Presentation and immediate outcome of critically ill children presenting to acute care unit, MulagoHospital
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Background: Each year about eleven million children die before reaching their fifth birthday. About a third of these deaths occur in health units and most of health unit deaths happen within 24 hours of presentation. It is therefore important to identify children presenting to health units that are at most risk of death, so that effective interventions are put in place to prevent these deaths. This study describes the presentation, immediate outcome, and factors associated with mortality in critically ill children presenting at ACU in Mulago hospital. Methods: This was a cohort study of children aged 2 months-59 months with critical illness as identified by the WHO/IMCI triage system as patients in need of emergency care. This triage system identifies children with one or more of the following signs: Obstructed breathing, central cyanosis, rapid and weak pulse, cold and blue hands, feet capillary refill > 3sec, lethargy/ unconsciousness, sunken eyes, very slow skin pinch and active convulsions. All patients presenting to Acute Care Unit in Mulago hospital were screened for these signs of critical illness. Those meeting the study criteria were consecutively recruited until the required sample size was attained. Emergency care and specific therapy were offered using the hospital guidelines and the patients then followed up for 48-hours or until death (if this occurred earlier), to determine survival. Results: During the study period, 2867 children were screened for eligibility. Of the 2867 children, 283 (9.9%) children had signs of critical illness. Thirteen children were excluded because of incomplete data. Two hundred seventy were recruited into the study, and 268 were analyzed following completion of follow up. The majority of patients, 150/268 (55.9%) were males and 203/268 (75.7%) were under the age of 2 years. Signs of impaired perfusion was the most common presenting feature; 106 (39.6%) had sunken eyes, 87 (32.5%) had a very slow skin xi pinch, and 82 (30.6%) had a weak and rapid pulse. The other critically ill children had; obstructive breathing 42 (15.7%), active convulsions 66 (24.4%) cyanosis 25(9.3%) or unconsciousness 20 (7.5%). Overall, 40/268 (15%) died within 48 hours of admission. The majority, 27/40 (67.5%) of these deaths occurred within the first 12 hours of admission. Risk factors independently associated with death at 48 hours were inability to feed, (OR 4.26, 95% CI 1.79-10.16, p=0.001), difficulty in breathing (OR 4.55, 95% CI 1.98-10.48, p=<0.001), thin pulse volume, (OR 6.27, 95% CI 2.42-16.27, p=< 0.001); and malnutrition, (OR 4.30, 95% CI 1.28-14.48, p=0.018). Conclusions: Mortality among critically ill children admitted in the ACU is unacceptably high at 15% with majority dying within the first 12 hours of admission. Signs of impaired perfusion were the commonest presentations. Factors independently associated with death include difficulty in breathing, inability to feed, malnutrition, thin volume pulse and being female. Recommendations: An unacceptable number of critically ill children die in our setting; there is therefore need for improved emergency care of these children especially in the first 12 hours. Fluid resuscitation may be a life saving intervention since the majority present with signs of impaired perfusion. Further studies should be done to describe health unit factors that affect patient outcome and to investigate if early intervention in fluid and airway support would result in mortality reduction in the first 12-hours and also investigate reasons for higher mortality in the malnourished and female gender in view to rectifying.