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Outcomes after Surgery for Children in Africa a Fourteen-Day Prospective Observational Cohort Study (ASOS-Paeds)

32 Pages Posted: 19 Oct 2023

See all articles by Alexandra Torborg

Alexandra Torborg

University of KwaZulu-Natal - Discipline of Anaesthesiology and Critical Care

Heidi Meyer

University of Cape Town (UCT) - Department of Anaesthesia and Perioperative Medicine

Mahmoud Elfiky

Kasr Al Ainy Faculty of Medicine, Cairo University

Maher Fawzy

Faculty of Medicine, Cairo University

Muhammed Elhadi

Faculty of Medicine, University of Tripoli

Adesoji O. Ademuyiwa

Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital

Babatunde Osinaike

University of Ibadan - Department of Anaesthesia

Adam Hewitt-Smith

Busitema University

Mary T. Nabukenya

Makerere University - Department of Anaesthesia and Critical Care

Ronald Bisegerwa

Makerere University - Department of Anaesthesia and Critical Care

Souad Bouaoud

University of Ferhat Abbas Setif 1

Meriem Abdoun

University of Ferhat Abbas Setif 1

Ahmed Rhassane El Adib

Cadi Ayyad University - University Hospital Center Mohamed VI

Fitsum Kifle

Debre Berhan University

Meseret Gebre

Armauer Hansen Research Institute

Desalegn Bekele Taye

Ministry of Health (Ethiopia)

Nahla Kechiche

University of Monastir - University Hospital of Monastir

Tarig Fadalla

National Ribat University

Bareeq Abdallah

National Ribat University

Maman Sani Chaibou

National Hospital of Niamey - Intensive Care and Emergency

Mame Yaa Adobea Nyarko

Princess Marie Louise Children’s hospital

Kélan Bertille Ki

Université de Ouagadougou - Centre hospitalier universitaire pédiatrique Charles de Gaulle

Sarah Shalongo

Windhoek Central Hospital

Wakisa Mulwafu

Kamuzu University of Health Sciences

Emma Thomson

Kamuzu University of Health Sciences

Mamadou Mour Traore

Université Cheikh Anta Diop (UCAD) - Cheikh Anta Diop University

Andrew Ndonga

Mater Misericordiae Hospital

Mustapha Bittaye

Ministry of Health and Social Welfare, The Gambia

Ahmadou Lamin Samateh

Edward Francis Small Teaching Hospital

Dolly Matondo Munlemvo

Université de Kinshasa - Kinshasa University Hospital

Yacaria Coulibaly

Gabriel Touré University Hospital in Bamako

Yousseff Coulibaly

University of Mali

Vaonandianina Ravelojaona

Operation Smile, Madagascar

Lalatiana Andriamanarivo

Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona Madagascar

Arsitide Romain Raherison

Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona Madagascar

Mamy Richard Randriamizao

Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona Madagascar

Kushal Ramkalawan

Ministry of Health and Wellness

Mohamed Abdinor Omar

Ministry of Health Somalia

Raymond Ndikontar

University of Yaounde I - Faculty of Medicine and Biomedical Sciences

Donamou Joseph

Donka University - Donka University Hospital

Shukri Dahir

Edna Adan University Hospital

Mubarak Mohamed Jama

Edna Adan University Hospital

Hassan Ali Daoud

Amoud University

Pisirai Ndarukwa

Bindura University of Science Education

Gilbert Fabrice Otiobanda

Marien Ngouabi University

Milliard Derbew

Addis Ababa University - School of Medicine

Marvin Fanny

University of Seychelles

Isaac Smalle

University of Sierra Leone - Department of Surgery

Elliott H. Taylor

University of Cape Town (UCT) - Department of Surgery

Hanel Duvenage

Nutrition, Research and Development Manager, Safe Surgery South Africa

Anneli Hardy

University of Cape Town (UCT) - Department of Statistical Sciences

Hyla Kluyts

Department of Anaesthesiology, Sefako Makgatho Health Sciences University

Rupert M. Pearse

Queen Mary University of London - Critical Care and Perioperative Medicine Research Group

Bruce Biccard

University of Cape Town (UCT) - Department of Anaesthesia and Perioperative Medicine

More...

Abstract

Background: Safe and affordable anaesthesia and surgery is a public health imperative. There are few data describing care provision and outcomes for children undergoing anaesthesia and surgery in Africa.  

Methods: International 14-day prospective, observational cohort study of children (<18 years) undergoing surgery in African countries. We aimed to recruit as many hospitals as possible across all levels of care providing surgical treatment for children. Each hospital recruited all eligible children for a 14-day period between January 2022 and December 2022. The primary outcome was in-hospital postoperative complications within 30 days of surgery. The secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities and procedures considered necessary for safe surgical care of children. 

Findings: We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (4.9) years, and 5675/8600 children (66%) were male. Most children were healthy (American Society of Anesthesiologists’ Class I, 6110/8579 children [71%]). 5325/8604 (62%) of children underwent elective surgery. Postoperative complications occurred in 1532/8515 (18·3%) of children. There were 199/8596 deaths (2·3%) following surgery. Deaths following postoperative complications occurred in 166 of 1530 complications (10·8%). Operating rooms were reported as safe for anaesthesia and surgery for neonates, infants, and children <6 years in 121/223 (54·3%), 147/223 (65·9%), and 188/223 (84·3%) of hospitals. 48/221 (22%) of hospitals did not have reliable electricity, and 42/221 (19%) did not have a reliable oxygen supply. 

Interpretation: Outcomes following anaesthesia and surgery for children in Africa are poor. Complication and mortality rates are fourfold and 11-fold higher respectively than high-income countries. To improve surgical outcomes for children in Africa, we need health system strengthening, provision of environments which are safe for the conduct of anaesthesia and surgery, and strategies to address the high rate of ‘failure to rescue’. 

Trial Registration: This study was registered on ClinicalTrials.gov (NCT05061407).

Funding: Jan Pretorius Research Fund of the South African Society of Anaesthesiologists (SASA)Association of Anesthesiologists of Uganda.

Declaration of Interest: This study was funded by Jan Pretorius Research Fund of the South African Society of Anaesthesiologists (SASA) and Association of Anesthesiologists of Uganda. The funders had no role in the study design, data collection, data analysis, data interpretation, or writing of the paper.

Ethical Approval: Research ethics and regulatory approvals were in place before starting the study at each site, in accordance with their national research regulations. The primary ethics approval was from the Health Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (HREC 466/2021). The study was undertaken as an international clinical audit with no significant risk to the study population. We expected that in most countries there would be no requirement for individual patient consent as all data were recorded as part of routine clinical care, and anonymised before being uploaded to the study database. This precedent had already been set in previous national and international studies of adults and children undergoing surgery in Africa and Europe. Only two ethics committees required informed consent, both in South Africa, affecting seven hospital sites. ‘Broadcasting’ signage, as an infographic poster with pictures and words, and as a poster with words only, were placed in participating hospitals to ensure that all patients and parents/guardians were aware that the hospital was participating in the study.

Keywords: anesthesiology, developing countries, hospital mortality, outcome assessment (healthcare), pediatrics, postoperative complications, prospective studies, specialties, surgical

Suggested Citation

Torborg, Alexandra and Meyer, Heidi and Elfiky, Mahmoud and Fawzy, Maher and Elhadi, Muhammed and Ademuyiwa, Adesoji O. and Osinaike, Babatunde and Hewitt-Smith, Adam and Nabukenya, Mary T. and Bisegerwa, Ronald and Bouaoud, Souad and Abdoun, Meriem and El Adib, Ahmed Rhassane and Kifle, Fitsum and Gebre, Meseret and Taye, Desalegn Bekele and Kechiche, Nahla and Fadalla, Tarig and Abdallah, Bareeq and Chaibou, Maman Sani and Nyarko, Mame Yaa Adobea and Ki, Kélan Bertille and Shalongo, Sarah and Mulwafu, Wakisa and Thomson, Emma and Traore, Mamadou Mour and Ndonga, Andrew and Bittaye, Mustapha and Samateh, Ahmadou Lamin and Munlemvo, Dolly Matondo and Kalango, Jean Jacques and Coulibaly, Yacaria and Coulibaly, Yousseff and Ravelojaona, Vaonandianina and Andriamanarivo, Lalatiana and Raherison, Arsitide Romain and Randriamizao, Mamy Richard and Ramkalawan, Kushal and Omar, Mohamed Abdinor and Ndikontar, Raymond and Joseph, Donamou and Dahir, Shukri and Mohamed Jama, Mubarak and Ali Daoud, Hassan and Ndarukwa, Pisirai and Otiobanda, Gilbert Fabrice and Banguti, Paulin and Neil, Kara and Derbew, Milliard and Fanny, Marvin and Smalle, Isaac and Taylor, Elliott H. and Duvenage, Hanel and Hardy, Anneli and Kluyts, Hyla and Pearse, Rupert M. and Biccard, Bruce, Outcomes after Surgery for Children in Africa a Fourteen-Day Prospective Observational Cohort Study (ASOS-Paeds). Available at SSRN: https://ssrn.com/abstract=4556560 or http://dx.doi.org/10.2139/ssrn.4556560

Alexandra Torborg (Contact Author)

University of KwaZulu-Natal - Discipline of Anaesthesiology and Critical Care ( email )

Heidi Meyer

University of Cape Town (UCT) - Department of Anaesthesia and Perioperative Medicine ( email )

Mahmoud Elfiky

Kasr Al Ainy Faculty of Medicine, Cairo University ( email )

Kasr Al Ainy Faculty of Medicine
Manial
Cairo, 11432
Egypt

Maher Fawzy

Faculty of Medicine, Cairo University ( email )

Muhammed Elhadi

Faculty of Medicine, University of Tripoli ( email )

Adesoji O. Ademuyiwa

Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital ( email )

Babatunde Osinaike

University of Ibadan - Department of Anaesthesia ( email )

Adam Hewitt-Smith

Busitema University ( email )

P.O Box 236
Tororo, 236
Uganda

Mary T. Nabukenya

Makerere University - Department of Anaesthesia and Critical Care ( email )

Ronald Bisegerwa

Makerere University - Department of Anaesthesia and Critical Care ( email )

Souad Bouaoud

University of Ferhat Abbas Setif 1 ( email )

Meriem Abdoun

University of Ferhat Abbas Setif 1 ( email )

Ahmed Rhassane El Adib

Cadi Ayyad University - University Hospital Center Mohamed VI ( email )

Fitsum Kifle

Debre Berhan University ( email )

Meseret Gebre

Armauer Hansen Research Institute ( email )

Ethiopia

Desalegn Bekele Taye

Ministry of Health (Ethiopia) ( email )

Nahla Kechiche

University of Monastir - University Hospital of Monastir ( email )

Tarig Fadalla

National Ribat University ( email )

Bareeq Abdallah

National Ribat University ( email )

Maman Sani Chaibou

National Hospital of Niamey - Intensive Care and Emergency ( email )

Mame Yaa Adobea Nyarko

Princess Marie Louise Children’s hospital ( email )

Kélan Bertille Ki

Université de Ouagadougou - Centre hospitalier universitaire pédiatrique Charles de Gaulle ( email )

Sarah Shalongo

Windhoek Central Hospital ( email )

Wakisa Mulwafu

Kamuzu University of Health Sciences ( email )

Emma Thomson

Kamuzu University of Health Sciences ( email )

Mamadou Mour Traore

Université Cheikh Anta Diop (UCAD) - Cheikh Anta Diop University ( email )

Andrew Ndonga

Mater Misericordiae Hospital ( email )

Mustapha Bittaye

Ministry of Health and Social Welfare, The Gambia ( email )

Ahmadou Lamin Samateh

Edward Francis Small Teaching Hospital ( email )

Dolly Matondo Munlemvo

Université de Kinshasa - Kinshasa University Hospital ( email )

Yacaria Coulibaly

Gabriel Touré University Hospital in Bamako ( email )

Yousseff Coulibaly

University of Mali ( email )

Vaonandianina Ravelojaona

Operation Smile, Madagascar ( email )

Lalatiana Andriamanarivo

Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona Madagascar ( email )

Arsitide Romain Raherison

Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona Madagascar ( email )

Mamy Richard Randriamizao

Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona Madagascar ( email )

Kushal Ramkalawan

Ministry of Health and Wellness ( email )

Mohamed Abdinor Omar

Ministry of Health Somalia ( email )

Raymond Ndikontar

University of Yaounde I - Faculty of Medicine and Biomedical Sciences ( email )

Donamou Joseph

Donka University - Donka University Hospital ( email )

Shukri Dahir

Edna Adan University Hospital ( email )

Mubarak Mohamed Jama

Edna Adan University Hospital ( email )

Hassan Ali Daoud

Amoud University ( email )

Pisirai Ndarukwa

Bindura University of Science Education ( email )

Bindura
Zimbabwe

Gilbert Fabrice Otiobanda

Marien Ngouabi University ( email )

Milliard Derbew

Addis Ababa University - School of Medicine ( email )

Marvin Fanny

University of Seychelles ( email )

Isaac Smalle

University of Sierra Leone - Department of Surgery ( email )

Elliott H. Taylor

University of Cape Town (UCT) - Department of Surgery ( email )

Hanel Duvenage

Nutrition, Research and Development Manager, Safe Surgery South Africa ( email )

Anneli Hardy

University of Cape Town (UCT) - Department of Statistical Sciences ( email )

Hyla Kluyts

Department of Anaesthesiology, Sefako Makgatho Health Sciences University ( email )

Rupert M. Pearse

Queen Mary University of London - Critical Care and Perioperative Medicine Research Group ( email )

London
United Kingdom

Bruce Biccard

University of Cape Town (UCT) - Department of Anaesthesia and Perioperative Medicine ( email )

Cape Town
South Africa

No contact information is available for Jean Jacques Kalango
No contact information is available for Paulin Banguti
No contact information is available for Kara Neil

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