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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
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
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