gastroschisis and in intestinal atresia. Edmond Ntaganda,MD,MMed - - PowerPoint PPT Presentation

Fin inding ways to im improve neonatal surgical

• utcomes in

in Rwanda: An early evaluation of f gastroschisis and in intestinal atresia.

Edmond Ntaganda,MD,MMed ,FCS (ECSA) Paed

13/09/2019

Team

• Principal Investigator: Edmond Ntaganda, MMed, FCSECSA
• Co-Investigator: Robin Petroze, MD, MPH
• Sub-Investigator: Andrea Riner, MD MPH
• Sub-Investigator: Deborah Igiraneza, MD
• Sub-Investigator: James Davis, MS2
• Sub-Investigator: Alice Nsengiyumva, MS4
• Sub-Investigator: Philip Hong, MS2
• Sub-Investigator: Rosine Umutoni, M

13/09/2019

Background

• In 2010, 30-32.9% of the global disease burden were deemed to be

surgical.1,2

• In 2015, the Lancet Commission estimated that five billion people are

without access to safe, affordable surgical and anesthesia care when needed

• 1. Shrime MG, Bickler WS, Alkire BC, Mock A. Global burden of surgical disease: an estimation from

the provider perspective. Lancet Glob Health 2015;3:S8–9.

• 2. Meara, J, Leather A, Hagander L, et al. Global surgery 2030: Evidence and solutions for achieving

health, welfare, and economic development. Lancet 2015;386:569-624.

13/09/2019

Background CTD

• The Global Initiative for Children’s Surgery (GICS) has estimated that

the number of children without access to safe, affordable surgical and anesthesia care when needed is 1.7 billion children worldwide

Bhargava M, Grabski D, Ameh E, et al. Estimates of number of children and adolescents without access to surgical care. Bull World Health Organ 2019;97:254-258

13/09/2019

Background CTD

• infant mortality has improved dramatically across the globe over the

lifetime of the Millennium Development Goals

• neonatal mortality has however failed to show significant change

WHO U A decade of tracking progress for maternal, newborn and child survival: the 2015 report. Geneva: WHO; 2015.

13/09/2019

Background ctd

• Global disparity in neonatal mortality
• Gastroschisis survival is >95% in HIC with limited long-term morbidity

and in LIC the survival is less than 25% and often closer to 0%.1

• Probable cause: high cost of care ,infrastructure,and the influence of

sepsis and poor access to parenteral nutrition in LIC.2

1.Wright NJ, Langer M, Norman ICF, et al. Improving outcomes for neonates with gastroschisis in low-income and middle-income countries: a systematic review protocol. BMJ Paediatr Open 2018;2(1):e000392 2.Zalles-Vidal C, Penarrieta-Daher A, Bracho-Blanchet E, et al. A Gastroschisis bundle: effects of a quality improvement protocol

• n morbidity and mortality. J Pediatr Surg 2018;53(11):2117-2122.

13/09/2019

Methods

• Retrospective chart review
• Intestinal atresia and gastroschisis diagnoses
• 2016 through 2019
• patient demographics, referral history, geographic location
• initial imaging, admission laboratory studies, operative details, in-

hospital complications, length of stay, and long-term survival.

• patient weight, feeding, intravenous access, issues with intravenous

access (lost IV access, skin breakdown, bloodstream infection), and antimicrobial usage

13/09/2019

Demographics

Overall (N=112) Gastroschisis (N=92) Intestinal Atresia (N=20) p Age at arrival 2.5 (8.1); 1 [0, 1] (0, 81) 0.55 (0.75); 0 [0, 1] (0, 5) 11.3 (16.8); 8.5 [4, 10] (2, 81) <.0001 Birth weight 2.3 (0.50); 2.2 [2.0, 2.5] (1.38, 4.0) 2.3 (0.45); 2.2 [2.0, 2.5] (1.4, 3.6) 2.3 (0.71); 2.2 [1.7, 2.7] (1.4, 4.0) .875 Gestational age 35.6 (2.6); 36 [34, 37] (28, 40) 36.0 (2.2); 36 [34, 38] (32, 40) 33.9 (3.1); 35 [32, 36] (28, 39) .045 Gender F 54 (48.2) 47 (51.1) 7 (35.0) .224 M 58 (51.8) 45 (48.9) 13 (65.0) Birth location District hosp 60 (55.0) 50 (54.9) 10 (55.6) .711 Health center 42 (38.5) 34 (37.4) 8 (44.4) Other 7 (6.4) 7 (7.7) 0 (0) Premature N 55 (56.1) 48 (60.8) 7 (36.8) .074 Y 43 (43.9) 31 (39.2) 12 (63.2)

13/09/2019

Admission data

Overall (N=112) Gastroschisis (N=92) Intestinal Atresia (N=20) p Sepsis trt at arrival N 16 (14.3) 6 (6.5) 10 (50.0) <.0001 Y 96 (85.7) 86 (93.5) 10 (50.0) Sepsis evid arrival N 56 (50.0) 43 (46.7) 13 (65.0) .217 Y 56 (50.0) 49 (53.3) 7 (35.0) Sepsis Evid+Trt Evident+No trt 2 (1.8) 0 (0) 2 (10.0) <.0001 Evident+treated 54 (48.2) 49 (53.3) 5 (25.0) Not evident+no trt 14 (12.5) 6 (6.5) 8 (40.0) Not evident+trt 42 (37.5) 37 (40.2) 5 (25.0)

• Interv. at arrival

13/09/2019

Admission location/weight

Admission location Neonatology 6 (5.4) 5 (5.4) 1 (5.0) 1 Pediatric ED 106 (94.6) 87 (94.6) 19 (95.0) Weight at admit 2.2 (0.46); 2.2 [2.0, 2.5] (1.3, 3.6) 2.3 (0.44); 2.2 [2.0, 2.5] (1.4, 3.6) 2.0 (0.50); 2.0 [1.6, 2.4] (1.3, 3.1) .026 Overall (N=112) Gastroschisis (N=92) Intestinal Atresia (N=20) p

13/09/2019

Arrival data: interventions

Overall (N=112) Gastroschisis (N=92) Intestinal Atresia (N=20) p Antibiotics N 13 (11.6) 4 (4.3) 9 (45.0) <.0001 Y 99 (88.4) 88 (95.7) 11 (55.0) IV fluids N 16 (14.3) 13 (14.1) 3 (15.0) 1 Y 96 (85.7) 79 (85.9) 17 (85.0) Incubator N 44 (39.3) 54 (58.7) 14 (70.0) .451 Y 68 (60.7) 38 (41.3) 6 (30.0) Supp O2 N 76 (67.9) 59 (64.1) 17 (85.0) .111 Y 36 (32.1) 33 (35.9) 3 (15.0) Intubation N 112 (100) 92 (100) 20 (100) 1 Y 0 (0) 0 (0) 0 (0)

13/09/2019

Initial antibiotics

Penicillin on arrival N 22 (19.6) 9 (9.8) 13 (65.0) <.0001 Y 90 (80.4) 83 (90.2) 7 (35.0) Cephalosporin N 74 (66.1) 60 (65.2) 14 (70.0) .798 Y 38 (33.9) 32 (34.8) 6 (30.0) Aminoglycoside N 50 (44.6) 34 (37.0) 16 (80.0) .0009 Y 62 (55.4) 58 (63.0) 4 (20.0) Carbapenem N 112 (100) 92 (100) 20 (100) 1 Y 0 (0) 0 (0) 0 (0) Macrolide N 112 (100) 92 (100) 20 (100) 1 Y 0 (0) 0 (0) 0 (0) Fluoroquinolone N 112 (100) 92 (100) 20 (100) 1 Overall (N=112) Gastroschisis (N=92) Intestinal Atresia (N=20) p

13/09/2019

Initial antibiotics (ctd)

Monobactams N 112 (100) 92 (100) 20 (100) 1 Y 0 (0) 0 (0) 0 (0) Vancomycin N 111 (99.1) 91 (98.9) 20 (100) 1 Y 1 (0.9) 1 (1.1) 0 (0) Tetracyclines N 112 (100) 92 (100) 20 (100) 1 Y 0 (0) 0 (0) 0 (0) Metronidazole N 106 (94.6) 88 (95.7) 18 (90.0) .291 Y 6 (5.4) 4 (4.3) 2 (10.0) Other antibiotic N 112 (100) 92 (100) 20 (100) 1 Y 0 (0) 0 (0) 0 (0) Overall (N=112) Gastroschisis (N=92) Intestinal Atresia (N=20) p

13/09/2019

Outcomes

Overall Gastroschisis Intestinal Atresia Survival to discharge (N (%)) 33 (29.5%) 21 (22.8%) 12 (60%) Length of Stay (survivors only) (mean (SD); median [IQR] (range) 24.7 (11.0); 25 [17, 29] (5, 54) 28.3 (10.4); 28 [22, 36] (12, 54) 18.4 (9.5); 17.5 [14, 22] (5, 40)

13/09/2019

Intestinal atresia and infection

Sepsis N 3 (15.0) 0 (0) 3 (100) .242 Y 17 (85.0) 8 (47.1) 9 (52.9)

13/09/2019

Overall (N=20) Died in hospital (N=8, 40%) Discharged alive (N=12, 60%) p Resp distress N 19 (95.0) 8 (42.1) 11 (57.9) 1 Y 1 (5.0) 0 (0) 1 (100) Klebsiella N 18 (90.0) 8 (44.4) 10 (55.6) .495 Y 2 (10.0) 0 (0) 2 (100) Staphlococcus N 18 (90.0) 7 (38.9) 11 (61.1) 1 Y 2 (10.0) 1 (50.0) 1 (50.0)

• E. coli

N 20 (100) NA Acinetobacter N 20 (100) NA

Gastroschisis and infection . . .

Klebsiella N 75 (81.5) 59 (78.7) 16 (21.3) .526 Y 17 (18.5) 12 (70.6) 5 (29.4) Staphlococcus N 79 (85.9) 65 (82.3) 14 (17.7) .009 Y 13 (14.1) 6 (46.2) 7 (53.8)

• E. coli

N 87 (94.6) 68 (78.2) 19 (21.8) .320 Y 5 (5.4) 3 (60.0) 2 (40.0) Acinetobacter N 89 (96.7) 68 (76.4) 21 (23.6) 1 Y 3 (3.3) 3 (100) 0 (0) Percent of days

• n antibiotics

86.2% 89.6% 74.6% 0.0001

Overall (N=92) Died in hospital (N=71, 77.2%) Discharged alive (N=21, 22.8%) p

13/09/2019

Resp distress N 89 (96.7) 68 (76.4) 21 (23.6) 1 Y 3 (3.3) 3 (100) 0 (0)

Observations

• Significant proportion of missed ante-natal diagnoses
• Delayed diagnosis and /or referral of patients with intestinal atresiae
• Suspected/ evident sepsis a significant burden ( at arrival and during

hospital stay)

• Resistant germs frequently isolated
• Prolonged use of broad spectrum antibiotics
• High mortality rate

13/09/2019

Way forward

• Detailed analysis ongoing for current available data
• Prospective study basing on identified issues
• advocacy

13/09/2019

MURAKOZE!

13/09/2019