Browsing by Author "Morrow, Brenda M"

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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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    An audit of transfers into the PICU at the Red Cross War Memorial Children's Hospital: a follow up study
    (2016) Dimitriades, Konstantinos; Argent, Andrew C; Morrow, Brenda M
    Background: Children are transferred from various facilities into the paediatric intensive care unit (PICU) at the Red Cross War Memorial Children's Hospital for critical care, without a specialised paediatric transfer service. A previous audit in 2003 reported a high incidence of technical, clinical and critical adverse events during transfers. Objective: To conduct a follow -up audit on interfacility transfers into PICU to determine practice and outcome changes. Methodology: Prospective observational study of all patients transferred into PICU between 1 Dec ember 2013 and 30 November 2014 and compared to the 2003 audit by Hatherill et al. Results: Analysis was performed on 204 transfers (median (IQR) age 1.8 (0.2 – 12.6) months and compared to results reported by Hatherill et al (2003). The proportion of medical transfers decreased (49% to 34.3% p=0.003) as well as the referrals from metropolitan hospitals (34.7% to 17.6%, p = 0.0001), whilst the number of referrals from academic hospitals increased from 35.1% to 44.6% (p = 0.05). Staff accompanying transfers and transfer times remained unchanged. The proportion of fixed wing transfers increased from 14.4% to 25.5% (p=0.006) whilst Helicopter transfers decreased from 9.9% to 1% (p <0.0001). 58.4% of patients were in tubated for transfer in 2003 compared to 69.1% in 2014 (p = 0.02). The rate of technical (35.6% to 39.7%, p = 0.4), clinical (26.7% to 31.9%, p = 0.25), and critical (8.9% to 8.8%, p = 0.97) adverse events remained unchanged. PICU Mortality decreased from 16.8% to 9.45% (p=0.03) with a decrease in Standardized Mortality Rate from 1.11 to 0.68. Three children died on arrival to PICU. The communication tool was used in 45.1% of transfers and its use was noted to be associated with significantly less critical adverse events (4.3% vs. 12.5%, p = 0.048). Technical adverse events were positively correlated with the clinical adverse events (Spearman's R = 0.3; p=0.000008) and critical adverse events (Spearman's R = 0.1; p = 0.03). In turn the total number of clinical adverse events were positively correlated with the total number of critical adverse events (Spearman's R = 0.5; p < 0.000001). The multiple regression analysis for PICU mortality found the total number of clinical adverse events to be independently associated with ICU mortality (adjusted OR 95% CI 2.8 (1.7 -4.7); p = 0.0001) Conclusion: The rate and staffing structure of interfacility transfers into PICU have remained unchanged, and associated adverse event rates remain high. Changes are noted in the profile of transferred patients as well as adverse events. Efforts to formalize the paediatric transfer service must be strengthened whilst using interim measures to improve the current standard through education, improved skills and PICU support.
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    An evaluation of the compliance to the ventilation aspects of airborne infectious disease control in Cape Town, South Africa
    (2016) Groenewald, Coenraad; Morrow, Brenda M; Meintjes, Jack
    Background: Tuberculosis (TB) is a major healthcare problem worldwide and is endemic to Cape Town, South Africa. Health Care Workers in Emergency Centers (ECs) are at high risk of nosocomial TB infection. The aim of this study was to determine whether the isolation rooms (IRs)in emergency centers, for patients with diagnosed or suspected TB, comply with set National Core Standards. Methods: This was a cross-sectional descriptive study of ECs in the Cape Town Metropolitan area. .The characteristics of IRs with regards to air changes per hour (ACH), negative pressure ventilation with relation to the surrounding areas and appropriate discharge of air outdoors or via filters before recirculation was measured using standard objective engineering methods. Results: 19 IRs in 8 ECs were evaluated, none of which complied with the National Core Standard's ideal requirements for IRs. Five complied with minimal requirements . Eleven (57,9%) IRs were designed to have negative pressure; and 8 (42,1%) rooms were not designed for isolation purposes, . IR volumes ranged from 15,5 m³ to 67,2 m³ (median 35,6 m³). Five (26,3%) IRs were under negative pressure; 7 (36,8%) had erratic air flow; and 7 (36,8%) showed positive airflow from the IR into adjacent clinical areas. Fifteen (78,9%) IRs had central provision of air via a ventilation system; 6 (31,6%) had central air extraction; 6 (31,6%) had local extraction; and 7 (36,8%) used natural ventilation only. Four local extraction units had zero flow rate. Airflow in naturally ventilated IRs was significantly lower than flow with other systems (p = 0,0002). The ACH ranged from 0 (n=4) to 112.37 (median 11,9); and was significantly greater in rooms ventilated with central extraction compared to other systems (p = 0,00002). Discussion: The ventilation aspects of airborne infectious disease control are generally poorly implemented. This may contribute to, and fail to mitigate, the high risk of nosocomial transmission of airborne infectious diseases to staff and other patients utilising emergency facilities in the TB endemic areas of Cape Town. Conclusion: Existing ECs should improve adherence to standards of airborne infectious disease transmission prevention in order to protect patients and staff from nosocomial airborne transmitted diseases, such as TB. New Hospitals should place a high priority on the amount, positioning and maintenance of IRs when planning their facility.
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    Indication for and outcomes of continuous Positive Airways Pressure (CPAP) and High Flow Nasal Cannula oxygen therapy (HFNC) in children admitted to Red Cross War Memorial's Hospital (RCWMCH) excluding those with primary respiratory aetiologies
    (2017) Browde, Kate; Morrow, Brenda M; McCulloch, Mignon
    Aim: Noninvasive Continuous Positive Airway Pressure (nCPAP) and High Flow Nasal Cannula oxygen therapy (HFNC) are non-invasive ventilation (NIV) modalities appropriate for children in developing countries. There is minimal literature describing nCPAP and HFNC use in children with respiratory compromise secondary to non-pulmonary disease. This study aimed to describe the characteristics and outcomes of all children without primary lung pathology, who received nCPAP and HFNC during their admission to Red Cross War Memorial Children's Hospital, Cape Town, South Africa. Methods: This was a prospective observational study of routinely collected data, between August 2015 and January 2016. Primary and secondary outcome measures were NIV failure (progression to intubation and invasive ventilation) and Paediatric Intensive Care Unit (PICU) admission respectively. Comparative statistics were conducted using Mann-Whitney U tests. Data significantly associated with the primary and secondary outcomes on univariate analysis were entered into backward stepwise logistic regression models to determine independent predictive factors. Results: There were 31 cases of nCPAP and one case of HFNC use in 31 patients (median (IQR) age 3.5 (1.8 – 7.6) months. The majority (n=23; 71.9%) presented with primary diarrhoeal disease. There were two deaths (6.5%), 17 (53.1%) Paediatric Intensive Care (PICU) admissions, and five (15.6%) cases received invasive ventilation (NIV failure). Median (IQR) duration of hospital stay was 11.50 (6.0 – 17.5) days. Patients who failed NIV had lower admission SaO2 than those without treatment failure (95 (95-99)% vs 100 (100-100)%; p = 0.03). On multiple logistic regression, lower temperature (OR 0.19; 95% CI 0.05 – 0.78; p = 0.02) and receiving inotropes in the emergency setting, (OR 23.05; 95% CI 1.64 – 325.06; p = 0.02) were independently associated with PICU admission. Conclusions: nCPAP is used clinically for the management of children with respiratory compromise secondary to non-pulmonary illnesses, particularly diarrhoeal disease. Larger controlled clinical studies are needed to determine the effectiveness and utility of nCPAP in this population. HFNC was not commonly used, and this modality requires further investigation in this population.
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    Informed consent in paediatric critical care research – a South African perspective
    (BioMed Central, 2015-09-09) Morrow, Brenda M; Argent, Andrew C; Kling, Sharon
    Background: Medical care of critically ill and injured infants and children globally should be based on best research evidence to ensure safe, efficacious treatment. In South Africa and other low and middle-income countries, research is needed to optimise care and ensure rational, equitable allocation of scare paediatric critical care resources. Ethical oversight is essential for safe, appropriate research conduct. Informed consent by the parent or legal guardian is usually required for child research participation, but obtaining consent may be challenging in paediatric critical care research. Local regulations may also impede important research if overly restrictive. By narratively synthesising and contextualising the results of a comprehensive literature review, this paper describes ethical principles and regulations; potential barriers to obtaining prospective informed consent; and consent options in the context of paediatric critical care research in South Africa. Discussion: Voluntary prospective informed consent from a parent or legal guardian is a statutory requirement for child research participation in South Africa. However, parents of critically ill or injured children might be incapable of or unwilling to provide the level of consent required to uphold the ethical principle of autonomy. In emergency care research it may not be practical to obtain consent when urgent action is required. Therapeutic misconceptions and sociocultural and language issues are also barriers to obtaining valid consent. Alternative consent options for paediatric critical care research include a waiver or deferred consent for minimal risk and/or emergency research, whilst prospective informed consent is appropriate for randomised trials of novel therapies or devices. Summary: We propose that parents or legal guardians of critically ill or injured children should only be approached to consent for their child’s participation in clinical research when it is ethically justifiable and in the best interests of both child participant and parent. Where appropriate, alternatives to prospective informed consent should be considered to ensure that important paediatric critical care research can be undertaken in South Africa, whilst being cognisant of research risk. This document could provide a basis for debate on consent options in paediatric critical care research and contribute to efforts to advocate for South African law reform.
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    An investigation into regional ventilation in infants and children; its distribution and determinants
    (2017) Lupton-Smith, Alison Rosalie; Morrow, Brenda M; Argent, Andrew C
    Changing body position is commonly used in the management of individuals with respiratory diseases and those receiving mechanical ventilation, in order to optimise ventilation and oxygenation. In acute respiratory distress syndrome (ARDS), prone positioning is reported to improve oxygenation by recruiting collapsed dorsal lung regions, although this has not been confirmed in children. Ventilation distribution is well established in adults as being gravity dependent. Clinical practice in the paediatric population has been guided by the notion that all children, irrespective of the presence or absence of disease and age, consistently demonstrate the opposite ventilation distribution pattern to adults and this pattern is said to occur until the second decade of life. Studies in the paediatric population are limited to a few reported from the 1980's, on very heterogeneous populations. With advances in technology, new methods of examining regional ventilation, such as electrical impedance tomography (EIT), have become available. Recent neonatal studies using EIT have reported a dissimilar ventilation distribution to the conventional paediatric pattern. Despite a growing number of studies examining the effects of various interventions on ventilation distribution, very few exist in infants and children older than 6 months of age. Furthermore, differing methodologies and the manner in which ventilation distribution is described and analysed makes pooling the available data in the paediatric population extremely difficult. An understanding of how ventilation is distributed under normal conditions is imperative when examining the effects of different interventions and medical conditions on ventilation distribution. This thesis aimed to describe the effects of body position, head position, age, and respiratory muscle activity on ventilation distribution in children between six months and nine years of age under normal conditions, with respiratory disease, neuromuscular disease, and during mechanical ventilation. Furthermore, the effect on ventilation distribution of prone positioning in children with ARDS was evaluated. Regional ventilation distribution was measured using thoracic EIT and respiratory muscle activity was measured using surface electromyography (sEMG) using standardised methodology. Results of a series of sub-studies indicate that ventilation distribution is more complex and variable than previously thought, with no standard "paediatric pattern" of ventilation. Overall, greater ventilation occurred in the right and dorsal lungs, respectively, in different positons. Head position did not affect regional ventilation in the children studied. Age had a variable effect on ventilation distribution, with healthy children under 12 months of age more likely to follow the paediatric pattern, particularly in side lying positions; however the response was not uniform. The presence of mechanical ventilation, disease state and respiratory muscle activity did not affect ventilation distribution with these children also showing variable patterns of regional ventilation distribution. Data suggests that turning children with ARDS into the prone position does not result in recruitment of the dorsal lung regions, but rather more homogenous ventilation throughout the lungs. Furthermore, results suggest that children with greater ventilation inhomogeneity at baseline are more likely to respond positively (improvement in oxygenation index) to prone positioning. This research provides novel insights into ventilation distribution and respiratory muscle activity in infants and children older than six months of age under a number of different conditions. These results contribute to a better understanding of the factors influencing the distribution of regional ventilation and the mechanisms by which prone positioning in ARDS may improve oxygenation in this population. These findings have potentially important clinical implications, as well as providing baseline data for future clinical studies. Given the variability observed, these studies highlight the potential clinical utility of EIT to monitor different interventions and outcomes. An important strength of the studies presented in this thesis, is that they were performed in a standardised manner, using relatively homogenous individual populations and validated measures of describing ventilation distribution. This methodology could provide a template for future studies in the paediatric population, to allow for comparison between studies.
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    An investigation into the use of intensive therapy, with and without constraint-induced movement therapy, in South African children with hemiplegia
    (2005) Geretto, Esther; Jelsma, Jennifer; Morrow, Brenda M
    This research project aimed to determine whether a two-week period of intensive physiotherapy in groups, using the Neurodevelopmental Approach or Constraint Induced Movement Therapy (CIMT), would result in a functional improvement in the hand function of children with hemiplegia. It also aimed to determine if group CIMT was more effective than group physiotherapy based on the Neurodevelopmental (NDT) approach. The feasibility of CIMT in the South African context was also investigated Sixty-five children with hemiplegia were requested to participate in the research study at the Red Cross Children's Hospital in Cape Town, South Africa. Twelve of these patients eventually participated in the study. They were divided into CIMT and NDT based physiotherapy groups. Both groups received intensive physiotherapy for a period of two weeks (every day for two hours). The non-affected upper limb of the CIMT group was restrained with a glove, whilst the NOT based physiotherapy group was unrestrained. The children were assessed before therapy, directly after therapy at two weeks, using the Peabody Developmental Fine Motor Scale and kinematic analysis (Vicon Clinical Manager), and again one month later using the Peabody Developmental Fine Motor Scale. The results showed that the children (in both the CIMT and NDT-based physiotherapy groups) demonstrated a significant improvement in grasp function (with a change in median grasp score from 28.5 to 33.0, p<0.02) and visual motor integration (with a change in median VMI score from 71.0 to 78.0, p<0.02) following two weeks of intensive physiotherapy and that this improvement in function was maintained for a month following therapy. There did not appear to be any benefit of group CIMT over that of NDT based physiotherapy - however this is said with caution due to the small sample size. Through the questionnaire and informal interviews, it was felt that CIMT in its' current form was not feasible for use in the South African context, mainly due to lack of financial and human resources. Further research is recommended to determine whether a different mode of CIMT therapy would be more feasible in the South African context. However, it was felt that due to the improvement seen after two weeks of group intensive physiotherapy, an attempt should be made to integrate periodic sessions of intensive group therapy into local community settings, particularly in the South African context of inadequate resources, to provide regular therapy to children living in rural areas.
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    Pneumocystis pneumonia in South African children diagnosed by molecular methods
    (BioMed Central, 2014-01-10) Morrow, Brenda M; Samuel, Catherine M; Zampoli, Marco; Whitelaw, Andrew; Zar, Heather J
    Background: Pneumocystis pneumonia (PCP) is an important cause of hospitalization and mortality in HIV-infected children. However, the incidence of PCP has been underestimated due to poor sensitivity of diagnostic tests. The use of polymerase chain reaction (PCR) for pneumocystis has enabled more reliable diagnosis. This study describes the incidence, clinical features and outcome of PCP in South African children diagnosed using PCR. Methods: A prospective study of children hospitalised in South Africa with suspected PCP was done from November 2006 to August 2008. Clinical, laboratory and radiological information were collected. Lower respiratory tract specimens were obtained for PCP immunofluorescence (IF), real- time PCR for pneumocystis, bacterial and mycobacterial culture. Nasopharyngeal aspirates were taken for immunofluorescence (IF), real-time PCR for pneumocystis and PCR for respiratory viruses. A blood specimen for bacterial culture and for cytomegalovirus PCR was taken. Children were followed for the duration of their hospitalisation and the outcome was recorded. Results: 202 children [median (interquartile range, IQR) age 3.2 (2.1– 4.6) months] were enrolled; 124 (61.4%) were HIV infected. PCP was identified in 109 (54%) children using PCR, compared to 43 (21%) using IF and Grocott staining (p < 0.0001). Most PCP cases (88, 81%) occurred in HIV-infected children. All 21 cases (19%) occurring in HIV- negative children had another risk factor for PCP. On logistic regression, predictive factors for PCP were HIV infection, lack of fever, high respiratory rate and low oxygen saturation whilst cotrimoxazole prophylaxis was protective (OR 0.24; 95% CI 0.1 to 0.5; p < 0.002). The case fatality of children with PCP was higher than those without PCP (32.1% versus 17.2%; relative risk 1.87; 95% confidence interval (CI) 1.11 – 3.15). Amongst HIV-infected children, a CD4 less than 15% was the only independent predictor of mortality. Conclusions: The diagnostic yield for PCP is more than 2.5 times higher on PCR than other detection methods. PCP is a very common cause of severe hypoxic pneumonia and is associated with high mortality in HIV-infected African infants.
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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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    The use of assisted autogenic drainage in children with acute and chronic respiratory disease
    (2017) Corten, Lieselotte; Morrow, Brenda M; Jelsma, Jennifer
    Background: Respiratory problems, both acute and chronic, remain an important cause of disease burden for children worldwide. Airway clearance techniques, as part of the management of these conditions, might influence the course of the disease thereby reducing this burden. Objective: This PhD thesis aimed to explore the epidemiology and management of children with acute respiratory diseases admitted to a paediatric hospital in Cape Town, South Africa; and to determine the usefulness and safety of assisted autogenic drainage in children with an acute (pneumonia) or chronic (cystic fibrosis) respiratory disease. In order to do this, several linked studies were undertaken including a retrospective folder review, two systematic reviews and two pragmatic randomised controlled trials.