INCONTRO CON LA CARDIOCHIRURGIA PEDIATRICA DI PADOVA: STORIE DA RACCONTARE E DA CONOSCERE Le missioni umanitarie: « Progetto Elias» Prof. Giovanni Stellin UOC Cardiochirurgia Pediatrica e Cardiopatie Congenite Università degli Studi di Padova
Eritrea Italian colonization 1881-1941 • British administration 1941-1952 • Struggle for liberation 1952-1991 • Independency 1991 • 5 millions inhabitants
Capital: ASMARA 804.000 Inhabitants Altitude: 2.333 m Old Colonial City
Why Eritrea? One of the poorest countries of the world • Past 30 years war region (1962-1991) • No human and economic resources • No medical school until 2004 • No pediatric, no cardiac surgery •
Demographics Er USA I GER Population (mio) 6,08 313 61,3 81,3 Total fertility rate 4,4 2,06 1,40 1,41 Birth rate (per 1000 pop.) 32 13,7 9,06 8,33 Population growth rate (%) 2,4 0,96 0,38 - 0,2 Median age of pop. (years) 18,7 36,9 43,5 44,9 (Urban, 06.2011)
Health Workforce Er USA F Physicians 1,2 5 293 350 Nurses 1 56 982 868 Midwifes 1 2 -- 26 1 per 100.000 population 2 in all: 12 pediatricians and 7 surgeons
Maternal and Child Health Indicators Er USA F Births (%) attended 1 28 98 100 Maternal mortality 2 240 21 8 Neonatal mortality 3 17 4 2 Infant mortality 3 42 6,1 3,3 Child < 5 years mortality 3 55 8 4 1 by skilled personnel 2 per 100.000 births 3 per 1.000 life births
Incidence of CHD in Eritrea 185.000 Life births per year 4.000 Neonates with congenital anomalies 1.300 Newborns with CHD (Urban, 06.2011)
Hammer Forum is a German group of physicians • who care for children in war and precarious regions of Europe In 1996 Hammer Forum started an humanitarian • project in Eritrea THE GOAL To build an equipe at the International Operation • Center for Children in Asmara (IOCCA) To commence surgical treatment for children in • Asmara on a multidisciplinary basis including open heart surgery
The Model Project • Central organization by ArcheMed (NGO) • Infrastructure & equipment from all CT-teams • Individual team funding by respective NGO • Conjoint CT-team strategy & quality control
Participating NGOs • ArcheMed e.V. Möhnesee, Germany • Un Cuore Un Mondo Massa Carrara, Italy • Un Cuore Un Mondo Padova, Italy • Kinderherzen.ch Zurich, Switzerland
Participants teams Andreas Urban, M.D. Bruno Murzi, M.D. Pascal Berdat, M.D. Giovanni Stellin, M.D. Former Director of Pediatric Massa Carrara Hospital, Italy Heart Care Medical AG Director of Pediatric Cardiac Surgery, Saint Zurich, Switzerland Cardiac Surgery, Padova, Agostin Hospital - Germany Italy (Teams Coordinator)
Mission Eritrea Local coordinator University of Padua Team (Italy) (project Elias) Since 2004 Mr. Alem Demoz
Padova Cardiac Team composition � Paediatric cardiologist 2/1 � Anaesthesiologists 2 � Pediatric cardiac surgeon 2 � OR nurses 2/1 � Perfusionist 2/1 � Intensivist 2 � PICU nurse 6/4 Total 13/18
Objectives of the Mission • Correct CHDs • Training of local people
The International Operation Center for Children in Asmara/Eritrea (IOCCA) (Former ‘‘Ospedale Regina Elena‘‘)
The hospital
The Operating Room
Postoperative ICU 4 equiped beds (sometimes more…)
Subintensive ICU 5 beds …sometimes more..
Italian Equipement Supply • Echocardiographers 4 • Heart-lung machine 1 • Heat exchange blanket 2 • Portable x-ray machine 1 • Electrocardiographer 1 • Pediatric ventilator 1 • Portable monitors 4 • Infusion pumps 4 • External Pacemakers 4
Hospital renovation and supply (ArchMed, Germany) Medical gases • Modular oxygen producer – Electricity • Photovoltaic unit at the roof – Uninterrupted power supply (UPS) – Hygiene • Floor, windows, doors enlarged – Water • At the moment supplied by tank trucks; process of creating independent water supply –
Hospital renovation and supply (ArchMed, Germany) Operating room • Anaesthesia room • Cardiac surgical I.C.U. • Cardiac surgical intermediate care • Cath lab ? •
Patients’ management • A forward team of pediatric cardiologists will screen patients with local cardiologists and select candidates for surgery • Selected pts are further discussed among surgeons, cardiologists, anesthetists before surgery
Pediatric cardiologists (Prof. Ornella Milanesi + 1 younger pediatric cardiologist, rotating) Screening: clinical assessment + 2D-echo
Anesthesia team TEE Echo
CRITERIA for Patients’ selection (I) • Single ventricle malformations are not usually treated • Down syndrome patients are accepted, upon patients’ request • No selection is made in according to age, body weight and/or CHD complexity
CRITERIA for Patients, selection (II) • CHDs with associated severe pulmonary hypertension (i.e. large VSDs, CAVC) are selected for palliation (PA banding) and corrected 12 months later • Arterial switches for TGA are performed when a large VSD is present and the LV is not deconditioned
Surgical activity Needs to be adapted to the local availability for • Prosthetic material • ICU efficiency and quality of care • Drugs availability • ICU beds
Pre operative patients’ status Nearly all of them have: • Hypoalbuminemia • Anemia • Recurrent pulmonary infections • Malnutrition • Long-standing cardiac diseases (cyanosis, left-to-right shunt with CHF and PAH)
The OR team
Results ( CT-Operations 2003-2016 all teams) 120 100 80 Number of cases 60 NO CPB CPB 40 20 0 Year
Procedures Op‘s without CPB Op‘s with CPB complex ASD others valves coarct. PDA VSD
Results (2003-2017 all teams) Cardiac-Procedures n = 1076 • With CPB n = 716 • No CPB n = 360 • Early + late mortality 20 + 1 (2%) •
Cost-Effectiveness For the expense of one neonatal heart operation in Europe i.e. € 50.000,- A team of 16 people including doctors, nurses and technicians can travel to, diagnose, operate and treat 20 children with CHD in Eritrea
Results at last follow-up • All patients have been followed by Dr. Tsagareda (local pediatric cardiologist) • Late death 1 pt 14 year-old patient after mitral valve plasty
MAIN GOAL: Training the local people Dr. Yoseph Tewolde Ghidei
Continuing education Multi-disciplinary teaching sessions included: • In-job training • Clinical lectures For doctors in-training, medical student and personnel, at different levels
Funding • Donations • Government support • Industrial sponsorship • Charitable foundations
Summary The goal of developing a Pediatric Cardiac Surgical program in Eritrea has been achieved by a European multi-institutional cooperation of 4 different surgical teams Early and long term results can be compared with those of the best cardiac surgical units in Europe and US
Future goals • Catheterization Laboratory (nearly operating) • Continue medical and surgical education • Develop a totally indipendent Eritrean team
Conclusions • A conjoint international multi-institutional cardio-thoracic team approach is feasible • It could serve as a model for providing a sustained humantiarian Paediatric Cardiac- Service in a poor no-resource countries
The Eritreans are very thankful to us for saving their children‘s lives We are very grateful to the Eritrean people for the great value in humanitarian experience which helps us in our daily work
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