Adult Intensive Care in Uganda: A Systematic Review

Abstract

Background: Intensive (ICU) care in many African countries, such as Uganda is comparatively underdeveloped and underprioritized, largely because of other pressing healthcare system needs. However, experiences like the COVID-19 pandemic, declines in infectious disease-associated mortality, and the ongoing epidemiologic transition make the current state of critical-care in the region important. But most countries in the region, including Uganda, do not collect ICU data, leaving published studies as one of few potential sources of robust data. Existing systematic reviews utilize this fact; however, these studies report their findings in aggregate, making country-specific conclusions impossible. As a result, aspects of critical care in several individual African countries remain unknown. Objective: To assess intensive care utilization in Uganda over time; specifically, we ascertain patient demographics and the most common reasons for ICU admission. Methods: We performed a systematic search of the following indexing databases: PuBMed, EMBASE, Google scholars, and African Journals Online prior to March 2020. To assess the gray literature, we searched the dissertation databases of the largest public universities in the country (Makerere & Mbarara University) for relevant papers. Inclusion criteria for studies were: (i) study conducted in Uganda at a facility with intensive care capacity, (ii) adult population; (iii) N>100 patients. Findings: A total of 10 papers, collectively reporting on 3519 adult patients and published between 2005 and 2018 met our study’s inclusion criteria. The median of the average age on admission was 35.50 [IQR: 26.11-43.4], with post-operative management as the most common reason for ICU admission. Median mortality was 37.50% [IQR: 28.5-40.5]. Conclusions: Our study provides evidence supporting previous anecdotal reports of a comparatively low median age of patients in Uganda’s ICUs. However, we also find that most ICU research is conducted at the national referral hospital, Mulago, in the country’s capital, Kampala. This second finding highlights a significant knowledge gap, as private ICUs (whose catchment population includes Uganda’s rapidly growing middle class), and other districts in the country are not represented. As a result, these results should be interpreted cautiously. Future research studies should attempt to include private hospitals and those outside Kampala. Systematic review registration: PROSPERO. Registration ID: CRD42020168940

First use of a new frugal CPAP device: the LeVe CPAP System, in adult patients with COVID-19 pneumonitis at Mengo Hospital, Kampala, Uganda

“…By this stage, global experience and literature had demonstrated the importance of CPAP as a tool to manage moderate to severe cases, and CPAP had been shown to avoid the need for invasive mechanical ventilation (9,17,18,24). This was key as ventilator availability and critical care capacity was stretched globally, with particular concern in Uganda and other LMICs with limited critical care capacity (1,19). The availability of CPAP in Uganda and other LMICs, is unfortunately severely limited, even outside of the pandemic (25).…”

“…Similarly, studies show the importance of high-ow nasal oxygen (HFNO) as an alternative noninvasive technique to manage acute hypoxemic respiratory failure in COVID-19 patients outside the intensive care setting (12). HFNO has been shown to be superior to conventional oxygen therapy, is well tolerated and reduces the need for invasive ventilation (12)(13)(14)(15)(16) In Uganda, as with many low-and middle-income countries (LMICs), there are huge limitations for patients to receive high dependency or intensive care, and invasive or non-invasive ventilation (NIV) (1,(17)(18)(19)(20)(21). These limitations stem from a multitude of well-known factors including aspects of infrastructure, human resources, local expertise, equipment availability and maintenance, training levels of healthcare staff, and nancial burden to patients and relatives (17).…”

“…These limitations stem from a multitude of well-known factors including aspects of infrastructure, human resources, local expertise, equipment availability and maintenance, training levels of healthcare staff, and nancial burden to patients and relatives (17). In Uganda adult intensive care medicine has been under-prioritised, leaving it unprepared for a surge in demand, with a limited capacity of only 55 functional critical care beds for a population of around 40 million (17,19,21). Therefore, tools for managing patients outside of critical care are crucial in this setting, hence the prioritisation of building CPAP capacity locally.…”