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
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).
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.