Survival Status and its predictors among Patients Admitted to Pediatric Intensive Care Unit at Selected Tertiary Care Hospitals in Ethiopia: A Prospective Observational Study

doi:10.21203/rs.3.rs-1658360/v1

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Survival Status and its predictors among Patients Admitted to Pediatric Intensive Care Unit at Selected Tertiary Care Hospitals in Ethiopia: A Prospective Observational Study

https://doi.org/10.21203/rs.3.rs-1658360/v1

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Background: Advances in pediatric intensive care have radically improved the prognosis for critically sick patients. Despite high burden of critically ill patients in low-income countries, there is scarce evidence on the incidence of mortality and its predictors among patients admitted to Intensive care unit (ICU) in Ethiopia. Therefore, we designed this study to determine the survival status and predictors of mortality among patients admitted to pediatric ICU at selected tertiary care hospitals in Ethiopia.

Methods: A prospective observational study involving 206 admitted patients from October 2020 to May 30, 2021 was conducted in selected tertiary care hospital in Ethiopia. Data were collected on socio-demographic, clinical characteristics, treatment-related variables and entered into Epi-data version 4.6, and then exported to SPSS version 23.0 for analysis. Kaplan-Meier was used to compare the survival experience of the patients and Cox regression was used to identify independent predictors of in-ICU mortality. The hazard ratio was used as a measure of the strength of association and a p-value of < 0.05 was considered to declare statistical significance.

Results: Fifty-nine (28.6%) patients were died during follow-up time, and the incidence of mortality was 3.6 deaths per 100 person-day observation. The mean ± SD survival times among patients with infectious and non-infectious related illnesses were 19.96 ± 1.84 and 27.24 ± 2.52 days respectively (log rank p = 0.08). Respiratory failure 19 (32.2%) was the commonest cause of death. In-ICU complications (AHR: 2.13; 95%CI: [1.02, 4.42]; p = 0.04), sepsis diagnosis (AHR: 2.43; 95%CI: [1.24, 4.78]; p = 0.01), GCS<8 (AHR: 1.96; 95%CI: [1.12, 3.43]; p = 0.02), use of sedative drugs (AHR: 2.40; 95%CI: [1.16, 4.95]; p = 0.02) were linked with increased risk of in-ICU mortality. In contrast, the use of mechanical ventilation was associated with decreased mortality (AHR: 0.45; 95%CI: [0.21, 0.92]; p = 0.03).

Conclusion: The study found high incidence of in-ICU mortality among admitted pediatrics patients in selected Ethiopian tertiary care hospitals. In-ICU complications, sepsis diagnosis, GCS<8, and patient use of sedative drugs were independent predictors of in-ICU mortality. Prudent follow up is warranted for those patients with aforementioned risk factors.

Survival status

Predictors of mortality

Pediatric Intensive Care Unit

Ethiopia

Intensive care is a multi-disciplinary and inter-professional specialty committed to the management of patients with serious organ dysfunction (1). The PICU is a specifically staffed, separate, and independent area in the health care facilities dedicated to the broad management of patients with critical illnesses to reduce mortality by strictly monitoring and treating severely ill patients who are considered to be at high risk of death (1,2).

Regardless of significant improvement in decreasing child mortality, worldwide childhood mortality rates remain high and children continue to face extensive regional disparities in their chances of existence(3). The WHO report shows that the major causes of pediatric death in developing countries are preventable and curable diseases if treatment is optimized (4,5). The prevalence of PICU mortality was varied in developed and developing countries, which is very high in the low-income countries (6–10) as compared to high-income countries (11–13). In the United States (US), the primary causes of mortality among under-five children were congenital anomalies and accidental injuries, But in unindustrialized countries, most childhood mortality were due to infections such as pneumonia, diarrhea, and severe malaria(2).

Advances in pediatric intensive care have radically enhanced the prognosis for critically ill patients, but pediatric critical care services were reasonably young in developing countries and children’s mortality remains a major health problem; particularly in Sub-Saharan Africa (SSA) with varying qualities and quantities of infrastructure necessary for the provision of suitable critical care services(14). In 2020 alone, SSA remains to be the region with the highest under-five mortality rate, which accounts for 53% of all under-five deaths globally (3,15). Studies conducted in Mozambique, Rwanda and Eritrea showed that mortality rates in the ICU were found to be high which were 25%, 50% and 25.3%, respectively (9,16,17).

Ethiopia is one of the top five countries with the world's highest under-five mortality rates, which accounts for 59 deaths per 1000 live births (4,18). Based on available findings , pediatric ICU is where the utmost number of mortality happens in the most hospitals of Ethiopia and studies conducted in Ethiopia reported that the overall mortality rate of patients admitted to pediatric ICU was 8.5%, 32.6%, and 39.8% with the most common cause of death being neurologic disorders, infections, and cardiovascular disease, respectively (6,10,19).

Despite of the high burden of critically ill children in developing countries and while PICU is an essential area of service to save the lives of patients with acutely life-threatening conditions; organizational details of pediatric ICUs in low-income settings and available data on pediatric intensive care, specifically on the incidence of mortality, and its predictors among patients admitted to PICU in our country remain insufficient. Also, most of the existing evidence of mortality in the pediatric ICUs were limited to single-center, revised patient medical charts retrospectively (6,8,10,19,20).

In Ethiopia, there are a small number of pediatric ICUs established for the pediatric patients and in addition to that; there is an inadequate resource to provide care for critically ill patients. This makes the establishment of adequate service and enhancement of outcomes difficult. So, there is a great need to conduct an extensive study on the hospitals based, particularly ICU basis to obtain reliable information on this area. Therefore, the aims of this study was to determine the incidence of mortality and its predictors among patients admitted to selected tertiary care hospitals in Ethiopia.

Study design, period, and setting

An institutional-based prospective observational study was conducted among pediatrics patients admitted to the PICU at Jimma Medical Center (JMC), and St. Paul’s Hospital Millennium Medical College (SPHMMC) from October 2020 to May 2021. JMC is the teaching and referral hospital in southwest Ethiopia located in Jimma town and it provides services for over 20 million catchment population. Currently, the hospital has more than 600-bed capacities, and its PICU has four beds with electronic monitors and mechanical ventilators for patients admitted from different departments of the hospital.

SPHMMC is a tertiary care hospital located in Addis Ababa, the capital city of Ethiopia. It is one of the largest government hospitals in the nation and its core services included the provision of medical care, teaching, and research. The hospital gives for patients coming from Addis Ababa and all over Ethiopia. Currently, the hospital has more than 750 beds, of these; the PICU has six beds with electronic monitors and mechanical ventilators for patients admitted to PICU.

Source and study population

All pediatric patients admitted to the pediatric ICU of JMC and SPHMMC were our source population, while pediatric patients admitted to the pediatric ICU during the study period that fulfilled the inclusion criteria were our study population.

Study Variables

Dependent Variables

Survival statuss at PICU discharge (ICU mortality)

Independent Variables

Age, gender, residence, weight, patient category, nutritional and vaccination status, source of admission, frequency of admission, the reason for admission presence of comorbid illness, mental status, organ dysfunction, intervention during ICU stay, PIM2 score, and length of ICU stay, and caregiver’s related factors.

Eligibility criteria

All pediatric patients who were admitted to the PICU of JMC and SPHMMC during the study period were included, while those who died on arrival or died within two hours of admission and patients who had inadequate data were excluded.

Sample Size Determination and Sampling procedures

The sample size for this study was calculated using a single population proportion formula where, No = minimal sample size required, z = 1.96 (normal deviate corresponding to 95% confidence interval), w = 0.05 (degree of precision of 5%), p = 0.326 (a mortality rate of 32.6%; from study conducted in Ethiopia (10).

Since the target population was less than 10,000, then the exact sample size was adjusted as; nf = No/1+No/N, nf is the corrected sample size and N is obtained from the previous admission data from two hospitals (SPMMC = 229, JMC = 186), which was 415.

Then, by adding a 10% contingency value, the final sample size was 206 patients. Based on the previous admissions, this number was proportionally divided for both hospitals in the ratio of 1:1.24. Accordingly, 92 and 114 patients were allocated for JMC and SPHMMC, respectively. A consecutive sampling technique was used and all consecutively admitted patients to PICU from October 2020 to May 2021 were included, based on the inclusion criteria.

Data collection Tools and Procedures

To ensure content validity, the data collection tool was adapted from previous related studies and patient charts were examined as per the objectives of the study. The data were collected by one bachelor nurse and one clinical pharmacist recruited from each department who was working at SPHMMC and JMC after taking assent from the caregivers. Training on data collection was given for data collectors before beginning the data collection. Clinical character such as SBP, pupillary light reflex; oxygen saturation, and need for mechanical ventilation (MV) were assessed within the first hour and entered into an electronic application to calculate the Pediatric Index of Mortality 2 (PIM2) Score (21).

Data Quality Assurance

Before the actual data collection, the questionnaire adapted from previous studies was translated to the local official languages (Amharic and Afan Oromo), and then back to the English version to ensure the data content. A pretest was done on 5% of a sample before the actual data collection to check the consistency and validity of the structured data collection format. The collected data were double-checked by the data collector and the principal investigator for completeness, accuracy, and clarity.

Data processing and Analysis

Data were checked manually for completeness, and entered into Epi-data manager version 4.6 and then sent to SPSS version 23 for statistical and survival analysis. Descriptive analysis was performed to recap baseline characteristics, and results were presented by the text, tables, and figures. Kaplan-Meier curves were computed to compare the survival status of patients. Bivariate analysis was conducted and variables having a p-value < 0.25 were considered as candidates for multi-variable regression. Multi-variable cox proportional hazard model was performed to identify factors associated with in-ICU mortality. The hazard ratio was used as a measure of the strength of association and variables with a p-value of < .05 were reflected to declare statistical significance.

Operational definitions

Pediatric Intensive Care Unit – is a specially staffed, separate, and self-contained area in the hospital dedicated to the detailed management of critically ill patients (1,2).

In-ICU mortality: is defined as all-cause ICU mortality from index admission to discharge ascertained by death summary from healthcare records/physicians

Event (death): is the cessation of all biological function that sustains an organism (patient who died in the hospital during on treatment).

Censored: It refers to patients who were discharged alive from the pediatric ICU.

In-ICU complications are patient who develops other conditions during their ICU stay.

Length of ICU stay: refer to the duration of ICU stay in days from the date of admission to the date of discharge from pediatric ICU

Clinical outcome: It’s the outcome of the patient until he or she leaves the hospital.

Pediatric Index of Mortality (PIM2) score: is a mortality prediction tool that considers data on the type of admission (elective or emergency), diagnosis risk, mechanical ventilation, systolic blood pressure, base excess by blood PH, arterial oxygen pressure, and pupillary examination data within the first hour of ICU admission (21).

Out of 217 consecutive patients admitted to pediatric ICU of JMC and SPHMMC over eight months period, 206 patients were included. Of these patients enrolled, eleven patients were excluded (age < 1 month = 4, died < 2 hours of ICU admission = 5, parent’s reject assent = 2). Finally, data of 206 patients were included in the study. A majority, 114 (55.3%) of the patients were from SPHMMC. Of patients analyzed, 179 (86.9%) patients were medical and 27 (13.1%) with surgical admissions (Figure1)

Socio-demographic characteristics

Of patients admitted, 113 (54.9%) were female, giving a male to female ratio of 1:1.22. The mean ± SD age of the patients admitted in ICU was 55.99±54.93 months. More than half, 124 (60.2%) of the patients were from a rural area, and 94 (45.6%) patients were admitted from the pediatric emergency department. Of all the patients analyzed, 38 (18.4%) were severely malnourished (<–3 Z-score). The majority of patients were medical patients, which accounted for 179 (86.9%) and 157 (76.2%) were new admissions. Regarding the vaccination status, 120 (58.3%) was fully vaccinated. The majority, 185 (89.8%) of the caregivers were parents and 80 (38.8%) had no formal education and around 94 (45.6%) of them were farmers (Table1)

Clinical Characteristics of admitted Patients

The most common cause for ICU admission was severe pneumonia, 35 (17%), followed by septic shock 32 (15.5%), and complicated meningitis 25 (12.1%) (Table2). Regarding the consciousness level of patients at arrival to the ICU, 52 (25.2%) patients were presented with severe impairment of consciousness. One hundred twenty-two (59.2%) patients had oxygen saturation < 90% at ICU admission. The mean ±SD of PIM-2 score was 7.08± 5.93 with the majority of them, 135 (65.5%) were >5 scores. More than two-thirds, 142 (68.9%) of patients were mechanically ventilated. The median length of stay in the PICU was 5 (IQR: 3–9) days and the majority, 104 (50.5) of patients were died within 7 days of ICU admission. Forty-eight patients (23.3%) developed complications during their ICU stay (Table 3).

Type of Treatment Given During PICU Stay

Of medication prescribed in pediatric ICU, almost all patients were treated with different types of antibiotics 185 (89.8%), followed by fluid resuscitation 158 (76.7%), analgesics, 109 (52.9%), and nutritional treatments (Table 4). Majority, 149 (72.3%) of the patients were treated with ceftriaxone followed by vancomycin 71 (34.5%), morphine 68 (33%), and metronidazole 63 (30.6%) (Figure 2).

Survival status of admitted patients

In-ICU mortality: During the study period, 59 (28.6%) patients died, and the incidence of mortality was 3.6 deaths per 100 person-day observations One hundred forty-seven (71.4%) patients were survivors, among them the majority 76 (51.7%) were improved and transferred to the wards (Figure 3). The (mean ±SD) survival times among patients admitted with infectious and non-infectious related diseases were 19.96 ±1.84, and 27.24 ± 2.52 days respectively (log-rank p= 0.08) (Figure 4). The commonest causes of death were respiratory failure, 19 (32.2%), followed by septic shock, 11 (18.6%), cardiac arrest, 9 (11.9%), multi organ failure 7(11.9%), and complicated meningitis, 6 (10.1%) (Table 5).

Predictors of in-ICU mortality

Cox regression was done to identify the association between baseline characteristics and in-ICU mortality. Accordingly, sepsis diagnosis, sex, infectious disease, organ dysfunction, need of mechanical ventilator, PIM2 score, patient use of sedative drugs, Oxygen saturation at admission, antibiotics use, GCS at admission, and complications in the ICU had a p-value of < 0.25. With a multivariate cox proportional hazard regression modeling, complications in the ICU (AHR: 2.13; 95%CI: [1.02, 4.42]; p = 0.04), sepsis diagnosis (AHR: 2.43; 95%CI: [1.24, 4.78]; p = 0.01), GCS<8 (AHR: 1.96; 95%CI: [1.12, 3.43]; p = 0.02), use of sedative drugs (AHR: 2.40; 95%CI: [1.16, 4.95]; p= 0.02) were linked with increased risk of in-ICU mortality. The use of mechanical ventilation was associated with decreased mortality (AHR: 0.45; 95%CI: [0.21, 0.92]; p = 0.04). Then, the hazard of mortality was two times higher for patients who developed complications in pediatric ICU (AHR: 2.13; 95%CI: [1.02, 4.42]; p= 0.04) as compared with non-complicated patients. Also, the hazard of mortality was 2.40 times higher in patients who used sedative drugs (AHR: 2.40; 95%CI: [1.16, 4.95]; p = 0.01) as compared with non-users of sedative drugs. Mortality was 55% lower for those who use mechanical ventilators during their ICU stay than non-users of MV (AHR: 0.45; 95%CI: [0.21, 0.92]) (Table 6).

This study assessed the survival status and its predictors among patients admitted to pediatric ICU patients treated at two selected Ethiopian tertiary care hospitals. Our study is the first report from a two-center prospective observational study in a PICU in Ethiopia that demonstrates the mortality is high and identified predictors of mortality such as complications in the ICU, use of sedative drugs, sepsis diagnosis, GCS < 8 and use of mechanical ventilator.

In this study, the overall in-ICU mortality was 28.6% with an incidence of 3.63 deaths per 100 person-day observations. This finding is consistent with the mortality rate in the studies conducted in Pakistan, (26.6%) (22), Egypt, (33.1%) (23), Mozambique, (25%) (7), Eritrea, (25.3%) (16) and Gonder (Ethiopia), (32.6%) (10). However, it is lower than the finding of a retrospective cross-sectional study done in Jimma (Ethiopia) from 2009 to 2013, (40%) (8).

The difference could be attributed to the higher proportion of trauma patients admitted in their PICU compared with ours. Furthermore, the proportion of mortality in our PICU is higher than the finding of a study conducted in Ayder Referral Hospital (Ethiopia), Iran, Pakistan, Nepal, and India (8.5%, 16.5%, 11.9%, 12.6%, and 14%), respectively (6,11,24–26).

The higher proportion of deaths in our setting could be explained by the fact that this is tertiary center, which accepts referrals from distant locations resulting in delayed presentation, and most of the patients were seriously ill when admitted to our setting. This may be due the insufficient mechanical ventilator in our setting for those in need. In addition, the lack of a high dependency unit in the study area might be one of the contributing factors for the higher rate of ICU mortality.

A higher proportion of death was reported among patients with infectious diseases (17.9%) versus non-infectious (10.7%). This finding is in line with most of the studies conducted in developing countries, in which more than half of deaths were attributed to infectious diseases (7,9,10,27). However, several findings from developed countries reported non-infectious disease as the most common cause of death (11–13). This could be because of low socio-economic, poor hygiene, and inaccessibility of health care facilities in developing settings.

Our study showed that respiratory failure was the leading cause of death accounting for (32.2%) of total death, followed by septic shock (18.6%), cardiac arrest (11.9%), and complicated meningitis (10.1%). This finding is comparable with the study conducted in Mozambique, Gonder (Ethiopia), Iran, Bangladesh, and India (7,10,11,27,28). In contrary to our finding, the leading cause of death was the withdrawal of life-sustaining treatments in the study done in the US, (13), trauma in a study done in Jimma (8), and renal failure in study conducted in Eretria (16). This difference might be due to differences in study design, the pattern of admission, and the ICU service provided.

The mean (± SD) length of stay in PICU was 7.87 ± 7.86 days with (59.7%) of patients stayed within 2 to 7 days of ICU admission in our study. This finding is consistent with the study done in Rwanda (6.8 ± 8.5 days) (9), and Nepal (6.29 days) (29), but on contrary to a study done in Pakistan (4.11 ± 1.88 days) (22). The difference in mean length of stay might be due to variation in admission pattern, the quality of care delivered to the patients in ICU, and in-ICU complications might be one of the contributing factors for the higher length of ICU stay in our setting.

This study also identified the independent predictors of in-ICU mortality. Hence, the presence of in-ICU complications, sepsis diagnosis, GCS < 8, and use of sedative drugs were found to be independent predictors of mortality at the PICU, while the use of a mechanical ventilator was associated with a lower risk of mortality. Patients who developed complications during their ICU stay were two times more likely to die than those without compilations (p = 0.04). There is no published study for comparison purposes. But, this could be since complications are associated with an increased probability of death because of a double burden on initial illnesses.

This study indicated that the hazard of mortality was 2.40 times higher in patients who took sedative drugs (p = 0.02). This is comparable with the study conducted in Rwanda (9), Greece, (11), and Harvard children’s hospital, Boston (30); the use of the sedative drug was correlated with increased risk of in-ICU mortality. This might be due to sedation leaves the patient at risk of needing prolonged respiratory support, specifically mechanical ventilator, prolonged ICU stays, and it also put critically ill patients at high risk of developing PICU-acquired complications (9,11,30).

Children admitted with reduced level of consciousness (GCS < 8) had nearly two times increased risk of mortality than those admitted with higher. This is consistent with the findings of studies done in Iran (11). The child who had a sepsis diagnosis had an increased hazard of mortality than those who had not. This finding was consistent with other studies conducted in Iran (31). This could be because of patients with severe sepsis have a low spare of physiologic function.

The in-ICU mortality was 55% lower for those who use mechanical ventilators during their ICU stay than non-users. This finding is contrasting with a study conducted in TASH (19), and Gonder (Ethiopia) (10), in which the use of mechanical ventilator was significantly correlated with an increased risk of in-ICU mortality. The possible justification that use of MV was associated with reduced risk of death in our study might be related to the fact that severe pneumonia which could lead to Acute Respiratory Distress Syndrome (ARDS) was the commonest cause of admission and most patients with ARDS benefit from MV.

Though this study is a two center prospective study conducted in resource limited country, it has some limitations. First, the income of caregivers that might affect the survival status of pediatric patients was not assessed because it was difficult to ascertain since the majority of admissions were from a rural area and they usually under-report the assets they have. Secondly, PIM2 scoring was based on 8 out of 10 parameters as there was no arterial blood gas analyzer in our PICU during the study period. Finally, sample size is small and it may affect power of the study.

The study found high incidence of in-ICU mortality among pediatrics patients in selected Ethiopian tertiary care hospitals. Respiratory failure, septic shock and cardiac arrest were the common causes of admission and death. In-ICU complications, sepsis diagnosis, GCS < 8, and use of sedative drugs were linked with increased risk of in-ICU mortality in contrast to the use of mechanical ventilator. Therefore, prudent follow up is warranted for those patients with aforementioned risk factors.

AHR: Adjusted Hazard Ratio

ARDS: Acute Respiratory Distress Syndrome

CHR: Crude Hazard Ratio

CI: Confidence Interval

EOPD: Emergency Outpatient Department

ETT: Endotracheal Tube

GBS: Gillian Barre Syndrome

GCS: Glasgow Coma Scale

ICU: Intensive Care Unit

IQR: Inter Quarter Range

JMC: Jimma Medical Center

LOS: Length of Stay

MV: Mechanical Ventilation

PICU: Pediatric Intensive Care Unit

PIM2: Pediatric Index of Mortality 2

SD: Standard Deviation

SPHMMC: Saint Paul’s Hospital Millennium Medical College

SPSS: Statistical Package of Social Science

SSA: Sub-Saharan Africa

TASH: Tikur Anbesssa Specialized Hospital

US: United States

WHO: World Health Organization

Ethics approval and consent to participate

The study was done in accordance with the declaration of Helsinki. An ethical clearance letter was obtained from the institutional review board of Jimma University (reference No: IRB000234/2012) and St. Paul’s Hospital Millennium Medical College (reference No: PM23/200). Then, a letter of cooperation was taken from each pediatrics and child health department of the hospital. Informed verbal consent was gotten from the caretakers. The name of patient was not recorded on the data collection form, and all information taken from the chart was kept strictly confidential and the data retrieved was used only for the study.

Consent for publication

Not applicable.

Availability of data and materials

Full data for this research is available through the corresponding author up on request.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Authors’ contributions

All authors contributed to the design of the study and the interpretation of data. AJB: also performed the data collection, statistical analysis and drafted the manuscript. All others authors critically revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank Jimma University for facilitating conducive environment for the research. We also would like to express our deepest heartfelt thanks to Jimma Medical Center and St. Paul’s Hospital Millennium Medical College for providing available information. Finally, our special thanks go to the study participants, data collectors and supervisors.

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Table 1

Socio-demographic characteristics among patients admitted to PICU of selected tertiary care hospitals in Ethiopia from October 01, 2020, to May 30, 2021, (N=206).

Socio demographic variables		Outcome n (%)		Frequency (%)	P-value
Socio demographic variables		Died	Survived	Frequency (%)	P-value
Study site	JMC	27 (29.3)	65 (70.7)	92 (44.7)	0.86
Study site	SPHMMC	32 (28.1)	82 (71.9)	114 (55.3)	0.86
Sex	Female	30 (26.5)	83(73.5)	113 (54.9)	0.25
Sex	Male	29 (31.2)	64 (68.8)	93 (45.1)	0.25
Age in months	1 to 12	24 (33.8)	47 (66.2)	71 (34.5)	0.02
	13 to 60	15 (25.9)	43 (74.1)	58 (28.2)
	61 to 120	9 (20.9)	34 (79.1)	43 (20.9)
	121 to 168	11(32.4)	23 (67.6)	34 (16.5)
Residence	Rural	32 (25.8)	92 (74.2)	124 (60.2)	0.99
Residence	Urban	27 (32.9)	55 (67.1)	82 (39.8)	0.99
Weight (kg)	(Mean± SD)	13.54 ±10.59	15.29±10.23		0.09
Patient category	Medical patient	51 (28.5)	128 (71.5)	179 (86.9)	0.90
Patient category	Surgical patient	8 (29.6)	19 (70.4)	27 (13.1)	0.90
Source of admission	Pediatric EOPD	24 (25.5)	70 (74.5)	94 (45.6)	0.28
	Pediatric ward	24 (30.4)	55 (69.6)	79 (38.3)
	Surgical ward	8 (32)	17 (68)	25 (12.1)
	Referral	3 (37.5)	5 (62.5)	8 (3.9)
Nutritional status	Normal	47 (29.9)	110 (70.1)	157 (76.2)	0.91
Nutritional status	Malnourished	12 (24.5)	37 (75.5)	49 (23.8)	0.91
Vaccination status	Fully vaccinated	38 (31.7)	82 (68.3)	120 (58.3)	0.18
Vaccination status	Not vaccinated	21 (24.4)	65 (75.6)	86 (41.7)	0.18
Frequency admission	Frist admission	44 (28)	113 (72)	157 (76.2)	0.27
Frequency admission	Readmission(≥2)	15 (30.6)	34 (69.4)	49 (23.8)	0.27
Caregiver’s	Parents	55 (29.7)	130 (70.3)	185 (89.8)	0.46
	Siblings	2 (16.7)	10 (83.3)	12 (5.8)
	Grandparents	2 (22.2)	7 (77.8)	9 (4.4)
Caregiver’s education	No formal education	25 (31.3)	55 (68.7)	80 (38.8)	0.60
	Primary school (1-8)	7 (19.4)	29 (80.6)	36 (17.5)
	Secondary school (9-12)	8 (25)	24 (75)	32 (15.5)
	College/University	19 (32.8)	39 (67.2)	58 (28.2)
Caregiver’s occupation	Farmer	26 (27.7)	68 (72.3)	94 (45.6)	0.99
	Merchant/labor work	14 (29.8)	33 (70.2)	47 (22.8)
	Employee (Govt./private)	14 (31.8)	30 (68.2)	44 (21.4)
	Others	5 (23.8)	16 (76.2)	21 (10.2)

Others: Unemployed, students, and Housewife. Govt.: Governmental, JMC: Jimma Medical Center, SD: Standard deviation, SPHMMC: St. Paul’s Hospital Millennium Medical College, EOPD: Emergency outpatient department.

Table 2

Reason for admission among the study participant admitted to PICU at selected tertiary care hospitals in Ethiopia from October 01, 2020, to May 30, 2021.

Variables		Outcome n (%)		Frequency (%)
Variables		Died	Survived	Frequency (%)
Reason for admission	Infectious	37 (33)	75 (67)	112 (54.4)
Reason for admission	Non-infectious	22 (23.4)	72 (76.6)	94 (45.6)
Primary Diagnosis	Severe Pneumonia	13 (37.1)	22 (62.9)	35 (17)
	Severe sepsis/septic shock	12 (37.5)	20 (62.5)	32 (15.5)
	Complicated meningitis	9 (36)	16 (64)	25 (12.1)
	Congestive heart failure	3 (13)	20 (87)	23 (11.2)
	Post-operative	3 (23.1)	10 (76.9)	13 (6.3)
	Guillen Barrie Syndrome	3 (23.1)	10 (76.9)	13 (6.3)
	Severe Asthma	1 (11.1)	8 (88.9)	9 (4.4)
	Upper airway obstruction	1 (14.3)	6 (85.7)	7 (3.4)
	Traumatic brain injury	2 (33.3)	4 (66.7)	6 (2.9)
	Acute Glomerulonephritis	1 (16.7)	5 (83.3)	6 (2.9)
	Disseminated Tuberculosis	2 (33.3)	4 (66.7)	6 (2.9)
	Cardiogenic shock	2 (40)	3 (60)	5 (2.4)
	Diabetic ketoacidosis	1 (20)	4 (80)	5 (2.4)
	Status epileptics	2 (40)	3 (60)	5 (2.4)
	Miscellaneous conditions*	4 (25)	12 (75)	16 (7.9)

Miscellaneous conditions*: Bronchiolitis, down syndrome, hepatic failure, generalized tetanus, corpulmonale, severe malaria, and organophosphate poisoning.

Table 3

Clinical characteristics of the study participant admitted to PICU at selected tertiary care hospitals in Ethiopia from October 01, 2020, to May 30, 2021.

Variables		Outcome n (%)		Frequency (%)	P-value
Variables		Died	Survived	Frequency (%)	P-value
Organ dysfunction	Yes	51 (33.1)	103 (66.9)	154 (74.8)	0.20
Organ dysfunction	NO	8 (15.4)	44 (84.6)	52 (25.2)	0.20
Level of consciousness	GCS > 8	36 (23.4)	118 (76.6)	154 (74.8)	0.02
Level of consciousness	GCS ≤ 8	23 (44.2)	29 (55.8)	52 (25.2)	0.02
Oxygen saturation (%)	Less than 90%	45 (36.9)	77 (63.1)	122 (59.2)	0.02
Oxygen saturation (%)	90 to 100%	14 (16.7)	70 (83.3)	84 (40.8)	0.02
Use of MV	Yes	49 (34.5)	93 (65.5)	142 (68.9)	0.05
Use of MV	No	10 (15.6)	54 (84.4)	64 (31.1)	0.05
Patient’s access to airway	ETT	42 (35.3)	77 (64.7)	119 (83.8)	0.65
Patient’s access to airway	Tracheotomy	7 (30.4)	16 (70.6)	23 (16.2)	0.65
PIM2 score	>5	45 (33.3)	90 (66.7)	135 (65.5)	0.75
PIM2 score	≤5	14 (19.7)	57 (80.3)	71 (34.5)	0.75
Length of stay on MV in days	< 2	22(39.3)	34 (60.7)	56 (39.4)	0.26
	2 to 7	20 (33.3)	40 (66.7)	60 (42.3)
	>7	7 (26.9)	19 (73.1)	26 (18.3)

GCS: Glasgow coma scale, ETT: Endotracheal tube, PIM2: pediatric index of mortality 2, MV: mechanical ventilation.

Table 4

Distribution of type of treatments given during ICU stays among patients admitted to PICU of selected tertiary care hospitals in Ethiopia from October 2020, to May 2021, (N=206).

Type of treatments given during ICU stays	Outcome n (%)		Frequency (%)
Type of treatments given during ICU stays	Yes	No	Frequency (%)
Antibiotics	56 (30.3)	129 (69.7)	185 (89.8)
Fluid therapy	40 (25.3)	118 (74.7)	158 (76.7)
Analgesics	28 (25.7)	81 (74.3)	109 (52.9)
Nutritional treatments	20 (27.8)	52 (72.2)	72 (35)
Steroids	11 (16.7)	55 (83.3)	66 (32)
Diuretics	15 (23.6)	42 (73.7)	57 (27.7)
Sedatives	9 (16.7)	45 (83.3)	54 (26.2)
Inotropes use	15 (29.4)	36 (70.6)	51 (24.8)
Anticonvulsants	11(30.6)	25 (69.4)	36 (17.5)
Stress-ulcer prophylaxis	10 (28.6)	25 (71.4)	35 (17)
ACE-Inhibitors	2 (7.4)	25 (92.6)	27 (13.1)
Anti-asthmatic	2 (10)	18 (90)	20 (9.7)
Anti-malarial	4 (21.1)	15 (78.9)	19 (9.2)
Miscellaneous drug class*	18 (26.9)	49 (73.1)	67 (32.5)

Miscellaneous drug class*: Insulin, blood transfusion, Thrombosis prophylaxis, Antifungal, Beta-blockers, Anti-hypertensive, and Anti-helminthic.

Table 5

Causes of death among patients admitted at JMC and SPHMMC, from October 1 to May 30, 2021.

*Causes of Death*	*Frequency (n=59, %)*
Respiratory failure	19 (32.2)
Septic shock	11 (18.6)
Cardiac arrest	9 (15.3)
Multi organ failure	7 (11.9)
Complicated meningitis	6 (10.1)
Brain death	5 (8.5)
GBS	2 (3.4)
Total	59 (100%)

Table 6

Bivariate and multivariable Cox proportional hazard regression to identify predictors of in-ICU mortality at JMC and SPHMMC, from October 01, 2020, to May 30, 2021

Variables		Outcome		CHR (95% CI)	AHR (95%CI)	P-value
Variables		Died	Survived
Sex	Female	30 (26.5)	83 (73.5)	1.38 (0.82, 2.33)	1.14 (0.65, 1.99)	0.65
Sex	Male	29 (31.2)	64 (68.8)	1	1
Infectious disease	Yes	37 (33)	75 (67)	0.52 (0.28, 0.94)	1.06 (0.57, 1.97)	0.86
Infectious disease	No	22 (23.4)	71 (76.6)	1	1
Sepsis diagnosis	Yes No	12 (37.5) 47 (27)	20 (62.5) 127 (73)	0.50 (0.27, 0.96) 1	2.43 (1.24, 4.78)	0.01
Organ dysfunction	Yes No	51 (33.1) 8 (15.4)	103 (66.9) 44 (84.6)	0.60 (0.28, 1.26) 1	1.06 (0.29, 3.98) 1	0.94
GCS	≤8	23 (44.2)	29 (55.8)	0.51 (0.30, 0.86)	1.96 (1.12, 3.43)	0.02
GCS	>8	36 (23.4)	118 (76.6)	1	1
Oxygen Saturation	≤90% >90%	45 (36.9) 14 (16.7)	77 (63.1) 70 (83.3)	0.52 (0.28, 0.94) 1	1.29 (0.62, 2.71) 1	0.49
PIM2 score	≥5 >5	45 (33.3) 14 (19.7)	90 (66.7) 57 (80.3)	0.67 (0.37, 1.22) 1	1.27 (0.53, 3.04) 1	0.59
Antibiotics use	Yes	56 (30.3)	129 (69.7)	0.49 (0.15, 1.56)	0.56 (0.17, 1.84)	0.34
Antibiotics use	No	3 (14.3)	18 (85.7)	1	1	0.34
Use of MV	Yes	49 (34.5)	93 (65.5)	0.58 (0.29, 1.15)	0.45 (0.21, 0.92)	0.03
Use of MV	No	10 (15.6)	56 (84.4)	1	1
Sedative drugs use	Yes	9 (16.7)	45 (83.3)	2.41 (1.18, 4.92)	2.40 (1.16, 4.95)	0.02
Sedative drugs use	No	50 (32.9)	102 (67.1)	1	1
In-ICU Complications	Yes	11 (23.9)	35 (76.1)	2.13 (1.08, 4.57)	2.13 (1.02, 4.42)	0.04
In-ICU Complications	No	48 (30)	112 (70)	1	1

CHR: Crude hazard ratio, AHR: Adjusted hazard ratio, CI: Confidence interval, MV: mechanical ventilation, ICU: Intensive care unit, PIM: Pediatric index of mortality, GCS: Glasgow coma scale.

No competing interests reported.

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Survival Status and its predictors among Patients Admitted to Pediatric Intensive Care Unit at Selected Tertiary Care Hospitals in Ethiopia: A Prospective Observational Study

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