[Perioperative management of laparoscopic cholecystectomy in children with homozygous sickle cell disease]. / Prise en charge périopératoire de la cholécystectomie par voie laparoscopique chez l'enfant drépanocytaire homozygote.

OBJECTIVE: Sickle cell disease is a public health problem in Africa. The aim of this prospective study was to evaluate per and post-operative complications of laparoscopic cholecystectomy in sickle cell children in Senegal. METHODS: from January 1999 to December 2006, an anesthetic protocol was applied to 39 sickle cell children undergoing a cholecystectomy. Among them, 20 experienced laparoscopic cholecystectomy. RESULTS: All these 20 patients had previously suffered from sickle cell visceral complications and were classified as ASA II (11 cases) and as ASA III (9 cases). Blood transfusion program aimed at sustaining haemoglobin level between 10 and 12 g/dl was implemented. The preoperative monitoring and anesthesia management were the same for these patients. During perioperative period, the prevention of pain, hypovolemia, hypothermia and acidosis was achieved. The mean insufflation duration of laparoscopy was 23 min (17-60 min), the mean surgery duration was 55 min (40-110 min), and the mean anesthesia duration was 78 min (88-135 min). Postoperative complications occurred in 9 patients: acute chest syndrome (n=2), postoperative hemolysis (n=5), vaso-occlusive crisis (n=2). CONCLUSION: Laparoscopic cholecystectomy can be carried out in sickle cell children affected with gallstones, provided that general anaesthetic rules were respected. An appropriate pre-, per- and postoperative anaesthesia is mandatory to reduce postoperative complications in children with sickle cell disease. Searching for early diagnosis of gallstones before occurrence of visceral complications should allow further optimal laparoscopic surgery.

[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.

[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.

[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.

[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.

[Anesthesia in the pleuropulmonary complications surgery of tuberculosis: a 79 cases study]. / Anesthésie-Reanimation dans la chirurgie des complications pleuropulmonaires de la tuberculose: a propos de 79 cas.

Reported is a retrospective study carried out from Aristide Le Dantec Hospital in patients who underwent pleuropulmonary surgery after tuberculosis complication, from June 1995 to June 1999. The aim of this study was to evaluate the anaesthesiology procedures and outcomes of tuberculosis pleuropulmonary complications surgery. Seventy nine patients were studied. Their mean age was 34.63 years, and the sex ratio was 3.14. They all underwent general anaesthesia procedures with barbituric, morphinics et myorelaxants drugs. The peroperative complications noted were distributed as follow: 50 cases of haemorrhage needing transfusion, 18 cases of hypotension associated to the anaesthesia. In the intensive care period, we have noticed 30 atelectasia cases associated to a spastic bronchopathy, 3 cases of pulmonary oedema and 1 case of pulmonary infarctus. In the postoperative period, 8 cases of hemodynamic instability occurred, including 5 cases of cardiovascular collapsus treated by filling, and 2 septic shocks cases. An infectious bronchopneumopathy was noticed on 11 patients with two cases of septicaemia. The mortality rate was 6.3% (5 cases of death). The pleuropulmonary surgery in tuberculosis complication is very haemorrhagic, and therefore require an adequate preoperative preparation.

[Anesthesia in the surgery of hyperthyroidism at Le Dantec Teaching Hospital]. / Anesthésie dans la chirurgie de l'hyperthyroïdie au CHU Le Dantec.

Authors report a study of 66 patients admitted to the clinic ORL of CHU Le Dantec between 1991 and 2000 for goiter and hyperthyroidism. They evaluate the perioperative management and underline the importance of the medical preparation. The age of patients varied between 15 and 74 years. There were 62 women and 4 men. Fifty three patients presented clinical and biological hyperthyroidism. Thirteen patients had functional hyperthyroidism without clinical signs of thyrotoxicosis. Exophthalmia was present in 20 patients. Twenty one patients have been addressed to the Internal Medicine service for preoperative management of hyperthyroidism. Forty five patients have been operated under general anaesthesia. The medical preparation comprised antithyroid drugs and beta-blockers. We found as complications 3 cases of difficult intubation, 7 cases of peroperative haemorrhage and 1 case of acute thyroid crisis. The anaesthesia for surgery of hyperthyroidism is currently well codified and operative outcome became simple. The medical preparation in case of hyperthyroidism allows to return the patient in euthyroidism and reduces considerably the acute thyroid crisis risk, the most fearsome complication and the most feared of the hyperthyroidism.

[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.

[Emergencies at a hospital center and university in a tropical area. An anesthesiologist's point of view]. / Les urgences dans un centre hospitalier et universitaire en milieu tropical. Le point de vue de l'anesthesiste reanimateur.

The purpose of this retrospective study was to determine the profile of medical emergencies and their management in a university hospital center in a tropical area. Between July 1 and December 31, 2001, all patients examined in a medical and surgical emergency room were included. Obstetrical emergencies, pediatric emergencies, emergencies admitted directly to the cardiology, ORL emergencies and urologic emergencies were not included. A total of 6740 patients were examined for medical/surgical emergencies during the 6-month study period. Mean patient age was 23 +/- 7 years. Most patients were male with a sex ratio of 3.4. Patients were from the city of Dakar in 50% of cases, suburbs of Dakar in 35% and other regions in 15%. The mean delay between the onset of emergency and admission was 17 +/- 9 hours. Patients were transferred to the hospital in 78% of cases by private transportation. Gastrointestinal events accounted for 20.23% of cases, cardiovascular events for 9.12%, respiratory events of 8.56%, metabolic events for 1.78%, trauma for 48.20% and infectious disease for 12.09%. Surgical mortality was 2.41%. Most problems facing the intensivist treating medical emergencies in a tropical setting involved resuscitation.

[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.

[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.

[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.