Marilyn Kioko, MD
Nominated From: University of Washington
Research Site: Kenya
Research Area: Pediatrics
Primary Mentor: Grace John-Stewart
Reduction of Shock-related Mortality in Pediatric Patients in Urban Kenya
Gertrude Children’s Hospital (GCH), Kenya’s only children’s hospital, has a 16 bed pediatric intensive care unit (PICU) and 8 satellite clinics located in Nairobi’s lowest- income neighborhoods, where children present late requiring varied levels of critical care. Despite abundance of equipment and dedicated staff, PICU admission data from 2010 documents mortality of 12%, 3-4 times the average mortality for all PICUs within the United States. Kenyatta National Hospital (KNH), the national referral center in Nairobi, sees comparable volume, with significant influx from rural districts. In 2007, 57,000 children presented to the outpatient department (OPD): 937 died prior to arrival and 151 died within the casualty, a childhood mortality rate of 13.4%. The high mortality rates within 24 hours of admission highlights the detrimental effect of late presentation, inadequate pre-hospital services and inaccessible critical care.
IRB approval was obtained in May 2013 to conduct research within GCH, begun within ICU and introduced in 3 clinics. We propose to expand study sites to KNH’s ICU and OPD. Cost-effective resource allocation, efficient resource utilization, timely intervention and transfer to PICU prevents escalation of critical illness, recognizing special populations where management varies from data published in developed nations. The protocol specifies fluid and blood transfusion parameters in severe anemia (Hb<5) malaria, sickle cell and severe malnutrition prone to cardiogenic failure. Within East Africa there is rising concern over aggressive fluid administration in these patient populations. Current data collected from GCH ICU reveals under-resuscitation and prolonged periods of metabolic acidosis, with base deficit ranging from -12.7 to -28 upon admission to ICU. Through education bundle, and high flow oxygen as an alternative to positive pressure ventilation in patients with adequate spontaneous respiration, we address this valid but often overestimated concern. Aim 1. Early Goal-Directed Therapy (EGDT) for shock to reduce mortality a. Assess current shock management in the study environment b. Implement and assess efficacy within private vs. public sector sites c. Assess pre-hospital resuscitation protocol on early (24-hour) mortality Aim 2. Develop locally adapted, internationally accepted acute care curriculum a. Provider resuscitation training and acute care education b. Assess retention of knowledge and skill-based training
Shock is a common pathway leading to mortality, as disease progresses from sepsis to severe sepsis, and septic shock. Sepsis, pneumonia, hypothermia, dehydration and malaria are leading diagnoses with most deaths occurring in 24 to 48 hours following admission. Late presentation and inadequate pre-hospital care contribute significantly to mortality, particularly within 24 hours of admission. Limited resources for critical care in Kenya, particularly mechanical ventilation, and regional practice variation necessitate focused training and implementation of appropriate monitoring, aggressive fluid resuscitation, early antibiotics, oxygen delivery and inotropic support. These fundamental steps outlined in the Global Sepsis Initiative have been shown to reduce mortality in a cohort of pediatric patients.
- Grace John-Stewart, MD, PhD, MPH
- John McGuire, MD
- Amelie von Saint Andre-von Arnim, MD
- Bhupi Reel, MD
- Rashmi Kumar, MD