[Nosocomial infections: definition, frequence and risk factors]. / Les infections nosocomiales: définition, fréquence et facteurs de risque.

Infection is nosocomial if it missed at the time patient admission in the health establishment. When infectious status of the patient on admission is unknown, infection is generally regarded as nosocomial if it appears after a time of at least 48 hours of hospitalization. For surgical site infection, the commonly allowed time is 30 days, or, in case of prosthesis or an implant, one year after surgical intervention. Nosocomial infections (NI) constitute major health care problem from their frequency, their cost, their gravity. Mortality related to NI can attempt 70% in certain units like intensive care units. Two ways of contamination are possible: the endogenous way is responsible of majority of hospital infections. The normally sterile sites are contaminated then colonized by the flora which is carrying the patient himself, with the favor of a rupture of the barriers of defense. The exogenic way is associated colonization, possibly followed by infection, of the patient by external bacteria, coming from others patients or from environment, transmitted in an indirect way (aerosols, manuportage, materials). Whatever its mode of transmission, apparition of nosocomial infection can be related to several supporting factors: age and pathology, certain treatments (antibiotic which unbalance patients' flora and select resistant bacteria, immunosuppressive treatments), invasive practices necessary to the patient treatment. The prevalence of nosocomial infections is higher in the intensive care units where certain studies bring back rates of 42.8% versus 12.1% in others services. The four sites of nosocomial infection most frequently concerned are: the respiratory site, urinary infections, bloodstream infections (Catheters related bloodstream infections in particular), and surgical sites infections. The relative proportion of these infections varies according to principal activity of the unity.

[Preventive measures and the strife against nosocomial infection]. / Les mesures préventives et la lutte contre les infections nosocomiales.

The nosocomial Infections are associated to an increase of the morbidity, of the mortality and costs. Their frequency stay on raised in our service of cares. Then it is recommended and broadly admitted what each hospital must dispose of a unity of nosocomial infections prevention and to dispose a staff specially vested in those duties. Of the fact the nosocomial infections frequency in reanimation, an imported part of the activity of this specialized staff will have to run out in services of intensive cares. The principal nosocomial infections feature observed is being directly or indirectly associated to engineerings of acting as invasives deputy used to palliate a vital lapse. Of a general manner, all sharp grave affection, as anything severe traumatism (accidental or surgical) drag a capacities reduction of defense against the infection, component so important factors of nosocomial infections installations. Preventive measures pass by the engineerings respect of hands hygiene, the harbour of clean conformable dress, the measures respect of isolation (septic or preventive), the cares grading, the upkeep of the hardware and the bedroom, the respect of the circuit of the linen salts and lastly the sorting and the losses management of activity of cares. For that it must a policy of strife against nosocomial infections with the placing in place of operational unities of hygiene in all hospitals and the redynamisation of the committee of strife against nosocomial infections already existed in different public establishments of health.

[Severe thrombocytopenic thrombotic purpura and pregnancy: a case report]. / Purpura thrombotique thrombocytopénique grave et grossesse: a propos d'un cas.

INTRODUCTION: Thrombotic thrombocytopenic purpura failure (TTP) is a micro angiopathy caracterized in its severe form by multivisceral involement and early death. The association with pregnancy is rare, the diagnosis is difficult, but imperative because that will allow an early specific management and will improve the diagnosis CASE: Our patient is a 25 years old woman admitted in intensive care unit after cesarian section for eclampsia at term. Clinical and biological assessement were in favor at Hellp syndrome. Toxemia complicated with eclampsia and Hell syndrome was the final diagnosis and appropriate treatment followed. However the treatment, diffuse purpuric petechia appeared associated with jaundice, thrombocytopenia. The diagnosis of T.T.P was considered and corticotherapy started at day 8. Patient responded within 48 h and healins was complete after 5 weeks. CONCLUSION: Authors emphasized on the importance of the diagnosis and specific management.

[Nosocomial ventilator-associated pneumonia in a tropical intensive care unit]. / Pneumopathies nosocomialesacquises sous ventilation mécanique dans un service de réanimation en milieu tropical.

INTRODUCTION: Nosocomial ventilator-associated pneumonia (VAP) occupy an important place among nosocomial infections and are responsible for a very high mortality. The objective of this work was to study epidemiologic, diagnostic and therapeutic aspects of ventilator-associated pneumonia in a tropical Intensive Care Unit and to release an adapted strategy of antimicrobial treatment. PATIENTS AND METHODS: It is a prospective descriptive study carried out from January to December 2002 in the polyvalent intensive care unit, in collaboration with the laboratory of bacteriology-virology of the CHU Dantec of Dakar. We included all the patients admitted and who presented radiological pulmonary infiltrates appearing after 48 hours of mechanical ventilation, associated to at least 2 clinic or biologic criteria and to a positive tracheal aspirate with a cut off value of 10(4) CFU/ml. RESULTS: Thirty two cases of VAP have been diagnosed among 446 patients admitted in our ICU. The incidence was 7.16 per 100 admitted patients and 50 per 100 ventilated patients. The reasons for ICU admission were dominated by trauma (44%). Microorganisms responsible of VAP were essentially Gram negative bacilli (GNB), 68% with in head the Pseudomonas. Acinetobacter strains were practically resistant to all usually used antibiotics. The more used antibiotics were gentamicine, 3rd generation cephalosporins and fluoroquinolones. Antibiotic treatment was appropriate in only 13 cases in 26 patients at whom intrinsic antibacterial activities of antimicrobial agents were examined. The mortality rate was of 81%. CONCLUSION: The improvement of the prognosis of these VAP require preventive measures with protocols of care, a qualified staff, diagnostic means and active antibiotics on the responsible pathogens.

[Acute chloroquine poisonning in Le Dantec Teaching Hospital]. / Intoxication Aigue a la Chloroquine au Chu Le Dantec.

Chloroquine poisoning is an acute severe drug induce entity increasingly frequent in Senegal. This is due on one hand to its easy accessibility and its conditioning, on the other hand to its frequent use, in the voluntary attempt of ending pregnancy. The aim of this study is to assess the frequency and the severity of such poisoning in a senegalese intensive unit care. We undertook a descriptive retrospective study from January 1998 to December 2003 in the intensive care unit of Aristide Dantec Hospital. All patients admitted for voluntary or accidental acute intoxication to chloroquine were included. The parameters studied were: reason of admission, alledged ingested amount, delay of admission, hemodynamic modifications, therapeutic data and evolution. During the study period, forty-nine cases of chloroquine intoxication were listed out of 239 acute intoxications. Among these 49 cases, 16 files were not processable. These accounted for 1,48% of all admissions during this period. Women were more represented (78.78%). In 90.90% of the cases, the intoxication was voluntary, they were related to suicidal attempt in 57.57% of the cases. The willingness to end a course of a pregnancy was found in 33.33% of the cases. The average age was 22.69 years (11 years - 38 years). The average time of admission was 4 hours. with extremes of 1 and 8 hours. The clinical symptoms were dominated by hemodynamic, neuropsychiatric and respiratory disorders. Toxicological analysis was not carried out. Ionic disorders were dominated by hypokaliémies and electrocardiographic disorders by a widening of QRS. Symptomatic treatment systematic, was based on a vascular filling and the use of adrenalin. evacuation treatment consisted of a systematic gastric "lavage" and the use of activated charcol on (3.03%). Diazepam as treatment antidotic was seldom used. Psychiatric consultation was systematically carried out. Total mortality was 6%. The authors emphasize the nécessaty to: Inform the population on the absence of drugs being able to stop a pregnancy. Think on the urgency need to implement a medical emergency and reanimation departments (SMUR). Create poison control centers in Senegal.

[Management of thermal severe burns in children in Le Dantec University Teaching Hospital]. / Prise en charge des brûlures thermiques Graves de l'Enfant au CHU le Dantec.

INTRODUCTION: Bums in children are serious public health problem. Burns management in developing countries encounters huge problems at any stage. The goals of this study were to descrive the epidemiological, clinical and therapeutic characterics. MATERIALS AND METHODS: In the university Teaching Hospital of Dakar from January to December 2003, we conducted a retrospective survey of 41 patients less than 16 years admitted for severe thermal burns. We carried a year retrospective study in ICU and pediatric surgery unit of Aristide Le Dantec Hospital. Were involved all. The following parameters were studied: age, sex, mechanism and circumstances of the burns, period time between the injury and the admission, clinical status of the patient, management and outcome. RESULTS: The age range between 5 days and 13 years, 47.72% are less than 3 years. The average period before admission was 33 hours (2 hours to 7 days). The accident occurs in 75% of cases in the kitchen. Bum by hot water was the most frequent mechanism with a percentage of 62%. Areas interested the whole body with frequent face localisation (n=18) and the perineal region (n=22). Immediate complications were shock in 37% of children and acute respiratory failure in 7 patients. Fluids and electrolytes resuscitation using Parkland formula (75%) or Carvajal formula (25%). Feeding was done to enteral route. Spontaneous epitheliasation through secondary heeling was the main therapeutic attitude, skin grafting was performed in 10 childrens. Total mortality was 18.18%; These death concerns patients for whom the UBS score range between 75 and 140 UB and the ABSI score between 9 and 12. Sepsis was the direct main cause of death. Sequellaes were jointed a nd facial contractures. CONCLUSION: The authors emphasize on the need in setting up adequate preventive measures towards high risk population (under 3 years), and specialized unit for adapted management.

[The para-umbilical block in children: 75 cases report]. / Le bloc para-ombilical chez l'enfant: a propos de 75 cas.

The objective of this study is to assess both intra and post operative analgesia in infants undergoing umbilical hernia repair under general anaesthesia with neither opioid nor muscle relaxant, associated with a para umbilical block. It's a prospective study covering a 15 months period. The study included 75 infants (age = 5 months - 13 years; body weith = 6 kg - 35 kg). General anaesthesia was induced with either thiopentone or halothane and, maintained with halothane in a N2O - O2 50 VOL % mixture. Para-umbilical block was obtained using 1 ml/kg of 0.25% marcaïne. Pain was assessed using time course of respiratory rate, heart rate and mean arterial pressure. A change of more than 20% in one of these variables was considered criterion of poor analgesia. Intraoperative analgesia was adequate in all patients but four, 5 minutes after incision. Surgical conditions were considered as being godd or satisfactory in 90.6% and 9.4% of cases, respectively. Post operative analgesia, assessed 1 and 6 hours after completion of surgery was convenient in 93.3% of infants. The block appears as simple, most after efficient and safe in umbilical surgery.

[Digestive system surgical emergencies in neonates at the University Hospital of Dakar]. / Les urgences chirurgicales digestives néonatales au CHU de Dakar.

The goal of this study was for the authors to evaluate their series of digestive surgical emergencies in the neonates. It is a retrospective study on 69 babies treated for a digestive surgical emergency between january 1998 and december 2000. Only 52 babies were born in a medical unit. There was one case of antenal diagnosis and 16 of immediate post-natal diagnosis. The babies ages in the delayed cases ranged from 1 to 17 days with a mean of 7 days and medium of 3 and 6 days. The following malformations were diagnosted: 41 anorectal malformations; 11 omphaloceles; 2 laparoschisis; oesophageal atresia in 8 cases; duodenalatresia in 5 cases; hirschsprungs disease in 2 cases. On presentation, 25 patients were dehydrated, 24 had respiratory difficulties, 5 a severe infection and 20 had hypothermia. The post operatives complications were mostly respiratory. Global mortality rate was 44.92%. The delay in diagnosis and hospital care, the occurrance of hypothermia and respiratory complications are the main reasons of this high mortality.

[Traumatic tracheobronchial rupture: importance of early respiratory resuscitation and bronchoscopy]. / Rupture trachéo-bronchique traumatique: intérêt de la réanimation respiratoire et de la bronchoscopie précoces.

Traumatic tracheobronchial rupture is a rare and serious complication of blunt chest trauma. Authors report the case of a 9 years old girl who was hit by a car. She presented to the admission, a respiratory distress with subcutaneous emphysema, hemoptysis, bilateral pneumothorax and pneumomediastinum. Apparently persistent pneumothorax in spite of clinic improvement after oxygenoterapy and pleural drainage, had made consider tracheobronchial rupture. The bronchoscopy achieved in emergency, had shown a low lesion of the trachea and a desinsertion of the left main bronchus. A right thoracotomy had permitted to repair the lesions. Post-operative outcome was good and authors insist in interest of early management.

[Assessment of the management of polytrauma patients at Le Dantec Hospital, Dakar]. / Evaluation de la prise en charge des polytraumatisés au CHU Le Dantec de Dakar.

Traumatisms represent the first reason of death in people less than 40 years in the developed countries. In Senegal, with the growth of urbanization, road accidents are more and more frequent and mortality by polytrauma is raised. The aim of this study was to evaluate the management of polytrauma patients in our hospital and to determine factors of mortality. This prospective study was carried out from January to June 2000 at the surgical emergencies department and the intensive care unit in Le Dantec Teaching Hospital of Dakar. One hundred and six polytrauma patients were taken care of during the study period. The mean age of patients was 30 years. There were 85 men and 21 women. Circumstances of trauma were dominated by road accidents (74.5%) and in 77.4% of cases patients were evacuated without prehospital care. The mean delay from the accident to the arrival at emergencies was 8 hours. Half of the patients presented to the admission a clinical picture of circulatory failure; respiratory distress was also present among 50% of patients and 53.8% of patients had a serious head injury with a Glasgow coma scale lower than 8. The global mortality was 69.8% and 80.6% of these deaths were attributable to serious head injury. Management of trauma patients in Dakar could be improved by setting up a medical transport system and by the improvement of the technical means in the hospitals. These measures, in combination with the prevention of road accidents, will surely allow to reduce the number of accidents, polytrauma and deaths.

[Acquired bacteraemias at the intensive care unit]. / Bactériémies acquises dans un service de réanimation.

Acquired bacteraemias in intensive care unit (ICU) have some serious consequences in terms of morbidity, mortality and costs. The emergence of multiresistant germs in ICUs, and the therapeutic difficulties that ensue, participate in the aggravation of the prognosis of these infections. The aim of this work was to study the epidemiological aspects of acquired bacteraemias in ICU and the responsible germs sensitivity, to determine strategies of adequate antimicrobial treatment. During the period of study, 31 positive blood cultures collected from 19 patients were considered to be true bacteraemias, giving an incidence rate of 6.3 for 100 admissions. The mean age of our patients was 27.7 years old. There were 16 men and 3 women. Traumatology was the underlying pathology in 52.63% of cases. The origin of the infection was unknown in 84.2%. Flavobacterium spp was the most frequent germ (42%), followed by Pseudomonas aeruginosa (26.2%), and Staphylococcus negative coagulase (10.6%). Only one anaerobic germ was isolated. Flavobacterium spp and Pseudomonas aeruginosa were in general sensitive to most antibiotics used with the exception of aminosides. Staphylococci negative coagulase were methi - resistant. The sensitivity of the anaerobic germ was not tested. The antimicrobial treatment was adapted in 84.2% of cases; the association ciprofloxacine-cefotaxime could be a good alternative in serious infections to Gram negative bacteria. The global death rate among our patients was 42%. The death was directly related to bactereamia in only 15.3% of cases. The existing committee for nosocomial infections control should be more effective in our hospital. The role of this committee is to carry out microbiological surveillance, to recommand and make sure of the application of preventive measures against nosocomial infections, to promote the accessibility of antibiotics such as imipeneme, aztreonam, ceftazidime, vancomycine...., and to propose an appropriate antimicrobial treatment strategy; these measures could reduce notably the morbidity and mortality related to nosocomial infections in general and bactereamias in particular.

[Spinal anaesthesia for cesarean section: rate and management of complications in 110 Senegalese parturients]. / Rachianesthésie pour cesarienne: fréquence et prise en charge des complications à propos de 110 parturientes senegalaises.

The goal of this prospective work is to study the per- and post-operative complications of spinal anaesthesia for cesarean and to evaluate their management. We included in the study all parturients undergoing cesarean section to the maternity of hospital Aristide Le Dantec since December 1998 to March 1999. Patients presented contra-indications of spinal anaesthesia, arterial hypertension and/or acute fetal distress were excluded. After a vascular preload of 1000 ml of Ringer lactate, a spinal anaesthesia was realized through a 25 G needle between L3 and L4 in a sitting position with 12.5 mg of 0.5% bupivacain associated with 1 ml of 10% dextrose. Patients were installed after a left light lateral position and oxygenated via a facial mask with 3 1 per mn until the extraction of the child. Studied parameters are following: the sensitive level block before surgical incision, per- and post-operative complications and their management. Sensitive level block was up to T4 in 14.9%, between T4 and T6 in 74.6% and at T8 in 23.6%. Maternal hypotension was the only per-operative complication in our study: 52% with 2 cases of cardiac arrest who needed tracheal intubation and injection of epinephrine. Post operative complications were represented by post-dural headaches about 5.4% and no epidural blood-patch were necessary for their management. We have noted any neurological or infectious complication during supervision of our patients.

[Anesthesia for endoscopic extraction of lower respiratory tract foreign bodies in children]. / Anesthésie au cours de l'extraction endoscopique des corps étrangers des voies respiratoires inférieures chez l'enfant.

Foreign body inhalation is a serious emergency which raises both diagnostic and therapeutic problems. Progress achieved in the domain of instrumentation and anaesthesia permit the endoscopic extraction with incontestable comfort and security However, child's anaesthesia often in respiratory distress can prove to be difficult. The aim of this study was to evaluate problems encountered during anaesthesia for endoscopic extraction of foreign bodies in lower respiratory tract and to submit an adequate management strategy. This retrospective study was about 161 cases of lower respiratory tract foreign bodies admitted to the clinic O.R.L. of le Dantec hospital from January 1986 to December 2000. Sixteen patients have had a tracheotomy immediately, before endoscopy. One hundred and fifty six patients have had endoscopy. All endoscopic procedures have been achieved under general anaesthesia with intubation by the bronchoscope. Three patients presented peroperative cardiopulmonary arrest and 8 patients died after endoscopy. The improvement of technical means will permit to reduce morbidity and mortality linked to foreign body inhalation.