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

Fin inding ways to im improve neonatal surgical outcomes 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 on 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 Gastroschisis Intestinal Atresia Overall (N=112) (N=92) (N=20) p Age at arrival 11.3 (16.8); 2.5 (8.1); 0.55 (0.75); 8.5 [4, 10] 1 [0, 1] (0, 81) 0 [0, 1] (0, 5) (2, 81) <.0001 Birth weight 2.3 (0.50); 2.3 (0.45); 2.3 (0.71); 2.2 [2.0, 2.5] 2.2 [2.0, 2.5] 2.2 [1.7, 2.7] (1.38, 4.0) (1.4, 3.6) (1.4, 4.0) .875 Gestational age 35.6 (2.6); 36.0 (2.2); 33.9 (3.1); 36 [34, 37] 36 [34, 38] 35 [32, 36] (28, 40) (32, 40) (28, 39) .045 Gender F 54 (48.2) 47 (51.1) 7 (35.0) M 58 (51.8) 45 (48.9) 13 (65.0) .224 Birth location District hosp 60 (55.0) 50 (54.9) 10 (55.6) Health center 42 (38.5) 34 (37.4) 8 (44.4) Other 7 (6.4) 7 (7.7) 0 (0) .711 Premature N 55 (56.1) 48 (60.8) 7 (36.8) Y 43 (43.9) 31 (39.2) 12 (63.2) .074 13/09/2019

Admission data Intestinal Atresia Overall (N=112) Gastroschisis (N=92) (N=20) p Sepsis trt at arrival N 16 (14.3) 6 (6.5) 10 (50.0) Y 96 (85.7) 86 (93.5) 10 (50.0) <.0001 Sepsis evid arrival N 56 (50.0) 43 (46.7) 13 (65.0) Y 56 (50.0) 49 (53.3) 7 (35.0) .217 Sepsis Evid+Trt Evident+No trt 2 (1.8) 0 (0) 2 (10.0) 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) <.0001 Interv. at arrival 13/09/2019

Admission location/weight Intestinal Atresia Overall (N=112) Gastroschisis (N=92) (N=20) p Admission location Neonatology 6 (5.4) 5 (5.4) 1 (5.0) Pediatric ED 106 (94.6) 87 (94.6) 19 (95.0) 1 Weight at admit 2.2 (0.46); 2.3 (0.44); 2.0 (0.50); 2.2 [2.0, 2.5] 2.2 [2.0, 2.5] 2.0 [1.6, 2.4] (1.3, 3.6) (1.4, 3.6) (1.3, 3.1) .026 13/09/2019

Arrival data: interventions Intestinal Atresia Overall (N=112) Gastroschisis (N=92) (N=20) p Antibiotics N 13 (11.6) 4 (4.3) 9 (45.0) Y 99 (88.4) 88 (95.7) 11 (55.0) <.0001 IV fluids N 16 (14.3) 13 (14.1) 3 (15.0) Y 96 (85.7) 79 (85.9) 17 (85.0) 1 Incubator N 44 (39.3) 54 (58.7) 14 (70.0) Y 68 (60.7) 38 (41.3) 6 (30.0) .451 Supp O2 N 76 (67.9) 59 (64.1) 17 (85.0) Y 36 (32.1) 33 (35.9) 3 (15.0) .111 Intubation N 112 (100) 92 (100) 20 (100) Y 0 (0) 0 (0) 0 (0) 1 13/09/2019

Initial antibiotics Intestinal Atresia Overall (N=112) Gastroschisis (N=92) (N=20) p Penicillin on arrival N 22 (19.6) 9 (9.8) 13 (65.0) Y 90 (80.4) 83 (90.2) 7 (35.0) <.0001 Cephalosporin N 74 (66.1) 60 (65.2) 14 (70.0) Y 38 (33.9) 32 (34.8) 6 (30.0) .798 Aminoglycoside N 50 (44.6) 34 (37.0) 16 (80.0) Y 62 (55.4) 58 (63.0) 4 (20.0) .0009 Carbapenem N 112 (100) 92 (100) 20 (100) Y 0 (0) 0 (0) 0 (0) 1 Macrolide N 112 (100) 92 (100) 20 (100) Y 0 (0) 0 (0) 0 (0) 1 Fluoroquinolone 13/09/2019 N 112 (100) 92 (100) 20 (100) 1

Initial antibiotics (ctd) Intestinal Atresia Overall (N=112) Gastroschisis (N=92) (N=20) p Monobactams N 112 (100) 92 (100) 20 (100) Y 0 (0) 0 (0) 0 (0) 1 Vancomycin N 111 (99.1) 91 (98.9) 20 (100) Y 1 (0.9) 1 (1.1) 0 (0) 1 Tetracyclines N 112 (100) 92 (100) 20 (100) Y 0 (0) 0 (0) 0 (0) 1 Metronidazole N 106 (94.6) 88 (95.7) 18 (90.0) Y 6 (5.4) 4 (4.3) 2 (10.0) .291 Other antibiotic N 112 (100) 92 (100) 20 (100) Y 0 (0) 0 (0) 0 (0) 1 13/09/2019

Outcomes Overall Gastroschisis Intestinal Atresia Survival to 33 (29.5%) 21 (22.8%) 12 (60%) discharge (N (%)) Length of Stay 24.7 (11.0); 28.3 (10.4); 18.4 (9.5); (survivors only) 25 [17, 29] (5, 54) 28 [22, 36] (12, 17.5 [14, 22] (5, (mean (SD); 54) 40) median [IQR] (range) 13/09/2019

Intestinal atresia and infection Died in hospital Discharged alive Overall (N=20) (N=8, 40%) (N=12, 60%) p Sepsis N 3 (15.0) 0 (0) 3 (100) Y 17 (85.0) 8 (47.1) 9 (52.9) .242 Resp distress N 19 (95.0) 8 (42.1) 11 (57.9) Y 1 (5.0) 0 (0) 1 (100) 1 Klebsiella N 18 (90.0) 8 (44.4) 10 (55.6) Y 2 (10.0) 0 (0) 2 (100) .495 Staphlococcus N 18 (90.0) 7 (38.9) 11 (61.1) Y 2 (10.0) 1 (50.0) 1 (50.0) 1 E. coli N 20 (100) NA Acinetobacter N 20 (100) NA 13/09/2019

Gastroschisis and infection . . . Died in hospital Discharged alive Overall (N=92) (N=71, 77.2%) (N=21, 22.8%) p Resp distress N 89 (96.7) 68 (76.4) 21 (23.6) Y 3 (3.3) 3 (100) 0 (0) 1 Klebsiella N 75 (81.5) 59 (78.7) 16 (21.3) Y 17 (18.5) 12 (70.6) 5 (29.4) .526 Staphlococcus N 79 (85.9) 65 (82.3) 14 (17.7) Y 13 (14.1) 6 (46.2) 7 (53.8) .009 E. coli N 87 (94.6) 68 (78.2) 19 (21.8) Y 5 (5.4) 3 (60.0) 2 (40.0) .320 Acinetobacter N 89 (96.7) 68 (76.4) 21 (23.6) Y 3 (3.3) 3 (100) 0 (0) 1 Percent of days on antibiotics 13/09/2019 86.2% 89.6% 74.6% 0.0001

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