Neonatal surgical mortality and morbidity in CHUK, a tertiary hospital in Rwanda: An analysis of predicting factors

Abstract

Background

Neonatal surgical conditions occur in 1 in 5000 live births worldwide and contribute to high morbidity and mortality among neonates. Factors contributing to neonatal mortality include prematurity, sepsis, low birth weight, and malnutrition. Neonates with surgical conditions are more prone to sepsis due to various factors including wound infection, impaired metabolism and poor feeding. The Rwandan health system allows neonates with surgical conditions to be transferred to Centre Hospitalier Universitaire Kigali (CHUK), the largest referral hospital with a specialized pediatric surgical unit for neonatal surgical management. Despite the high number of neonatal admissions at CHUK, among which neonates with surgical conditions occupy a significant proportion, little is known about determinants of surgical outcomes among newborns whose clinical conditions require surgical management. The aim of this study was to assess the predicting factors of neonatal surgical mortality and to evaluate the outcomes of neonates with surgical conditions. Methods

A prospective cross-sectional study was conducted at the University Teaching Hospital of Kigali from October 2019 to March 2020 among neonates with surgical conditions, defined as all neonates who received surgical consultation and diagnosis confirmed by a pediatric surgeon. We excluded neonates with surgical conditions who were transferred post operatively from different hospitals to continue care at CHUK. A data collection tool was used to collect information. The outcome variables were neonatal mortality and a composite morbidity of sepsis, malnutrition, surgical site infection, and need for mechanical ventilation among neonates with gastroschisis and neonates with other surgical conditions. Data were analyzed using SPSS software version 25. Chi square and Fisher’s exact tests were used to calculate the association between variables considering alpha value of 0.05 and student t-test was used to compare means. An ethical clearance was obtained from the University of Rwanda and CHUK before data collection. Results

Eighty-two neonates were recruited in this study. 45.1% were admitted within the first 24 hours of life, 61% were males 26.9% were preterm, 51.2% had birth weight less than 2500g. Gastroschisis was the main reason of transfer among 43 (52.4%) followed by intestinal atresia that occupied 12.2%. The overall mortality rate was 57%. Mortality was more likely to occur among neonates with gastroschisis compared to neonates with non-gastroschisis surgical conditions (76.7% vs 35.9%, OR=5.893, p<0.001). Among neonates with gastroschisis, factors associated with mortality were failure of initiation of enteral feeding (100%, p=0.002) and sepsis (82.5%, p=0.001). Among neonates with surgical conditions (non-gastroschisis), factors associated with mortality were prematurity (87.5%, OR:24, p=0.001), low birth weight (72.7% vs 21.4%, p=0.003), initiation of enteral feeding at more than 48 hours (33.3% vs 25.8%, p=0.006), sepsis (64.7% vs 13.6%, OR:11.61, p<0.001), and need of mechanical ventilation (63.6% vs 25%, OR:5.25, p=0.024,). Complications such as sepsis, malnutrition, need for mechanical ventilation

were the factors associated with the development of morbidity for surgical neonates with non-gastroschisis conditions. Conclusions

Neonatal surgical mortality is significantly high at CHUK and gastroschisis was the most common surgical condition that also accounts for the majority of deaths. This study showed that prematurity, low birth weight, initiation of enteral feeding more than 48 hours postoperatively, sepsis and need for mechanical ventilation are significant predictors of mortality for non-gastroschisis surgical conditions. In addition, sepsis and failure to initiate enteral feeding were factors that predicted mortality in neonates with gastroschisis. In this study, sepsis was a risk factor for mortality in neonates with gastroschisis and non-gastroschisis surgical conditions. These results were very important for planning of the clinical management and preventive measures to improve the outcome.