Research methodology
FACTORS CONTRIBUTING TO POOR PROGNOSIS IN PEADIATRIC COMA CASES AT ACUTE CARE UNIT MULAGO HOSPITAL
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This chapter describes the review of literature about socio-economic factors and health facility related factors done elsewhere in the world. Literature was acquired from journals and database.
Socio-economic and health facility factors contribute more to the prognosis of non-traumatic coma than has previously been recognized (Bondi et al, 2011).These factors include socio-economic variables in the individual patients, their families, and the hospitals or health institutions (Cullen et al, 2010).
2.2 Socio-Economic factors that contribute to the poor prognosis in pediatric coma
According to a population based study in the UK, Bragatti, et al, (2010) Coma is a relatively common condition in critical pediatric care. Epidemiological studies generally divide studies by traumatic and non-traumatic causes, the incidence of non-traumatic coma was five-times greater in children under 16 years of age than in the general population (30.8 per 100,000 vs 6.0 per 100,000 per year, respectively), with a notably higher incidence in the first year of life (160 per 100,000 children per year).
In a study in USA, Infection is the most common overall cause of coma in childhood, with an overall mortality of 46%. Regarding traumatic brain injury in children, there were an estimated 546,240 children with head injuries not associated with motor vehicles in the USA during 1978 who required emergency room care. Head injuries account for 11% of hospital emergency room visits by children with non-motor vehicle trauma. A fifth of head injuries among adolescents were associated with concussion. Among the 33,635 cases of concussion in children studied, twice as many males had concussion than females (Marcovitch 2011)
According to a study in northern parts of Nigeria there was high prevalence of pediatric coma cases in poor communities than in wealthier places. Coma can be produced by one of three situations: structural lesion with bilateral hemispheric damage; a focal brainstem lesion (especially with bilateral impairment of the upper pons); or a metabolic derangement, with suppression of the reticular activating system. Several primary neurological disorders and general medical conditions are able to cause coma. Most frequently, patients become comatose after a diagnosis of drug intoxication, hypoxic–ischemic insult secondary to cardiac arrest, stroke, trauma or medical disorders, such as hyperosmolar coma (Kallela et al. 2014).
According to a study in northern Nigeria Prognosis of coma depends principally on its causes, in the study it was assessed and duration of coma and age of patients are important measured, the findings also further revealed that Children younger than 2 years old have a very poor prognosis. There is no doubt that problem in pediatric practice accounting for 10-15% of all prolonged coma after a hypoxic ischemic insult in hospital admissions; it makes a heavy demand on childhood carries a very poor prognosis, later onset intensive care units (Lindsberg & Soinila 2015).
The age, sex, and occupation of the patients are important social determinants of the behavioral pattern. The family as a support system and decision makers for the patients’ health-seeking pathways or behavior appears to be relevant and the mode of intervention, measured in terms of time and quality of medical intervention and social support for the indigent patient contributes much too poor prognosis (Cullen et al, 2010).
2.2.1 Age
An exact age threshold for identifying children at high risk of paediatric coma following infections or head injury has not been identified, but it is clear that increasing age is associated with an increased risk and a poorer prognosis. Commonly used thresholds are1, 5, 10 and 15 years. There is evidence that the prevalence of paediatric coma in younger children and infants is much higher than in older children. However, this should be weighed against the fact that an unknown, but significant, proportion of infections or head injuries that are prevalent. These infections and injuries may result in a different pattern of morbidity to that seen in younger children, and obviously require investigation regardless of cause (Dehmer, et al, 2010).
Age has been identified in many studies as a strong prognostic factor in coma of any etiology. In the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), age of 70 years or older and infancy were one of five clinical independent variables associated with 2 month mortality in non-traumatic coma (Murphy et al, 2013).
2.2.2 Gender
According to a study in Ghana, (Kolawole et al, 2000) there is not known difference between the males and female children on the risk factors and cause medical coma, this is because all children at young age presented the same level of vulnerability to pediatric medical coma cases.
In another study in Ethiopia indicates that female tend to suffer less cases of poor prognosis in peadiatric coma cases ( Yamaura et al., 2011). Many reasons have been adducted to explain this trend, especially in Africa (Dada et al, 2009). Also, there is the tendency to care for the male child more than the female. Lastly, it is believed that males have more risky or disease promoting lifestyles than females and so are more likely to fall sick and present to hospital.
In another study in Uganda, One hundred and fifty-two of the 200 patients studied died giving an overall mortality of 76%. There was an overall male predominance of 66% (132) over the females’ 34% (68). However, the difference between the respective mortality rates of 78.8% and 70.6% was not of statistical significance and pediatrics suffer the same consequences (MoH, 2012).
2.2.3 Occupation
According to Fenella et al, (2011), occupational distribution showed that the self-employed (made up of small scale businessmen, traders, artisans, taxi drivers, commercial motorcyclists, farmers, clergymen) constituted 52.5% of the study population, followed by the unemployed (students, housewives, the retired/or disengaged from service/job) who constituted 28.5% and lastly the public/civil servants who made up the remaining 19%. The mortality rates, however, showed that the self-employed had the highest rate of 81% due to less time for their family in search of the small money to take care of their families, followed by the public/civil servants with 79% who are always occupied with office work and tight programs and the unemployed with the lowest rate of 65% because they are always in touch with their families.
2.2.4 Family Support
Peadiatric coma patients who had above 50% family support and were able to pay for some relevant investigations had a better outcome than those who had poor or less than 50% family support or failed to pay for investigations. This report is in consonance with that of Jorgensen et al,(2009).
Less aggressive care for the pediatrics by family members and health care providers was responsible for poor functional outcome, while the presence of a spouse was a strong predictor of a good functional outcome in young patients with the most severe strokes (Kallela et al. 2014).
Family support had a strong influence on outcome has a strong influence on the mortality rate which a percentage effect of 56.8% in patients who have excellent family support which is lower than 86.1% and 97.1%, respectively, for those who had good and poor family support (Castren et al., 2012.).
2.2.5 Ignorance
In a study in northern state of Nigeria the results indicates that there is poor prognosis of children from illiterate parents because of lack of knowledge on the presence of better health facilities in a Similar study in Kenya as mortality was highest (84.1%) in patients whose family members had the least knowledge and lowest (64.8%) in those whose family members had excellent knowledge.
2.2.6 Nutrition.
Children who were previously exposed to poor nutritional status, with mothers or care takers who have full time jobs or busy with domestic work like farming, with no time dedicated to infants feeding behavior as well as those with low or little knowledge of infants feeding requirements increase the possibility of pediatric coma poor outcome resulting from reduced body immunity, poor brain development and brain growth (Nathaniel, et al, 2011).
2.2.7 Cultural beliefs and religious affiliation
Although Christians (62%) were more than Moslems (38%) among the study population, religious affiliation did not have any significant impact on outcome. The impact of ethnicity could not be assessed, as 95% of these patients were Yoruba, while the other 4.5% were from other Nigerian tribes and 0.5% Senegalese.
Children and families have different cultural backgrounds which affect their medical approach and experience to the treatment setting. Treatment of children with Coma is individualized, is provided in the language(s) used by the individual, and is done so with sensitivity to cultural beliefs, values and norms. Different dimensions of culture may influence the family’s belief system in seeking care and external support, for example, some cultures may have a sense of shame or feel it is necessary to hide a disability and some believe in witchcraft, which may influence how an individual and caregivers approach and respond to coma in seeking care. (Allison et al, 2017; Denslow et al, 2012; Haarbauer-Krupa, 2012).
2.3 Facility/hospital based factors
2.3.1 Delayed Referrals
Delayed presentation to hospital was a major factor in this study. About 45% of the patients were brought to hospital more than 6 hour after onset of coma, and this group had statistically significantly higher mortality. Many of these patients (32%) were referred from private hospitals and other primary and secondary health facilities where they were first seen. Many of these patients presented to UCH with co-morbid illnesses and complications, hence the higher mortality. This also agrees with the observations of other workers, particularly with respect to stroke (Osuntokun et al, 2007) and hypoglycemia especially in Africa (Lester et al, 2012).
According to a study in Senegal , mortality was higher (76.7%) in the 45% (90) patients who presented after 6 hour than the 55% (110) who were brought within 6 hour (63.2%), although the difference was not statistically significant. 32.5% (65) of the patients who presented after 6 hour were referred from primary and secondary health facilities with a mortality rate of 89.6%, while the other 12.5% (25) brought in directly from their homes had a mortality rate of 68.7%(Venkatraman et al, 2011).
The management of paediatric coma child requires urgent intervention, with 12% of children under 1year requiring paediatric ICU in hospital set up because of the prognostic depression of respiratory centers in the brain., 94 % of the children if given immediate intervention in the hospital facility will improve and develop no neurological complications, however a delay to seek medical services is still a great menace especially in developing countries where only about 67% seek medical assistance (Gillmore et al., 2011).
2.3.2 Facility equipments, investigation and supplies
According to study in Uganda most of the hospitals with good facilities have the ability to ensure better quality care for the patients (MoH, 2013). In a related study in Nigeria hospitals in rural areas were responsible for poor quality medical services (Kaisvuo & Uotila 2013).
According to Storvik- Sydänmaa (et al. 2013) the equipments in a given health facility is responsible for the quality of Health services most of the health facilities in sub-Saharan Africa do not have the necessary equipments needed to effect better health services to the people.
According to the findings in Manchester Hospital the size and proportions of child’s and adult’s organs are different. Compared to adults, child has quite large brain and liver, large head and long limbs. However, the reproductive organs do not begin to develop until puberty. Child’s metabolism is more active, bone fractures heal more rapidly and body has higher liquid content than adults. (Leppäluoto et al. 2013.) Examining a pediatric patient differs from examining an adult patient in many different ways. Physiological features related to child’s growth and development should be taken into account when examining a pediatric patient. Variety of diseases is partly different in adult and pediatric patients, and same diseases can show different kind of symptoms in different stages of age. In addition, the same symptom can be caused by different disease in adult and pediatric patients. (Salonen 2009.)
In some countries where many hospitals lack equipment for electroencephalogram (EEG) and other neurophysiologic studies, mortality from non-convulsive status epilepticus might be high since many cases would be unrecognized. In a Lusaka hospital, only 3 out of 33 patients whose cause of coma could not be found, due to the lack of proper investigative tools and intensive care facilities, survived (Sinclair et al; 2009).
Although mortality rate is highest in patients admitted into the intensive care unit in a study in South Africa it was not significantly different from the rates observed in patients either in the accident and emergency unit or on the medical wards. The reasons for this result may not be far-fetched. All illnesses leading to coma portend a poor prognosis. High hospital charges, limited bed space, and no facilities for intensive care ensure exclusion of many who need these services and delayed resuscitation for the few patients who are privileged to access the care.
Mortality was worst in patients admitted into the intensive care unit (ICU) (83.3%), followed by those in the (A and E) unit with 80% and lastly 75.1% for patients admitted into the medical wards, although the differences were not statistically significant. Mortality was higher (85.4%) when diagnosis was delayed beyond 24 hours than when it was confirmed before 24 hours (73.6%), although the difference was also not statistically significant as more than two-third (79.5%) of the patients had their medical condition diagnosed within 24 hours.
All 17.5% (35) patients who had no investigations died (100% mortality), while the remaining 82.5% (165) who had some or all relevant investigations had a mortality rate of 67.3%. This difference was statistically significant.
2.3.3 Early recognition and knowledge by the health workers
The early recognition of patients who may require aggressive therapeutic measures is important, since animal and human studies have proved that early intervention results in better outcome (Malik et al, 2002).With good and quick medical intervention, many patients now survive illnesses which would previously have proved fatal, especially those associated with acute failure in one bodily system or another.Coma occurring in the course of an illness, irrespective of cause, implies a poor outcome, and physicians and families of comatose patients often have to make difficult decisions as they consider whether life extending care will achieve desirable outcomes. Health care planners also need to know the outcome of intensive care and other life-support services offered to comatose patients, for the purposes of planning and resource allocation (Lynn et al, 2012).
Pediatric nursing has its own special features which should be taken into account while taking care of a critically ill child patient. The keystones of pediatric nursing are good treatment and monitoring. In addition, it is essential that the nurses are able to use the needed technical equipment, machines and aids in order to provide professional nursing care. Furthermore, one vital part of pediatric nursing is to provide support and comfort for the parents, siblings and other relatives. The aim of pediatric nursing is to support and maintain the vital functions, prevent further complications and support health promotion. Nurses are in charge of basic and specialized nursing care of the critically ill child patient. (Storvik-Sydänmaa, Talvensaari, Kaisvuo & Uotila 2013.)
According to Marcovitch (2011) “the brain is the organ of the mind” and it needs continuous adequate supply of oxygen and glucose in order to function normally. Interruption of either of them will lead to disturbances in consciousness. (Marcovitch 2011.) Consciousness and unconsciousness can be determined in several ways. Generally speaking, consciousness means awareness of oneself and the environment; it is the state of being aware of physical events and mental concepts. Awareness means the ability to combine the data in memory to the surrounding internal and external stimuli. When a person is conscious, he or she is awake, responds to his or her surroundings and behaves meaningfully. Unconsciousness means lack of this awareness. (Marcovitch 2011; Puumalainen 2005; Westergård 2009; Lindsberg & Soinila 2015.)
Brain are involved in the regulation of consciousness, a relatively extensive disorder in the brain is underlying the state of unconsciousness. (Puumalainen 2005.) Unconsciousness is a sign of different degrees of malfunction either in the brain stem activating system (ARAS) or in both cerebral hemispheres simultaneously. Hence, for example, one-sided hemisphere damage does not lead to unconsciousness, unless its mass effect extends to the other side of the brain or to the brain stem. (Kallela et al. 2014.) According to Castren et al. (2012) an unconscious patient is always a high risk patient. It is essential to monitor the patient and document patients’ actions and consciousness level in regular basis especially in the beginning of the treatment. Once the patient is stable and the cause of unconsciousness is clear, monitoring can be reduced step by step. (Kallela et al. 2014; Ahonen, 2014.).
