post Traumatic Stress Disorder (PTSD). Discussion Most of the studies identified are from high income countries and only include short-term follow up. More data is needed from low- and middle-income countries and over longer terms. The studies were markedly heterogenous and were all observational. Agreement is needed regarding which outcomes are most important to measure as well as standardised methods of assessing them. Further research is needed to identify the risk factors which cause children to have poorer outcomes as well as to identify predictive and modifiable factors which could be targeted in practice improvement initiatives.
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    Pathways to care for critically ill or injured children: A cohort study from first presentation to healthcare services through to admission to intensive care or death
    (Public Library of Science, 2016) Hodkinson, Peter; Argent, Andrew; Wallis, Lee; Reid, Steve; Perera, Rafael; Harrison, Sian; Thompson, Matthew; English, Mike; Maconochie, Ian; Ward, Alison
    Purpose Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. METHODS: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. RESULTS: The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. CONCLUSIONS: The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.
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    A retrospective review of patients admitted to the Paediatric ICU at Red Cross War Memorial Children's Hospital during 2010 with the clinical diagnosis of measles or measles-related complications
    (2013) Coetzee, Saskia; Argent, Andrew; Morrow, Brenda M
    Includes abstract. Includes bibliographical references.
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    Serious adverse drug reactions at two children’s hospitals in South Africa
    (2020-01-04) Mouton, Johannes P; Fortuin-de Smidt, Melony C; Jobanputra, Nicole; Mehta, Ushma; Stewart, Annemie; de Waal, Reneé; Technau, Karl-Günter; Argent, Andrew; Kroon, Max; Scott, Christiaan; Cohen, Karen
    Abstract Background The high HIV prevalence in South Africa may potentially be shaping the local adverse drug reaction (ADR) burden. We aimed to describe the prevalence and characteristics of serious ADRs at admission, and during admission, to two South African children’s hospitals. Methods We reviewed the folders of children admitted over sequential 30-day periods in 2015 to the medical wards and intensive care units of each hospital. We identified potential ADRs using a trigger tool developed for this study. A multidisciplinary team assessed ADR causality, type, seriousness, and preventability through consensus discussion. We used multivariate logistic regression to explore associations with serious ADRs. Results Among 1050 patients (median age 11 months, 56% male, 2.8% HIV-infected) with 1106 admissions we found 40 serious ADRs (3.8 per 100 drug-exposed admissions), including 9/40 (23%) preventable serious ADRs, and 8/40 (20%) fatal or near-fatal serious ADRs. Antibacterials, corticosteroids, psycholeptics, immunosuppressants, and antivirals were the most commonly implicated drug classes. Preterm neonates and children in middle childhood (6 to 11 years) were at increased risk of serious ADRs compared to infants (under 1 year) and term neonates: adjusted odds ratio (aOR) 5.97 (95% confidence interval 1.30 to 27.3) and aOR 3.63 (1.24 to 10.6) respectively. Other risk factors for serious ADRs were HIV infection (aOR 3.87 (1.14 to 13.2) versus HIV-negative) and increasing drug count (aOR 1.08 (1.04 to 1.12) per additional drug). Conclusions Serious ADR prevalence in our survey was similar to the prevalence found elsewhere. In our setting, serious ADRs were associated with HIV-infection and the antiviral drug class was one of the most commonly implicated. Similar to other sub-Saharan African studies, a large proportion of serious ADRs were fatal or near-fatal. Many serious ADRs were preventable.
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    Why, how and when do children die in a Paediatric Intensive Care Unit (PICU) in South Africa?
    (2020) Wege, Martha Helena; Morrow, Brenda; Rossouw, Beyra; Argent, Andrew
    Objectives: To describe the characteristics of children who died and their modes of dying in a South African Paediatric Intensive Care Unit (PICU). Design: Retrospective review of data extracted from the Child Healthcare Problem Identification Programme (Child PIP)and the PICU summary system (admission and death records) on children of any age who died in the PICU between 01 January 2013 and 31 December 2017. Setting: Single-centre tertiary institution. Patients: All children who died during PICU admission were included. Measurements and Main Results: Four-hundred and fifty-one (54% male; median (IQR) age 7 (1-30) months) patients died in PICU on median (IQR) 3 (1-7) days after PICU admission; 103 (22.8%) had a cardiac arrest prior to PICU admission. Mode of death in 23.7% (n=107) was withdrawal of life sustaining therapies; 36.1% (n=163) died after limitation of life sustaining therapies; 22.0% (n=99) died after failed resuscitation and 17.3% (n=78) were diagnosed brain dead. Ultimately, 270 (60%) children died after the decision to limit or withdraw life sustaining therapies. There was no difference in the number of deaths during office and after-hours periods (45.5% vs. 54%; p = 0.07). Severe sepsis (21.9%) was the most common condition associated with death, followed by cardiac disease (18.6%).Ninety-four (20.8%) patients were readmitted to the PICU within the same year; 278 (61.6%) had complex chronic disorders. During the last phase of life, 75.0% (n=342) were on inotropes, 95.9% (n=428) were ventilated, 12.0% (n=45) received inhaled nitric oxide and 10.8% (n=46) renal replacement therapy. Only 1.5% (n=7) of children became organ donors and postmortems were done in 47.2% (n=213) of the patients. Conclusions: Most PICU deaths occurred after a decision to limit or withdraw life-sustaining therapy. Severe sepsis was the most common condition associated with death. Referral for organ donation was extremely rare.