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Papers by Andrew Argent

Research paper thumbnail of Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death

PloS one, 2016

Critically ill or injured children require prompt identification, rapid referral and quality emer... more Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identi...

Research paper thumbnail of Hospital-acquired hyponatremia is associated with excessive administration of intravenous maintenance fluid; Authors' reply

Pediatrics, 2004

... Pediatrics. 2004;113:1776 –1782 2. Najib-Farah. Defensive role of bilirubinemia in pneumococc... more ... Pediatrics. 2004;113:1776 –1782 2. Najib-Farah. Defensive role of bilirubinemia in pneumococcal infection. Lancet. ... Aripipra-zole and extrapyramidal symptoms. J Am Acad Child Adolesc Psychiatry. 1268;42:1268 –1269 3. Kane JM, Carson WH, Saha AR, et al. ...

Research paper thumbnail of Paediatric nonbronchoscopic bronchoalveolar lavage: overview and recommendations for clinical practice

Research paper thumbnail of Status epilepticus – a plea for phenobarbitone

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde

Research paper thumbnail of Informed consent in paediatric critical care research – a South African perspective

BMC Medical Ethics, 2015

Medical care of critically ill and injured infants and children globally should be based on best ... more Medical care of critically ill and injured infants and children globally should be based on best research evidence to ensure safe, efficacious treatment. In South Africa and other low and middle-income countries, research is needed to optimise care and ensure rational, equitable allocation of scare paediatric critical care resources. Ethical oversight is essential for safe, appropriate research conduct. Informed consent by the parent or legal guardian is usually required for child research participation, but obtaining consent may be challenging in paediatric critical care research. Local regulations may also impede important research if overly restrictive. By narratively synthesising and contextualising the results of a comprehensive literature review, this paper describes ethical principles and regulations; potential barriers to obtaining prospective informed consent; and consent options in the context of paediatric critical care research in South Africa. Voluntary prospective informed consent from a parent or legal guardian is a statutory requirement for child research participation in South Africa. However, parents of critically ill or injured children might be incapable of or unwilling to provide the level of consent required to uphold the ethical principle of autonomy. In emergency care research it may not be practical to obtain consent when urgent action is required. Therapeutic misconceptions and sociocultural and language issues are also barriers to obtaining valid consent. Alternative consent options for paediatric critical care research include a waiver or deferred consent for minimal risk and/or emergency research, whilst prospective informed consent is appropriate for randomised trials of novel therapies or devices. We propose that parents or legal guardians of critically ill or injured children should only be approached to consent for their child's participation in clinical research when it is ethically justifiable and in the best interests of both child participant and parent. Where appropriate, alternatives to prospective informed consent should be considered to ensure that important paediatric critical care research can be undertaken in South Africa, whilst being cognisant of research risk. This document could provide a basis for debate on consent options in paediatric critical care research and contribute to efforts to advocate for South African law reform.

Research paper thumbnail of Parent perception of quality of care in a South African paediatric intensive care unit (PICU)

Research paper thumbnail of Influenza A (H1N1) pdm09 in critically ill children admitted to a paediatric intensive care unit, South Africa

Southern African Journal of Critical Care

Research paper thumbnail of of Intravenous Maintenance Fluid Hospital-Acquired Hyponatremia Is Associated With Excessive Administration

Research paper thumbnail of Paediatric Index of Mortality scores: An evaluation of function in the paediatric intensive care unit of the Red Cross War Memorial Children’s Hospital

Southern African Journal of Critical Care, 2014

Background. Paediatric Index of Mortality (PIM) and PIM 2 scores have been shown to be valid pred... more Background. Paediatric Index of Mortality (PIM) and PIM 2 scores have been shown to be valid predictors of outcome among paediatric intensive care unit populations in the UK, New Zealand, Australia and Europe, but have never been evaluated in the South African context. Objective. To evaluate the PIM and PIM 2 as mortality risk assessment models. Method. A retrospective audit of case records and prospectively collected patient data from all admissions to the Paediatric Intensive Care Unit (PICU) of Red Cross War Memorial Children's Hospital, Cape Town, during the years 2000 (PIM) and 2006 (PIM 2), excluding premature infants, children who died within 2 hours of admission, or children transferred to other PICUs. Results. For PIM and PIM 2 there were 128/962 (13.3%) and 123/1113 (11.05%) PICU deaths with expected mean mortality rates of 12.14% and 12.39%, yielding standardised mortality risk ratios (SMRs) of 1.1 (95% confidence interval (CI) 0.93 -1.34) and 0.9 (95% CI 0.74 -1.06), respectively. Receiver operating characteristic analysis revealed area under the curve of 0.849 (PIM) and 0.841 (PIM 2). Hosmer-Lemeshow goodness of fit revealed poor calibration for PIM (χ 2 =19.74; p=0.02) and acceptable calibration for PIM 2 (χ 2 =10.06; p=0.35). SMR for age and diagnostic subgroups for both scores fell within wide confidence intervals. Conclusion. Both scores showed good overall discrimination. PIM showed poor calibration. For PIM 2 both discrimination and calibration were comparable to the score derivation units, at the time of data collection for each. Calibration in terms of age and diagnostic categories was not validated by this study. S Afr J Crit Care 2014;30(1):8-13.

Research paper thumbnail of Guideline for the diagnosis, prevention and treatment of paediatric ventilator-associated pneumonia

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2009

Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to b... more Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to be a significant problem, with resulting increased morbidity and mortality in the paediatric intensive care unit population. This guideline is intended to review the evidence and recommendations for prevention and management of VAP in children and to provide, where possible, clear advice to aid the care of these children, to limit costly and unnecessary therapies and--importantly--limit inappropriate use of antimicrobial agents, The Working Group was constituted. Literature on the aetiology, prevention and management of paediatric VAP is reviewed. Evidence-based clinical practice guidelines are provided for VAP diagnosis and prevention in South Africa. In addition, the current status of antimicrobial use has been reviewed and clear recommendations are set out.

Research paper thumbnail of Acinetobacter baumannii infections in a South African paediatric intensive care unit

Journal of tropical pediatrics, Jan 31, 2015

To describe and compare characteristics and outcomes of patients colonized or infected with Acine... more To describe and compare characteristics and outcomes of patients colonized or infected with Acinetobacter baumannii (cases) to a control group. A retrospective case-controlled study of patients admitted to a South African paediatric intensive care unit (PICU) between January and December 2010. Acinetobacter baumannii was isolated in 194 patients. Mortality was similar between cases (9.3%) and controls (9.8%). Median duration of PICU stay and mechanical ventilation in cases vs. controls was 10 vs. 2 (p < 0.0001) and 9 vs. 1 days (p < 0.0001), respectively. Admission diagnosis of traumatic brain injury [adjusted odds ratio (OR): 5.6, 95% CI: 1.2-27.0; p = 0.03] and duration of mechanical ventilation (adjusted OR: 1.4, 95% CI: 1.3-1.5; p < 0.0001) were independently associated with A. baumannii aquisition. Acinetobacter baumannii acquisition was common and associated with increased morbidity, but not increased mortality.

Research paper thumbnail of Fluid overload in a South African pediatric intensive care unit

Journal of tropical pediatrics, 2014

Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid ove... more Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid overload (FO) yields increased morbidity. Prospective observational study of Red Cross War Memorial Children's Hospital pediatric intensive care unit admissions (February to March 2013). FO % = (fluid in minus fluid out) [liters]/weight [kg] × 100%. FO ≥ 10%, 28 day mortality. Median [interquartile range (IQR)] age: 9.5 (2.0-39.0) months, median (IQR) admission weight: 7.9 (3.6-13.7) kg. Median (IQR) FO with admission weight: 3.5 (2.1-4.9)%; three patients had FO ≥ 10%. The 28 day mortality was 10% (n = 10). Patients who died had higher mean (IQR) FO using admission weight [4.9 (2.9-9.3)% vs. 3.4 (1.9-4.8)%; p = 0.04]. Low FO ≥ 10% prevalence with 28 day mortality 10%. Higher FO% with admission weight associated with mortality (p = 0.04). We advocate further investigation of FO% as a simple bedside tool.

Research paper thumbnail of Linezolid dosing for staphylococcal pneumonia in children

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2009

CORRESPONDENCE 770 many were keen to stop smoking but weren't sure how to go about it. 1. Norberg... more CORRESPONDENCE 770 many were keen to stop smoking but weren't sure how to go about it. 1. Norberg J, Nilsson T, Eriksson A, Hardcastle T. The costs of a bullet -inpatient costs of firearm injuries in South Africa. S Afr Med J 2009, 99: 442-445.

Research paper thumbnail of Abstract 623

Pediatric Critical Care Medicine, 2014

Research paper thumbnail of Abstract 73

Pediatric Critical Care Medicine, 2014

Research paper thumbnail of Childhood drowning in South Africa: local data should inform prevention strategies

Pediatric Surgery International, 2014

Study objective Drowning is an important cause of childhood injury, however, little is known abou... more Study objective Drowning is an important cause of childhood injury, however, little is known about drowning in Africa. The aim of this study is to investigate submersion incidents in Cape Town, South Africa and provide specific prognostic factors as well as to develop ageappropriate prevention strategies. Methods A retrospective chart review performed at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Patients admitted because of 'drowning' or 'near-drowning' between January 2007 and April 2013 were included. Results 75 children were included. 63 (84 %) survived without complications, 8 (10.7 %) died and 4 (5.3 %) had permanent neurological sequelae. The median age was 2.2 years (range 0.1-12.4). 46 (60.5 %) incidents happened in or around the home, only 14 (18.7 %) were witnessed. 42 (56 %) took place in a pool (29 private, 13 public). Significant predictors of the outcome were: estimated submersion time, duration of apnea, unresponsive and dilated pupils, intubation and use of inotropes. On arrival at the ER we found these significant predictors of the outcome: CPR, a GCS \5, hypothermia, bradycardia, asystole, as well as the PIM2calculated mortality risk for patients admitted to the ICU. Conclusion The majority of incidents were unwitnessed and occurred in or around the home. Prevention programs should be focused on adult supervision for younger children and creating awareness on the dangers of drowning in the home environment. While bathing in baths or buckets, children should never be left alone and parents should be made aware of the dangers. In our study, the majority of incidents occurred in swimming pools and limiting access to these could prevent many incidents of drowning among older children. Although children of all language groups are at risk for drowning, English-or Afrikaans-speaking children were particularly at risk for drowning in private pools while Xhosa-speaking children mostly drowned in baths or buckets. We also report multiple prognostic factors for the outcome, but none of them were absolute predictive of the outcome, indicating that each victim of submersion deserves full resuscitative treatment.

Research paper thumbnail of Mechanical insufflation-exsufflation for people with neuromuscular disorders

Research paper thumbnail of A simple method of reducing complications of pediatric nonbronchoscopic bronchoalveolar lavage

Pediatric Pulmonology, 2004

Our objective was to determine whether a simple method of maintaining positive pressure ventilati... more Our objective was to determine whether a simple method of maintaining positive pressure ventilation during nonbronchoscopic bronchoalveolar lavage (NB-BAL) would successfully reduce the incidence and/or severity of desaturation events. Our design was a clinical trial with historical controls. Seventy ventilated pediatric patients undergoing diagnostic NB-BAL participated. Two NB-BAL techniques were compared: 1) the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; method, where the suction catheter was passed through an open system, maintaining oxygenation but not airway pressure; and 2) the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; technique, which was identical except that the catheter was passed through a diaphragm, maintaining positive pressure ventilation throughout. NB-BAL was performed on 35 patients using the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; technique and 2 years later on 35 patients using the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; method. Heart rate and oxyhemoglobin saturation (SaO(2)) were recorded before, during, and after NB-BAL. There was no difference between groups with regard to demographic data, oxygenation, or ventilatory requirements (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or= 0.1). The &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group experienced a median drop in SaO(2) of 6.0% (range, -6% to 44%), and the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group a drop of 13.0% (-2% to 61%), during NB-BAL (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Patients with oxygenation index greater than 10 experienced the most severe desaturation events in both groups: 53.8% of patients in the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group with oxygenation index &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;10 desaturated to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;80% vs. 91.6% in the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). In conclusion, we describe a simple, inexpensive modification of the NB-BAL technique that reduces the incidence and severity of desaturation during NB-BAL.

Research paper thumbnail of Risks and complications of nonbronchoscopic bronchoalveolar lavage in a pediatric intensive care unit

Pediatric Pulmonology, 2001

This paper aims to document the risks and complications of nonbronchoscopic bronchoalveolar lavag... more This paper aims to document the risks and complications of nonbronchoscopic bronchoalveolar lavage (NB-BAL) in 35 mechanically ventilated patients with diffuse severe pneumonia in a single pediatric intensive care unit. A prospective collection of data on patients' ventilatory settings and oxygen requirements before NB-BAL, and oxyhemoglobin saturations and heart rate readings before, during, and after the procedure were taken on each patient.

Research paper thumbnail of An investigation into the prevalence and outcome of patients admitted to a pediatric intensive care unit with viral respiratory tract infections in Cape Town, South Africa

Pediatric Critical Care Medicine, 2012

To describe the prevalence and outcome of patients admitted to a pediatric intensive care unit wi... more To describe the prevalence and outcome of patients admitted to a pediatric intensive care unit with viral respiratory tract infections. Retrospective descriptive study. Pediatric intensive care unit in a tertiary pediatric hospital situated in Cape Town, South Africa. All children (n = 195; 20% pediatric intensive care unit admissions) with positive respiratory viral isolates between April 1 and December 31, 2009. None. Demographic, clinical, laboratory, and outcome data were recorded from medical folders. Complete data were available for 175 patients (median age [interquartile range] 4.7 months [2.3-12.9 months]; 49% male). One hundred four (59.4%) patients had comorbid conditions; 30 (17%) were HIV-infected. Rhinovirus (n = 76 [39%]), respiratory syncytial virus (n = 54 [27.7%]), adenovirus (n = 30 [15.4%]), influenza A (n = 26 [13.3%]), parainfluenza (n = 23 [11.8%]), and human metapneumovirus (n = 12 [6.2%]) were most commonly isolated. Ninety-five infections (51.4%) were isolated &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;48 hrs after admission. Seasonal patterns were identified for respiratory syncytial virus, human metapneumovirus, and influenza A, whereas others occurred throughout the year. Twenty-five patients (14.3%) had more than one viral isolate. Presumed bacterial coinfection, which occurred in 68 (39%) patients (18 [26.5%] HIV-infected), was associated with significantly longer pediatric intensive care unit and hospital stays but not with mortality. Twenty patients died (11%, standardized mortality ratio 0.64). High Pediatric Index of Mortality scores, HIV exposure and infection, nosocomial infection, and influenza A infection were associated with mortality. Viral respiratory tract infection is common in this pediatric intensive care unit associated with significant morbidity and mortality, which may relate to the high burden of comorbidity and HIV.

Research paper thumbnail of Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death

PloS one, 2016

Critically ill or injured children require prompt identification, rapid referral and quality emer... more Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identi...

Research paper thumbnail of Hospital-acquired hyponatremia is associated with excessive administration of intravenous maintenance fluid; Authors' reply

Pediatrics, 2004

... Pediatrics. 2004;113:1776 –1782 2. Najib-Farah. Defensive role of bilirubinemia in pneumococc... more ... Pediatrics. 2004;113:1776 –1782 2. Najib-Farah. Defensive role of bilirubinemia in pneumococcal infection. Lancet. ... Aripipra-zole and extrapyramidal symptoms. J Am Acad Child Adolesc Psychiatry. 1268;42:1268 –1269 3. Kane JM, Carson WH, Saha AR, et al. ...

Research paper thumbnail of Paediatric nonbronchoscopic bronchoalveolar lavage: overview and recommendations for clinical practice

Research paper thumbnail of Status epilepticus – a plea for phenobarbitone

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde

Research paper thumbnail of Informed consent in paediatric critical care research – a South African perspective

BMC Medical Ethics, 2015

Medical care of critically ill and injured infants and children globally should be based on best ... more Medical care of critically ill and injured infants and children globally should be based on best research evidence to ensure safe, efficacious treatment. In South Africa and other low and middle-income countries, research is needed to optimise care and ensure rational, equitable allocation of scare paediatric critical care resources. Ethical oversight is essential for safe, appropriate research conduct. Informed consent by the parent or legal guardian is usually required for child research participation, but obtaining consent may be challenging in paediatric critical care research. Local regulations may also impede important research if overly restrictive. By narratively synthesising and contextualising the results of a comprehensive literature review, this paper describes ethical principles and regulations; potential barriers to obtaining prospective informed consent; and consent options in the context of paediatric critical care research in South Africa. Voluntary prospective informed consent from a parent or legal guardian is a statutory requirement for child research participation in South Africa. However, parents of critically ill or injured children might be incapable of or unwilling to provide the level of consent required to uphold the ethical principle of autonomy. In emergency care research it may not be practical to obtain consent when urgent action is required. Therapeutic misconceptions and sociocultural and language issues are also barriers to obtaining valid consent. Alternative consent options for paediatric critical care research include a waiver or deferred consent for minimal risk and/or emergency research, whilst prospective informed consent is appropriate for randomised trials of novel therapies or devices. We propose that parents or legal guardians of critically ill or injured children should only be approached to consent for their child&amp;amp;amp;amp;amp;amp;amp;amp;#39;s participation in clinical research when it is ethically justifiable and in the best interests of both child participant and parent. Where appropriate, alternatives to prospective informed consent should be considered to ensure that important paediatric critical care research can be undertaken in South Africa, whilst being cognisant of research risk. This document could provide a basis for debate on consent options in paediatric critical care research and contribute to efforts to advocate for South African law reform.

Research paper thumbnail of Parent perception of quality of care in a South African paediatric intensive care unit (PICU)

Research paper thumbnail of Influenza A (H1N1) pdm09 in critically ill children admitted to a paediatric intensive care unit, South Africa

Southern African Journal of Critical Care

Research paper thumbnail of of Intravenous Maintenance Fluid Hospital-Acquired Hyponatremia Is Associated With Excessive Administration

Research paper thumbnail of Paediatric Index of Mortality scores: An evaluation of function in the paediatric intensive care unit of the Red Cross War Memorial Children’s Hospital

Southern African Journal of Critical Care, 2014

Background. Paediatric Index of Mortality (PIM) and PIM 2 scores have been shown to be valid pred... more Background. Paediatric Index of Mortality (PIM) and PIM 2 scores have been shown to be valid predictors of outcome among paediatric intensive care unit populations in the UK, New Zealand, Australia and Europe, but have never been evaluated in the South African context. Objective. To evaluate the PIM and PIM 2 as mortality risk assessment models. Method. A retrospective audit of case records and prospectively collected patient data from all admissions to the Paediatric Intensive Care Unit (PICU) of Red Cross War Memorial Children's Hospital, Cape Town, during the years 2000 (PIM) and 2006 (PIM 2), excluding premature infants, children who died within 2 hours of admission, or children transferred to other PICUs. Results. For PIM and PIM 2 there were 128/962 (13.3%) and 123/1113 (11.05%) PICU deaths with expected mean mortality rates of 12.14% and 12.39%, yielding standardised mortality risk ratios (SMRs) of 1.1 (95% confidence interval (CI) 0.93 -1.34) and 0.9 (95% CI 0.74 -1.06), respectively. Receiver operating characteristic analysis revealed area under the curve of 0.849 (PIM) and 0.841 (PIM 2). Hosmer-Lemeshow goodness of fit revealed poor calibration for PIM (χ 2 =19.74; p=0.02) and acceptable calibration for PIM 2 (χ 2 =10.06; p=0.35). SMR for age and diagnostic subgroups for both scores fell within wide confidence intervals. Conclusion. Both scores showed good overall discrimination. PIM showed poor calibration. For PIM 2 both discrimination and calibration were comparable to the score derivation units, at the time of data collection for each. Calibration in terms of age and diagnostic categories was not validated by this study. S Afr J Crit Care 2014;30(1):8-13.

Research paper thumbnail of Guideline for the diagnosis, prevention and treatment of paediatric ventilator-associated pneumonia

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2009

Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to b... more Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to be a significant problem, with resulting increased morbidity and mortality in the paediatric intensive care unit population. This guideline is intended to review the evidence and recommendations for prevention and management of VAP in children and to provide, where possible, clear advice to aid the care of these children, to limit costly and unnecessary therapies and--importantly--limit inappropriate use of antimicrobial agents, The Working Group was constituted. Literature on the aetiology, prevention and management of paediatric VAP is reviewed. Evidence-based clinical practice guidelines are provided for VAP diagnosis and prevention in South Africa. In addition, the current status of antimicrobial use has been reviewed and clear recommendations are set out.

Research paper thumbnail of Acinetobacter baumannii infections in a South African paediatric intensive care unit

Journal of tropical pediatrics, Jan 31, 2015

To describe and compare characteristics and outcomes of patients colonized or infected with Acine... more To describe and compare characteristics and outcomes of patients colonized or infected with Acinetobacter baumannii (cases) to a control group. A retrospective case-controlled study of patients admitted to a South African paediatric intensive care unit (PICU) between January and December 2010. Acinetobacter baumannii was isolated in 194 patients. Mortality was similar between cases (9.3%) and controls (9.8%). Median duration of PICU stay and mechanical ventilation in cases vs. controls was 10 vs. 2 (p < 0.0001) and 9 vs. 1 days (p < 0.0001), respectively. Admission diagnosis of traumatic brain injury [adjusted odds ratio (OR): 5.6, 95% CI: 1.2-27.0; p = 0.03] and duration of mechanical ventilation (adjusted OR: 1.4, 95% CI: 1.3-1.5; p < 0.0001) were independently associated with A. baumannii aquisition. Acinetobacter baumannii acquisition was common and associated with increased morbidity, but not increased mortality.

Research paper thumbnail of Fluid overload in a South African pediatric intensive care unit

Journal of tropical pediatrics, 2014

Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid ove... more Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid overload (FO) yields increased morbidity. Prospective observational study of Red Cross War Memorial Children's Hospital pediatric intensive care unit admissions (February to March 2013). FO % = (fluid in minus fluid out) [liters]/weight [kg] × 100%. FO ≥ 10%, 28 day mortality. Median [interquartile range (IQR)] age: 9.5 (2.0-39.0) months, median (IQR) admission weight: 7.9 (3.6-13.7) kg. Median (IQR) FO with admission weight: 3.5 (2.1-4.9)%; three patients had FO ≥ 10%. The 28 day mortality was 10% (n = 10). Patients who died had higher mean (IQR) FO using admission weight [4.9 (2.9-9.3)% vs. 3.4 (1.9-4.8)%; p = 0.04]. Low FO ≥ 10% prevalence with 28 day mortality 10%. Higher FO% with admission weight associated with mortality (p = 0.04). We advocate further investigation of FO% as a simple bedside tool.

Research paper thumbnail of Linezolid dosing for staphylococcal pneumonia in children

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2009

CORRESPONDENCE 770 many were keen to stop smoking but weren't sure how to go about it. 1. Norberg... more CORRESPONDENCE 770 many were keen to stop smoking but weren't sure how to go about it. 1. Norberg J, Nilsson T, Eriksson A, Hardcastle T. The costs of a bullet -inpatient costs of firearm injuries in South Africa. S Afr Med J 2009, 99: 442-445.

Research paper thumbnail of Abstract 623

Pediatric Critical Care Medicine, 2014

Research paper thumbnail of Abstract 73

Pediatric Critical Care Medicine, 2014

Research paper thumbnail of Childhood drowning in South Africa: local data should inform prevention strategies

Pediatric Surgery International, 2014

Study objective Drowning is an important cause of childhood injury, however, little is known abou... more Study objective Drowning is an important cause of childhood injury, however, little is known about drowning in Africa. The aim of this study is to investigate submersion incidents in Cape Town, South Africa and provide specific prognostic factors as well as to develop ageappropriate prevention strategies. Methods A retrospective chart review performed at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Patients admitted because of 'drowning' or 'near-drowning' between January 2007 and April 2013 were included. Results 75 children were included. 63 (84 %) survived without complications, 8 (10.7 %) died and 4 (5.3 %) had permanent neurological sequelae. The median age was 2.2 years (range 0.1-12.4). 46 (60.5 %) incidents happened in or around the home, only 14 (18.7 %) were witnessed. 42 (56 %) took place in a pool (29 private, 13 public). Significant predictors of the outcome were: estimated submersion time, duration of apnea, unresponsive and dilated pupils, intubation and use of inotropes. On arrival at the ER we found these significant predictors of the outcome: CPR, a GCS \5, hypothermia, bradycardia, asystole, as well as the PIM2calculated mortality risk for patients admitted to the ICU. Conclusion The majority of incidents were unwitnessed and occurred in or around the home. Prevention programs should be focused on adult supervision for younger children and creating awareness on the dangers of drowning in the home environment. While bathing in baths or buckets, children should never be left alone and parents should be made aware of the dangers. In our study, the majority of incidents occurred in swimming pools and limiting access to these could prevent many incidents of drowning among older children. Although children of all language groups are at risk for drowning, English-or Afrikaans-speaking children were particularly at risk for drowning in private pools while Xhosa-speaking children mostly drowned in baths or buckets. We also report multiple prognostic factors for the outcome, but none of them were absolute predictive of the outcome, indicating that each victim of submersion deserves full resuscitative treatment.

Research paper thumbnail of Mechanical insufflation-exsufflation for people with neuromuscular disorders

Research paper thumbnail of A simple method of reducing complications of pediatric nonbronchoscopic bronchoalveolar lavage

Pediatric Pulmonology, 2004

Our objective was to determine whether a simple method of maintaining positive pressure ventilati... more Our objective was to determine whether a simple method of maintaining positive pressure ventilation during nonbronchoscopic bronchoalveolar lavage (NB-BAL) would successfully reduce the incidence and/or severity of desaturation events. Our design was a clinical trial with historical controls. Seventy ventilated pediatric patients undergoing diagnostic NB-BAL participated. Two NB-BAL techniques were compared: 1) the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; method, where the suction catheter was passed through an open system, maintaining oxygenation but not airway pressure; and 2) the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; technique, which was identical except that the catheter was passed through a diaphragm, maintaining positive pressure ventilation throughout. NB-BAL was performed on 35 patients using the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; technique and 2 years later on 35 patients using the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; method. Heart rate and oxyhemoglobin saturation (SaO(2)) were recorded before, during, and after NB-BAL. There was no difference between groups with regard to demographic data, oxygenation, or ventilatory requirements (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or= 0.1). The &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group experienced a median drop in SaO(2) of 6.0% (range, -6% to 44%), and the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group a drop of 13.0% (-2% to 61%), during NB-BAL (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Patients with oxygenation index greater than 10 experienced the most severe desaturation events in both groups: 53.8% of patients in the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;sealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group with oxygenation index &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;10 desaturated to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;80% vs. 91.6% in the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;unsealed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; group (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). In conclusion, we describe a simple, inexpensive modification of the NB-BAL technique that reduces the incidence and severity of desaturation during NB-BAL.

Research paper thumbnail of Risks and complications of nonbronchoscopic bronchoalveolar lavage in a pediatric intensive care unit

Pediatric Pulmonology, 2001

This paper aims to document the risks and complications of nonbronchoscopic bronchoalveolar lavag... more This paper aims to document the risks and complications of nonbronchoscopic bronchoalveolar lavage (NB-BAL) in 35 mechanically ventilated patients with diffuse severe pneumonia in a single pediatric intensive care unit. A prospective collection of data on patients' ventilatory settings and oxygen requirements before NB-BAL, and oxyhemoglobin saturations and heart rate readings before, during, and after the procedure were taken on each patient.

Research paper thumbnail of An investigation into the prevalence and outcome of patients admitted to a pediatric intensive care unit with viral respiratory tract infections in Cape Town, South Africa

Pediatric Critical Care Medicine, 2012

To describe the prevalence and outcome of patients admitted to a pediatric intensive care unit wi... more To describe the prevalence and outcome of patients admitted to a pediatric intensive care unit with viral respiratory tract infections. Retrospective descriptive study. Pediatric intensive care unit in a tertiary pediatric hospital situated in Cape Town, South Africa. All children (n = 195; 20% pediatric intensive care unit admissions) with positive respiratory viral isolates between April 1 and December 31, 2009. None. Demographic, clinical, laboratory, and outcome data were recorded from medical folders. Complete data were available for 175 patients (median age [interquartile range] 4.7 months [2.3-12.9 months]; 49% male). One hundred four (59.4%) patients had comorbid conditions; 30 (17%) were HIV-infected. Rhinovirus (n = 76 [39%]), respiratory syncytial virus (n = 54 [27.7%]), adenovirus (n = 30 [15.4%]), influenza A (n = 26 [13.3%]), parainfluenza (n = 23 [11.8%]), and human metapneumovirus (n = 12 [6.2%]) were most commonly isolated. Ninety-five infections (51.4%) were isolated &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;48 hrs after admission. Seasonal patterns were identified for respiratory syncytial virus, human metapneumovirus, and influenza A, whereas others occurred throughout the year. Twenty-five patients (14.3%) had more than one viral isolate. Presumed bacterial coinfection, which occurred in 68 (39%) patients (18 [26.5%] HIV-infected), was associated with significantly longer pediatric intensive care unit and hospital stays but not with mortality. Twenty patients died (11%, standardized mortality ratio 0.64). High Pediatric Index of Mortality scores, HIV exposure and infection, nosocomial infection, and influenza A infection were associated with mortality. Viral respiratory tract infection is common in this pediatric intensive care unit associated with significant morbidity and mortality, which may relate to the high burden of comorbidity and HIV.