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Intensive-care management of snakebite victims

Intensive-care management of snakebite victims in rural sub-Saharan Africa: An experience from Uganda

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H-J Lang, J Amito, M Duenser, Raymond Towey

Background. Antivenom is rarely available for the management of snakebites in rural sub-Saharan Africa(sSA).

Objective. To report clinical management and outcomes of 174 snakebite victims treated with basic intensive-care interventions in a rural sSA hospital.

Methods. This cohort study was designed as a retrospective analysis of a database of patients admitted to the intensive care unit (ICU) of St. Mary’s Hospital Lacor in Gulu, Uganda (January 2006 – November 2017). No exclusion criteria were applied. Results. Of the 174 patients admitted to the ICU for snakebite envenomation, 60 (36.5%) developed respiratory failure requiring mechanical ventilation (16.7% mortality).

Results. suggest that neurotoxic envenomation was likely the most common cause of respiratory failure among patients requiring mechanical ventilation. Antivenom (at probably inadequate doses) was administered to 22 of the 174 patients (12.6%). The median (and associated interquartile range) length of ICU stay was 3 (2 – 5) days, with an overall mortality rate of 8%. Of the total number of patients, 67 (38.5%) were younger than 18 years.

Conclusion. Results suggest that basic intensive care, including mechanical ventilation, is a feasible management option for snakebite victims presenting with respiratory failure in a rural SA hospital, resulting in a low mortality rate, even without adequate antivenom being available. International strategies which include preventive measures as well as the strengthening of context-adapted treatment of critically ill patients at different levels of referral pathways, in order to reduce deaths and disability associated with snakebites in sSA are needed. Provision of efficient antivenoms should be integrated in clinical care of snakebite victims in peripheral healthcare facilities. Snakebite management protocols and preventive measures need to consider specific requirements of children.

Authors’ affiliations

H-J Lang, St. Mary’s Hospital Lacor, Gulu, Uganda

J Amito, St. Mary’s Hospital Lacor, Gulu, Uganda

M Duenser, Department of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Linz, Austria

Raymond Towey, St. Mary’s Hospital Lacor, Gulu, Uganda

Full Text available by clicking HERE

Cite this article

Southern African Journal of Critical Care 2020;36(1):39-45. DOI:10.7196/SAJCC.2020.v36i1.404

Article History

Date submitted: 2020-07-30
Date published: 2020-07-30

COVID 19 APPEAL

Dear African Mission supporter,

first of all I would like to thank you for all of the the support you have given to our work to date. 

We are all living with the impact of Covid 19 and the huge upheaval it is causing to our lives. As I write the death rate caused by the virus stands at 18,500 (ONS figures in the week up to the 10th April) here in the UK. The pandemic has yet to fully impact on Africa but when it does the numbers of death are expected to be very high. We have a short window of opportunity where we can provide some vital equipment to St Mary’s Hospital in Uganda that will help in the fight against this deadly disease.

Please click HERE to see an appeal from Dr Ray Towey, who has worked in St Mary’s Hospital since 2002. Any help that you can give at this time would be very much appreciated and could well be literally life saving.

The quickest way to give is online at https://cafdonate.cafonline.org/12578#!/DonationDetails or youcan also send a cheque made payable to ‘African Mission’ to our usual address (African Mission, 12 Melior Street, London SE1 3QP).

Thank you for considering this request.

Paddy Boyle,

African Mission Administrator

Having a party at Fatima, September 2018

The young people in the video below are those who are receiving an education at Fatima Mission. Of the 21 young people residing at Fatima, 10 are deaf & unable to speak, 7 are totally blind, 3 are partially sighted (one of whom who is also partially deaf) and 1 is physically handicapped.

Before coming to Fatima many of these young people led very isolated lives and were faced with a bleak future. Thanks to the education they are receiving and the fact that they are living in community with others, their confidence and ability to relate with others is growing as you are about to see …

Research Audit in St Mary’s Hospital, Lacor Gulu, Uganda, 2017

Original article published in the journal Anaesthesia, 2017

Intensive care medicine in rural sub-Saharan Africa

M. W. Deunser1,2 R. M. Towey3 J. Amito4 and M. Mer2,5
1 Senior Consultant in Intensive Care, Department of Anesthesiology, Peri-operative Medicine and General Intensive Care Medicine, Salzburg University Hospital and Paracelsus Private Medical University, Salzburg, Austria
2 Global Intensive Care Working Group, European Society of Intensive Care Medicine, Brussels, Belgium
3 Consultant, 4 Anaesthetic Officer, Department of Anaesthetics and Intensive Care, St. Mary’s Hospital Lacor, Gulu, Uganda
5 Consultant in Intensive Care, Intensive Care Unit, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa

Summary

We undertook an audit in a rural Ugandan hospital that describes the epidemiology and mortality of 5147 patients admitted to the intensive care unit. The most frequent admission diagnoses were postoperative state (including following trauma) (2014/5147; 39.1%), medical conditions (709; 13.8%) and traumatic brain injury (629; 12.2%). Intensive care unit mortality was 27.8%, differing between age groups (p < 0.001). Intensive care unit mortality was
highest for neonatal tetanus (29/37; 78.4%) and lowest for foreign body aspiration (4/204; 2.0%). Intensive care unit admission following surgery (333/1431; 23.3%), medical conditions (327/1431; 22.9%) and traumatic brain injury (233/1431; 16.3%) caused the highest number of deaths. Of all deaths in the hospital, (1431/11,357; 12.6%) occurred in the intensive care unit. Although the proportion of hospitalised patients admitted to the intensive care unit increased over time, from 0.7% in 2005/6 to 2.8% in 2013/4 (p < 0.001), overall hospital mortality decreased (2005/6, 4.8%; 2013/14, 4.0%; p < 0.001). The proportion of intensive care patients whose lungs were mechanically ventilated was 18.7% (961/5147). This subgroup of patients did not change over time (2006, 16%; 2015, 18.4%; p = 0.12), but their mortality decreased (2006, 59.5%; 2015, 44.3%; p < 0.001).

Discussion

This study is the first to offer a comprehensive insight into the epidemiology and outcome of critical illness in a rural sub-Saharan African setting. As the ICU is the only facility in the study hospital where critically ill patients are cared for, and because the study hospital is the only inpatient facility in the region, our study population is likely to represent the true spectrum of critical illness for a large rural sub-Saharan African region. Furthermore, the virtual absence of financial barriers preventing patients from entering the ICU, which may be the case in other ICUs in low-income countries [1, 2], eliminates an important selection bias from this study.

In conclusion, our study gives a comprehensive overview of the epidemiology and outcome of critical illness in a large sub-Saharan African ICU population. It represents the first and largest study from a rural ICU in sub-Saharan Africa, and serves as an important reference for a region where there is an paucity of data, offering a greater understanding of the practice of intensive care in such areas. Although only hypothesis-generating, these results support the role of intensive care medicine as a life-saving medical specialty, even under difficult conditions and with limited resources, as well as the need to foster and grow such services in these regions.