Validation of the Surgical Apgar Score After Laparotomy at a Tertiary Referral Hospital in Rwanda.

BackgroundPostoperative complications and mortality following laparotomy have remained high worldwide. Early postoperative risk stratification is essential to improve outcomes and clinical care. The surgical Apgar score (SAS) is a simple and objective bedside prediction tool that can guide a surgeon’s postoperative decision making. The objective of this study was to evaluate the performance of SAS in predicting outcomes in patients undergoing laparotomy at Mulago hospital.MethodA prospective observational study was conducted among eligible adult patients undergoing laparotomy at Mulago hospital and followed up for 4 months. We collected data on the patient’s preoperative and intraoperative characteristics. Using the data generated, SAS was calculated, and patients were classified into 3 groups namely: low (8–10), medium (5–7), and high (0–4). Primary outcomes were in-hospital major complications and mortality. Data was presented as proportions or mean (standard deviation) or median (interquartile range) as appropriate. We used inferential statistics to determine the association between the SAS and the primary outcomes while the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis.ResultsOf the 151 participants recruited, 103 (68.2%) were male and the mean age was 40.6 ± 15. Overall postoperative in-hospital major complications and mortality rates were 24.2% and 10.6%, respectively. The participants with a high SAS category had an18.4 times risk (95% CI, 1.9–177, p = 0.012) of developing major complications, while those in medium SAS category had 3.9 times risk (95% CI, 1.01–15.26, p = 0.048) of dying. SAS had a fair discriminatory ability for in-hospital major complications and mortality with the area under the curve of 0.75 and 0.77, respectively. The sensitivity and specificity of SAS ≤ 6 for major complications were 60.5% and 81.14% respectively, and for death 54.8% and 81.3%, respectively.ConclusionSAS of ≤ 6 is associated with an increased risk of major complications and/or mortality. SAS has a high specificity with an overall fair discriminatory ability of predicting the risk of developing in-hospital major complications and/or death following laparotomy.

Background: Peritonitis is a commonly encountered paediatric surgical emergency. We conducted this study to identify common causes of peritonitis among Rwandan children and factors affecting morbidity and mortality.Methods: The study sample consisted of children with peritonitis who underwent surgical treatment at a tertiary referral hospital in Rwanda from 1 September 2015 to 28 February 2016. Collected data included sociodemographic, clinical, paraclinical, management, and outcome information. The analysis included Pearson's chi-square test and multivariate logistic regression to determine factors associated with morbidity and mortality.Results: Of 63 patients, 28 were female. Ages ranged from 4 months to 15 years, with a mean of 8.8 years. Seventy-three percent of patients presented within the first week of symptom onset. Appendicular perforation (25.4%) and gangrenous intussusception (23.8%) were the most common causes of peritonitis. Fourteen patients (22.2%) died. On multivariate analysis, factors associated with mortality included sepsis (odds ratio [OR] = 11.60; 95% confidence interval [CI] = 2.15 to 62.5; P = 0.004) and intensive care unit (ICU) admission (OR = 7.38; 95% CI = 1.20 to 45.3; P = 0.031).Conclusions: Peritonitis among children is common and bears significant morbidity and mortality at our centre. Training of healthcare providers in district hospitals for early recognition of peritonitis, and improved ICU care availability may reduce mortality secondary to peritonitis in children.Keywords: epidemiology; peritonitis; paediatric surgery; Rwanda

Costs Associated With Surgical Infections at a Tertiary Referral Hospital in Rwanda

Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are increasing in globally. The aim of this study was to compare community-acquired infections (CAIs) and hospital-acquired infections (HAIs) and determine the rate of third-generation cephalosporin resistance and ESBL-PE at a tertiary referral hospital in Rwanda. This was a cross-sectional study of Rwandan acute care surgery patients with infection. Samples were processed for culture and susceptibility patterns using Kirby-Bauer disk diffusion method. Third-generation cephalosporin resistance and ESBL-PE were compared in patients with CAI versus HAI. Over 14months, 220 samples were collected from 191 patients: 116 (62%) patients had CAI, 59 (32%) had HAI, and 12 (6%) had both CAI and HAI. Most (n = 178, 94%) patients were started on antibiotics with third-generation cephalosporins (ceftriaxone n = 109, 57%; cefotaxime n = 52, 27%) and metronidazole (n = 155, 81%) commonly given. Commonly isolated organisms included Escherichia coli (n = 62, 42%), Staphylococcus aureus (n = 27, 18%), and Klebsiella spp. (n = 22, 15%). Overall, 67 of 113 isolates tested had resistance to third-generation cephalosporins, with higher resistance seen in HAI compared with CAI (74% vs 46%, p value = 0.002). Overall, 47 of 89 (53%) isolates were ESBL-PE with higher rates in HAI compared with CAI (73% vs 38%, p value = 0.001). There is broad and prolonged use of third-generation cephalosporins despite high resistance rates. ESBL-PE are high in Rwandan surgical patients with higher rates in HAI compared with CAIs. Infection prevention practices and antibiotic stewardship are critical to reduce infection rates with resistant organisms in a low-resource setting.

Management of critically ill patients is challenging in a low-resource setting. In Rwanda, peritonitis is a common surgical condition where patients often present late, with advanced disease. We aim to describe critical care management of patients with peritonitis in Rwanda. Data were collected at a tertiary referral hospital in Rwanda on patients undergoing operation for peritonitis over a 6-month period. Data included epidemiology, hospital course and outcomes. Patients requiring admission to the intensive care unit (ICU) were compared with those not requiring ICU admission using Chi-square and Wilcoxon rank-sum test. Over a 6-month period, 280 patients were operated for peritonitis. Of these, 46 (16.4%) were admitted to the ICU. The most common diagnoses were intestinal obstruction (N = 17, 37.0%) and typhoid intestinal perforation (N = 6, 13.0%). Thirty-nine (89%) patients had sepsis. The median American Society of Anesthesiologist score was 3 (range 2-4), and the median Surgical Apgar Score was 4 (range 0-6). Twenty-four (52.2%) patients required vasopressors, with dopamine and adrenaline being the only vasopressors available. Patients admitted to the ICU, compared with non-critically ill patients, were more likely to have major complications (80.4 vs. 14%, p < 0.001), unplanned reoperation (28 vs. 10%, p < 0.001) and death (72 vs. 8%, p < 0.001). Patients with peritonitis admitted to the ICU commonly presented with features of sepsis. Due to limited resources in this setting, interventions are primarily supportive with intravenous fluids, intravenous antibiotics, ventilator support and vasopressors. Morbidity and mortality remain high in this patient population.

Background: A ten-point surgical APGAR score (SAS) has been previously developed and validated that provides surgeons with a simple, objective and direct rating of operative performance and risk. This score has been evaluated in different types of surgeries till date. We validated SAS in both elective and emergency abdominal surgeries separately which was not done previously. Methods: In this prospective, observational and longitudinal study, 105 surgical cases undergoing open abdominal surgeries were studied. The SAS was calculated for all patients, patients were followed up for the occurrence of any major complications or mortality during hospital stay after surgery. All the patients were divided into three groups based on their SAS score (high risk: SAS 0–4, moderate risk: SAS 5–7 and low risk: SAS 8–10) using a threshold that has been previously established. Results: The occurrence of major complications was significantly higher in high-risk SAS group (12%) than in the moderate risk group (5%). In the low-risk SAS group, the occurrence of major complications was low (1%). The mortality rate in high-risk SAS was more than that in low-risk SAS group with statistical significance both in elective and emergency cases. Conclusions: In our study, we found that patients who belong to high-risk SAS group were significantly associated with post-operative major complications and mortality in both elective and emergency surgeries. A patient with low intraoperative SAS should be considered at risk and monitored meticulously. Trial Registration: Clinical Trials Registry-India (CTRI) identifier No. CTRI/2019/02/017567.

The Surgical Apgar Score (SAS) is a simple 10-point scoring system that has been shown to be predictive of major postoperative complications and death after surgery. We evaluated the predictive ability of this score in a cohort of patients undergoing emergency abdominal surgery in a Caribbean tertiary hospital. The SAS was calculated retrospectively from the anaesthesia records of all patients undergoing emergency abdominal surgery during a 12-month period. The postoperative surgical records of these patients were then examined for the presence of major complications and death. The association between the SAS and outcomes was tested using binary logistic regression, and the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis. Of the 220 patients studied, 72 (33%) suffered an in-hospital major complication or death. The highest complication rate occurred in the low-scoring groups, with 68% of those scoring <4 being affected. Low-scoring patients (<4) had four times the risk of major complications when compared to higher-scoring groups (relative risk [RR], 4.21; 95% confidence interval [CI], 2.5-7.3; p<0.001). The odds ratio (OR) for major complications or death per unit increase in the SAS was 0.58 (95% CI, 0.47-0.72; p<0.001). The c-statistic of the SAS for predicting major complications or death was 0.71 (95% CI, 0.68-0.73; p<0.0001). The SAS is a simple 10-point score that can be used in patients undergoing emergency surgery in a Caribbean setting to help identify those that are at a higher risk of postoperative complications. Due to its ease in calculation, it can be added to other commonly used criteria to help triage the postoperative patient.

Identifying Gaps in the Surgical Training Curriculum in Rwanda Through Evaluation of Operative Activity at a Teaching Hospital

Surgical apgar score in patients undergoing lumbar fusion for degenerative spine diseases

Background & Objectives: The Surgical Apgar Score (SAS) is a simple 10 point scoring system that has been shown to be predictive of major postoperative complications and death after surgery. The aim of the study was to evaluate the predictive ability of this score in a Caribbean cohort undergoing emergency abdominal surgery. Materials & Methods: The SAS was calculated by chart review from the anesthesia records of patients undergoing emergency general surgery during a two-year period. The perioperative surgical records of these patients were examined for in-hospital complications and mortality. The predictive ability of the score for major complications and death was tested. Results: Of the 220 patients studied, 67% experienced major complications and 33% died. The highest complication rate occurred in the low scoring groups. Low scoring patients (SAS <4) had four times higher risk of major complications when compared to higher scoring (SAS ≥ 7) groups (OR 4.21, 95% CI, 2.5-7.3, p <0.001). Logistic regression analyses showed that the lower SAS score, the higher the incidence of complications and mortality [OR: 0.57, (95% CI 0.45-0.73, p <0.005]. This was also confirmed by C-statistic of the SAS, which was 0.71 (95% CI 0.68-0.73, p <0.0001) for major complications or death. The area under the Receiver Operating Characteristic (ROC) curve for SAS was 0.71 (95% CI 0.64, 0.78). Conclusion: SAS is a simple and objective perioperative score that can be used by surgeons and anesthesiologists to predict the risk of perioperative complications and mortality in patients undergoing emergency abdominal surgery in our setting. Disclosure of Interest: None declared

Introducing a Morbidity and Mortality Conference in Rwanda

AIMTo assess whether the surgical apgar score (SAS) is a prognostic tool capable of identifying patients at risk of major complications following lower extremity amputations surgery.METHODSThis was a single-center, retrospective observational cohort study conducted between January 2013 and April 2015. All patients who had either a primary transtibial amputation (TTA) or transfemoral amputation (TFA) conducted at our institution during the study period were assessed for inclusion. All TTA patients underwent a standardized one-stage operative procedure (ad modum Persson amputation) performed approximately 10 cm below the knee joint. All TTA procedures were performed with sagittal flaps. TFA procedures were performed in one stage with amputation approximately 10 cm above the knee joint, performed with anterior/posterior flaps. Trained residents or senior consultants performed the surgical procedures. The SAS is based on intraoperative heart rate, blood pressure and blood loss. Intraoperative parameters of interest were collected by revising electronic health records. The first author of this study calculated the SAS. Data regarding major complications were not revealed to the author until after the calculation of SAS. The SAS results were arranged into four groups (SAS 0-4, SAS 5-6, SAS 7-8 and SAS 9-10). The cohort was then divided into two groups representing low-risk (SAS ≥ 7) and high-risk patients (SAS < 7) using a previously established threshold. The outcome of interest was the occurrence of major complications and death within 30-d of surgery.RESULTSA logistic regression model with SAS 9-10 as a reference showed a significant linear association between lower SAS and more postoperative complications [all patients: OR = 2.00 (1.33-3.03), P = 0.001]. This effect was pronounced for TFA [OR = 2.61 (1.52-4.47), P < 0.001]. A significant increase was observed for the high-risk group compared to the low-risk group for all patients [OR = 2.80 (1.40-5.61), P = 0.004] and for the TFA sub-group [OR = 3.82 (1.5-9.42), P = 0.004]. The AUC from the models were estimated as follows: All patients = [0.648 (0.562-0.733), P = 0.001], for TFA patients = [0.710 (0.606-0.813), P < 0.001] and for TTA patients = [0.472 (0.383-0.672), P = 0.528]. This indicates moderate discriminatory power of the SAS in predicting postoperative complications among TFA patients.CONCLUSIONSAS provides information regarding the potential development of complications following TFA. The SAS is especially useful when patients are divided into high- and low-risk groups.

Safe anesthesia care is challenging in developing countries where there are shortages of personnel, drugs, equipment, and training. Anesthetists' Non-technical Skills (ANTS)-task management, team working, situation awareness, and decision making-are difficult to practice well in this context. Cesarean delivery is the most common surgical procedure in sub-Saharan Africa. This pilot study investigates whether a low-cost simulation model, with good psychological fidelity, can be used effectively to teach ANTS during cesarean delivery in Rwanda. Study participants were anesthesia providers working in a tertiary referral hospital in Rwanda. Baseline observations were conducted for 20 anesthesia providers during cesarean delivery using the established ANTS framework. After the first observation set was complete, participants were randomly assigned to either simulation intervention or control groups. The simulation intervention group underwent ANTS training using low-cost high psychological fidelity simulation with debriefing. No training was offered to the control group. Postintervention observations were then conducted in the same manner as the baseline observations. The primary outcome was the overall ANTS score (maximum, 16). The median (range) ANTS score of the simulation group was 13.5 (11-16). The ANTS score of the control group was 8 (8-9), with a statistically significant difference (P = .002). Simulation participants showed statistically significant improvement in subcategories and in the overall ANTS score compared with ANTS score before simulation exposure. Rwandan anesthesia providers show improvement in ANTS practice during cesarean delivery after 1 teaching session using a low-cost high psychological fidelity simulation model with debriefing.

Missed or Delayed Cervical Spine or Spinal Cord Injuries Treated at a Tertiary Referral Hospital in Rwanda

Necrotizing soft tissue infections (NSTI) are emergency surgical conditions with severe physiologic and metabolic derangement. These infections are associated with increased rates of mortality and morbidity worldwide, particularly in developing countries if not diagnosed and treated early. This prospective, observational cohort study includes all patients aged 12 and above who presented at Department of Surgery, University Teaching Hospital of Kigali from April 2016 to January 2017 with NSTI. We describe epidemiology, operative management, and outcomes of care. We determined risk factors for mortality using multivariate logistic regression. We identified 175 patients with confirmed diagnosis of NSTI. The majority of patients (53%) were male, and the mean age was 44years. The median duration of symptoms was 8days [interquartile range (IQR) 5-14]. The median length of hospital stay was 23days (IQR 8-41). The overall mortality was 26%. Multivariate regression analysis revealed four independent predictors of mortality: presence of shock at admission [odds ratio (OR) 14.15, 95% confidence interval (CI) 0.96-208.01, p=0.050], renal failure (OR 8.92, 95% CI 1.55-51.29, p=0.014), infection located on the trunk (OR 5.60, 95% CI 0.99-31.62, p=0.050), and presence of skin gangrene (OR 4.04, 95% CI 1.18-13.76, p=0.026). In Rwanda, NSTI mortality is high and associated with advanced disease. It is imperative that efforts are focused on early consultation, diagnosis, and surgical management to prevent adverse outcomes.