បទបង្ហាញCPDខេត្តបាត់ដំបង10 08 23

ី ៈវវជាសាស្រ្តបន្តវ
ទិវាអភិវឌ្ឍវិជ្ជាជវ ក ំ ង ឆ្ន ំ២០២៣

ើ ទី១៩ វេត្តបាត្់ដប
The 19th Continuing Professional Development Symposium Battambang Province
1
រហែកខគ្ោមទ្ឹកខ្លោះមុន្ខេលឈឺខ ោះសំរាល
RUPTURE PREMATUREE DES MEMBRANES
បង្ហាញដោយ៖ខេជ្ជបណឌិត្ សយ
ុ សុេខែង
គ្រូដេទ្យេាបាលផ្នែកសម្ភេ និងដោរស្តសរី ម្នទីរដេទ្យបផ្ងកកដត្របា្ដំបបង
ថ្ងៃព្រហ្បត្ិ៍ ៩វោច ខេទុត្ិយាសាឍ ឆ្ន ំវ ោះ បញ្ច ្័ក រ.្ ២៥៦៧

ត្រូវនង
ឹ ថ្ងៃទី១០ ខែសីហា ឆ្ន២
ាំ ០២៣
មហហាត្សព សទឹងសខងែ ហែរតបារ់ដាំបង
មន្ទីរសុខាភិបាលនន្រដ្ឋបាលខេត្ត គណៈគ្គូខេទ្យខេត្ត
Administrative Provincial Health Department Provincial Medical Council
RUPTURE PREMATUREE DES MEMBRANEs
រហែកស្រោមទឹកស្្លោះមុនស្េលឈឺស្ ោះសំរាល
បង្ហាញដោយ៖
ខេជ្ជបណឌិត្ សយ
ុ សុេខែង
គ្រូដេទ្យេាបាលផ្នែកសម្ភេនិងដោរស្តសរី
ម្នទីរដេទ្យបផ្ងកកដត្របា្ដ ំបបង
2
I-GENERALITE
1-1.Définition
Rupture prématurée des membranes(RPM) រឺ
ជាការរផ្ែកស្សទាបដដស្ោម្ទ្ឹកដ្លោះAmnios et
Chorion ម្ុនដេលឈឺដ ោះសបោល។
3
1-2.Classification
▪ RPM ហែកខែញជា២: PROM>ou= 37SA, PPROM<37SA)
▪ RPM base : La rupture au pôle inférieur de l’oeuf
▪ RPM Haute : La rupture des membranes dans la cavité
utérine la poche des eaux avant la tête foetale est encore
intact( tête mobile).
▪ RPM Prolongée: Cas de rupture des membranes avant le
travail > 18 heurs,
4
1-3.Localisation
La rupture haute des
membranes
La rupture base des

membranes
5
1-4.Frequence de rupture prématurée des
membranes
▪ 5- 10 % ( Pan Afri Med 2017)

▪ 2-3 % avant 37 SA (En France 2018)
▪ 15 % ( Cambodge à Battambang 2022)
6
1-5.Causes
1-Fragilitisation ▪ Infection endo -cervacale et

des membranes amniotique+++
▪ Infection urinaire,
▪ Surdistension Utérine: gémellaire,
hydramnios, macrosomie, placenta
preavia, insertion maginale du
cordon…
2-Traumatisme TV, cerclage , amnioscope……
3-Maladie des ▪ Malinutrion: Vit.C, Cu, Zn..,

membranes
▪ Maladie de Collagène,
▪ Tabac
7
1-6.Germes en Cause
8
1-7.Complication des RPM
▪ Chorio-amniotite;
▪ Souffrance et mort périnatale;
▪ Accident du cordon ( procubitus ou procidence du
cordon);
▪ Hypoplasie pulmonaire, malformation des membres
du nouveau-né;
▪ Décollement du placenta causant un accouchement
prémuturé;
9
1-8.Traitements et suivis
Le traitement propose sera choisi en fonction:

▪ De l’âge gestationnel;
▪ Du bien-être fœtal;
▪ Des signes d’infection;
▪ Du début du travail ou non;
10
1-9.Selon les observations(ការសស្កេត)
▪ 50 %des cas, l’accouchement survient dans les

24-48H;
▪ 40 % des cas, l’accouchement survient dans les
48H;
▪ 10 % des cas, il y a prolongement une semaine ou
plus;
11
1-10.Score de Bishop modifié
0 1 2
Longeur du Col(en cm) >3 1-3 <1
Effacement(en %) 0-30 40-50 60-70

Dilatation(en cm) Fermé 1-2 3-4
Consistance Ferme Moyenne Molle
Position du Col Postérieur Médiane Antérieur
Niveau de Présentation -3 -1 à -2 0 ou +1
▪ Score < 6 défavorable,

▪ Score 6 et plus favorable,
▪ Score >=9 probabilité d’Acc./ Vaginal,
12
II-ករណីសិកា
ស្តសរីដ្មោះ តូច សុផា,៤០ឆ្ែប,G2P0

មុខរបរ៖ លកដំូរ
អាសយដ្ឋាន៖ តាដតាក,សបឡូ្,បា្ដំបបង
ទូរស័េទ៖ ០១៥ ២៤៤ ៧៧៤
ចូលមកហនែកសមភេស្េទយស្ខតតបាតដ
់ ប
ំ ក៖ 16/ 03/ 2023
ដេលាដ ៉ោ ង 09H30mn
បញ្ជូ នមកេ៖
ី HC តាដតាក(Tel: 017 807 298)
មូលស្ែតុ៖ គ្ជាបទ្ឹកដ្លោះ ,ផ្នទដ ោះគ្របដផ្ត
13
2-1.ការោកសួរនក
ិ េន
ិ ិតយ
▪ គ្បេ្រិសម្ភេ៖APAR: 0-0-1-0
ិ
▪ សញ្ញាជីេ្៖TA: 100/70 mm Hg, Pouls:88/mn
▪ Coeur et Poumon : Sont normaux.
▪ Digestive et Urinaire : Sont normaux
▪ Utérus gravide à terme : HU: 29 cm, RCF: 132 bpm et
oscillations: 10-25bpm.
▪ TV et Spéculum: Col est perméable 1 doigt, écoulement du
liquide claire de l’endocol.
14
Traitements:
- Amoxicilline 500mg 2cps x 3 po/J

- Paracétamol 500 mgx 3po/J
2-3.Résultats du J1 (16/03/2023 à 14H00)

▪ RCF 140 bpm et Oscillation 10-23 bpm
▪ Echo controle LA បរ ិ ណធម្មតា
▪ Pas de contraction utérine
▪ Perd des eaux minime et claire
▪ TV: Col est perméable 1 doigt
▪ Bishop: 3 points 16
Résultats(Hémogramme)
17
Bilan Clinique et para clinique (16/03/2023 à 16H00)
- Pas de douleur en travail,
- LA de quantité normal(Echo contrôle)
- RCF 144 bpm, et oscillation 10-25 bpm(CTG)
សំណួរ៖
❑ ស្តើស្រាគវិនិចយ
ឆ ័ យក
៉ា ដូចស្ម៉ាតច?
❑ ស្យក
ើ គួរស្្វអ្
ើ ជា
វី បនត?
18
❑ Diagnostic
Rupture prématurée des membranes.
❑ Surveillance
បនរតាម្ោនEvolution materno-foetal 3fois/J
( Doppler foetale, CTG, Echographie, Signes
vitaux, score de Bishop.)
19
2-4.Evolution materno-foetale (17/03/2023): J2
- TA 120/80, pouls: 78/mn. T:37.2C, RR: 24/mn

- Pas de fièvre,
- TV: Col est permáble 2doigt, écoulement du LA
minime,
- Echo. Controle: LA est moyenne abondant
- CU 1fois/10mn,
- RCF: 148 bpm, oscillation 12-26bpm
20
▪ ស្តសរីគ្ជាបទ្ឹកដ្លោះ>48H,ផ្្បរ ិ ណទ្ឹកដ្លោះដៅបងគួរ,
ថ្លល។
▪ ោាន្េស្តសរីនិងទារកល,ក
▪ Score de Bishop: 6 points,
▪ Antibiothérapie, et antipyrétique continue
* ការសនែិោានរលីនិច៖ “RPM prolongée, au début du
travail spontané”
21
2-5.Le 18/ 03/2023 :J3
ស្តសរីចាបដដនរើម្ឈឺដ ោះ
េិ្គ្បាកំ៖
- Bishop 9 pts
- LA clair,
- សបោលកូនដៅដ ៉ោ ង
12H45’, កូនស្សី2900grs
- Apgar: 7/9/10
- ោាន្េលកទាបង រ យ,កូន
22
ស្តសរីបានចាកដចញេីម្នទីរ
ដេទ្យ:
ដៅ២ផ្ងៃបន្ទទបដ 20/03/2023
à 10H00
Bilan de sorti:
Suite de couches normal
23
III. ស្សចកតីសនែិដ្ឋាន
▪ ស្សីម្
រ កម្នទីដេទ្យដត្រតាម្ការបញ្ូជ នម្កេីម្ណឌលសុត
្េ។
▪ ម្ូលដែ្ុ៖គ្ជាបទ្ឹកដ្លោះ,ផ្នទដ ោះគ្របដផ្ត
▪ Diagnostic anté-partum: RPM haute et prolongée
▪ Diagnostic intra-partum: Accouchement normal
▪ Diagnostic de post-partum: Suite de couches
normal
24
IV.អ្នុោសន ៏
▪ ស្តសរីបានសបោលកូនដោយធម្មតា,និងទារក នសុត្េ
ិ
លកក៏េិ្ផ្ម្ន ផ្្ដយើងរួររបបីេិនិ្យនិងអនុ្រន៏ដឡើងេញ
នូេេ្
ិ ីោរថ្នែកជា
់ តស
ិ ំរាបម
់ នទីរស្េទយបហកែកនក
ិ វិធានផ្នទកុ ករបស
ែ ់ស្យក
ើ
ហដលមានរោបស្់ ដើមបីស្ចៀសវាក “Morbidité et Mortalité
Materno-foetale”.
▪ រួរដគ្បើCTG ដោយបានទ្ូលបទ្ូលាយ
▪ ការនរលដដសវារួររបបី នតលប្់ បក
ឹ ា ដោយដ្ញៀេរបសដដយើង
បានយលដំឹងចាសដលាសដជាម្ុននង។
25
26
Cardio-Toco- graphie
27
Complication néo-natale post –RPM Prolongée
28
V-RÉFÉRENCES
1. េិធីោរថ្លែកដជា្ិ៖ ្ុ្េគ្មមនដគ្គ្មោះថ្លែកដសបោបដម្នទីរ
ដេទ្យបផ្ងកក២០១៨.
ិ
2. េធានផ្នទ កុង
ែ ម្នទីរដេទ្យបផ្ងកកដត្របា្ដំបបង, ផ្នែក
សម្ភេនិងដោរស្តសរី២០១៨.
3. Pan Afr Med J, 2017 26: 68,
4. https://www.jogc.com.
5. https://doi.org/10.1016/j.gofs.2018.10.19.
29
30
ើ ទី១៩ វេត្តបាត្់ដប 1
Etude rétrospective des aspects épidémio-cliniques et thérapeutiques

des infections du site opératoire en chirurgie ortho-traumatologie de
l’hôpital provincial de Battambang pendant 3 ans, à propos de 52 cas du
1er janvier 2020 au 31 décembre 2022.
Prof. Asst. Dr. HUOT SOCHEAT

Chirurgien des Hôpitaux
Département de Chirurgie Générale Hôpital Provincial de Battambang

ត្រូវនឹងថ្ងៃទី១០ ខែសីហា ឆ្ន២
ាំ ០២៣
UNIVERSITE DES SCIENCES DE LA SANTE
FACULTE DE MEDECINE
Etude rétrospective des aspects épidémio-cliniques

et thérapeutiques des infections du site opératoire
en chirurgie ortho-traumatologie de l’hôpital
provincial de Battambang pendant 3 ans, à propos
de 52 cas du 1er janvier 2020 au 31 décembre 2022.
Par:
Prof. Asst. Dr. HUOT SOCHEAT

Chirurgien des Hôpitaux
Département de Chirurgie Générale Hôpital Provincial de Battambang
PLAN
I- INTRODUCTION
II- OBJECTIFS D’ETUDE
III- MATERIEL ET METHODE
IV- RESULTAT
V- DISCUSSION
VI- CONCLUSION ET RECOMMENDATION
VII- REFERENCE
INTRODUCTION
Les infections post-opératoires restent, malgré les antibiotiques, très redoutées en
chirurgie ostéoarticulaire en raison de leur ténacité et du résultat fonctionnel qu’elles
obèrent souvent [1].
Le taux d’infections après le traitement par ostéosynthèse d’une fracture s’élève à 1–
5% et il dépend du type de fracture [2]. Dans env. 30% des cas de fractures ouvertes
en présence de lésions sévères des tissus mous et d’une colonisation primaire, et ce
malgré une antibiothérapie prophylactique péri opératoire et un traitement préemptif
[3].
L'infection postopératoire en chirurgie orthopédique est une catastrophe qui peut
ruiner le bénéfice d'une intervention destinée à améliorer la fonction d'une
articulation ou à réparer les conséquences d'un traumatisme [4].
INTRODUCTION (SUITE)
Elle est facilitée par la présence de matériel étranger, l'hématome et ainsi que par
l'ischémie et la nécrose tissulaire [5].
Aucune intervention n'est totalement aseptique [6];
- quel que soit le système de traitement utilisé et les précautions prises,
- même si un nombre important de bactéries contamine la plaie opératoire,
l'altération des défenses immunitaires locales au niveau de l'incision,
- et générale par l'intervention,
- rendent tout site opératoire vulnérable à l'infection et encore plus en présence de
matériel.
OBJECTIFS D’ETUDE
Objectif général :
Etudier les infections du site opératoire immédiate post- opératoire en chirurgie
osseuse dans le service de chirurgie générale de l’hôpital provinciale de
Battambang.
Objectifs spécifiques :
- Déterminer la prévalence des infections post-opératoires en chirurgie osseuse ;
- Identifier les facteurs de risque des infections ;
- Déterminer les différents types d’ostéosynthèse et ses complications survenues ;
- Identifier les germes retrouvés et leur sensibilité isolée lors des infections
postopératoires chez les patients hospitalisés dans le service ;
- Apprécier les modalités de prise en charge des infections postopératoires chez les
patients hospitalisés ;
- Evaluer les résultats thérapeutiques.
MATERIEL ET METHODE
- Type d’étude: rétrospective, 1er janvier 2020 au 31 décembre 2022
- Place d’étude: au service de chirurgie HPB
- Population d’étude : Toutes tranches d’âge, les deux sexes, des ISO en chirurgie
ortho- traumatologie au service de chirurgie HBTB pendant 3 ans.
- Taille d’échantillon et échantillonnage: 52 cas
- Critère d’inclusion: patients ISO en chirurgie ortho- traumatologie avec
dossier médical complet et le diagnostic précis.
- Critère d’exclusion: dossiers incomplets, et non opéré
- Collecté des données: fiche d’enquête,
- Procédures de collecte des données: dossiers médicaux, CRO
- Analyse des données: logiciel statistique Excel 2010
RESULTATS
Aspects sociodémographiques:
▪ Répartition des patients selon
la prévalence:
Durant 3 ans, concernant 1694 patients

opérés en chirurgie ortho-traumatologie,
il y avait 52 cas des ISO.
▪ Répartition des patients selon la tranche d’âge:
Âge moyen de nos patients était de 36,56 ans (14- 77 ans).
▪ Répartition des patients selon le sexe:
Sex-ratio: H/F était de 7,6 en

faveur des hommes
▪ Répartition des patients selon la profession:
▪ Répartition des patients selon la provenance:
▪ Répartition des patients selon la circonstance de survenue:
Note:
- AVP: Accident de la
voie publique
- AT: Accident de travail
- AS: Accident du sport
▪ Répartition des patients selon les facteurs de risques:
Aspects Cliniques:
▪ Répartition des patients selon le membre atteint:

▪ Diagnostic opératoire:
Distribution des patients selon le type de fracture
▪ Répartition des patients selon la technique chirurgicale:
▪ Répartition des patients selon les signes cliniques:
▪ Répartition des patients selon le type de complication:
▪ Délai de survenue des complications:
Aspects paracliniques:
Les examens complémentaires: Bilan Biologique et Radiographique
Radiographie osseuse: 7 cas (13%)

- Réaction périosté
- Ostéolyse et Séquestres
- Condensation osseuse
réactionnelles
- Infiltration des tissus mous
▪ Répartition des patients selon la bactériologie du pus et/ou
séquestres:
Aspects thérapeutiques:
▪ Répartition des patients selon la prise en charge:
▪ Répartition des patients selon la sensibilité aux antibiotiques:
Germes Staphylococcus Klebsiella Burkholderia
identifiés aureus Sp Pseudomallei
ABS Chloramphénicol Amox/Clav Ceftazidime

Trimeth/Sulfa Amikacine Trimeth/Sulfa
Cloxacilline Meropenem
Cefazolin
Aspects évolutive du traitement:
Note: Un cas de complication était de

séquelle invalide suite de l'infection
ostéoarticulaire du genou d'une fracture
comminutive supra-condylienne
fémorale, traité par PV chez un homme
âgé de 67 ans
La durée moyenne d’hospitalisation: 23,7 jours (10- 45 jours)
DISCUSSION
▪ Sur le plan sociodémographique:
Comparaison de prévalence aux autres littératures:
Littératures Prévalence des ISO
Notre série à Battambang 3%
Moyikoua et al [1] 1993 Congo 5,2%
Sidibe R [6] 2014 Mali 5,7%
Rémi CHARVET [7] 2010 France 0.77%
Kimmatkar et al [8] 2017 Inde 6,15%
Mutombo et al [9] 1993 Zaïre 19%

Comparaison du sexe aux autres littératures:
Littératures M F Sex-ratio
H/F
Notre série à Battambang 46 6 7,6
Garba et al [10] 2018 Niger 67 21 3,1
Moyikoua et al [1] 1993 Congo 19 2 9,5
Foni et al [11] 2015 Brésil 13 8 1,6

Comparaison de moyen âge aux autres littératures:
Littératures Âge moyen des patients
Notre série à Battambang 36,56 ans
Garba et al [10] 2018 Niger 33 ans
Quing Xu et al [12] 2014 Chine 35,6%
Moyikoua et al [1] 1993 Congo 34,5 ans
Said et al [13] 2013 Maroc 27 ans

▪ Sur le plan Clinique:
Selon les signes cliniques:
Nous avons trouvé les signes cardinaux des infections

locaux 58% et la fistulisation au/n de la plaie 24% plus
de fièvre 18% des cas.
Nos résultats étaient comparables à ceux de
BELGASSI [14] en 2014 au Maroc et Chaka
CAMARA [15] en 2011 au Mali.
Comparaison du membre atteinte aux autres littératures:
Littératures Membre Membre

supérieur inférieur
Notre série à Battambang 10% 90%
Moyikoua et al [1] 1993 Congo 23,81% 76,19%
Foni et al [11] 2015 Brésil 6,25% 93,75%

Belgassi [14] 2014 Maroc 18,3% 81,7%
Kodio [16] 2007 Mali 18% 82%
Dennis R [17] 2009 Danemark 13,95% 86,05%
Comparaison des facteurs de risque aux autres littératures:
Littératures Notre série Belgassi Kimmatk Amarade

[14]2014 ar et al ep et al
Facteurs de risque Maroc [8] 2017 [18] 2017
Inde Inde
Diabète + HTA 11,53% 4,8% 25% 45,45%

Tabagisme + 51,63% 14,30% 50% 27,27%
Alcoolisme
Comorbidité de 5,76% 14,3% 25% 18,18%
sujet âgé
Contusion diffuse 36,53% 23,8% 12,50% 9,09%

de partie molle
Comparaison aux autres littératures de diagnostic préopératoire:
Littératures Notre Moyikoua Belgassi Camara
série et al [1]1993 [14] [15]
Congo 2014 2011
Maroc Mali
Diagnostic
Fracture fémur 10% 50,46% 33,3% 53,33%

Fracture Jambe 88% 13,93% 19% 26,67%
Fracture SCH 2% 12,4% 14,3% 13,33%
Comparaison aux autres littératures selon le type d’implant infecté:
Type d’ostéosynthèse ECM PV FE
Littératures
Notre série 13,46% 59,61% 17,3%
Camara [15] 2011 Mali 26,67% 40% 10%
Kodio [16] 2007 Mali 36% 20,7% 4,5%
Belgassi [14] 2014 28,6% 28,6% 23,8%
Maroc
Comparaison aux autres littératures du type de complication:
Littératures Infections Infections

superficielles profondes
Type d’infection
Notre série 87% 13%
Moyikoua et al [1] 28,59% 47,61%
1993 Congo
Kimmatkar et al [8] 12,50% 87,5%
2017 Inde
Amaradeep et al 18,18% 81,81%
[18] 2017 Inde
Comparaison du microorganisme isolé aux autres littératures:
Littératures Notre Kimmatkar Kumar et al Zerouki et
série et al [8] 2017 [19]2017 al [20]
Inde Inde 2019 Alger
Bactéries
Staphylococcus 69% 54,54% 39% 39,5%
aureus
Klebsiella sp 23% 8,18% 17% 2,6%

▪ Sur le plan thérapeutique:
Comparaison de PEC thérapeutique aux autres séries
Littératures Notre Moyikoua et Belgassi Camara

série al [1] 1993 [14]2014 [15] 2011
Approche chirurgical Congo Maroc Mali
AMO + Séquestrectomie + 13% 19,04% 19% 16,67%

Drainage
DBR + Lavage + AB 12% 14,28% 76,1% 36,67%

Soins locaux + AB 75% 47,61% 95,2% 13,33%
▪ Evolution du traitement:
Comparaison d’évolution aux autres littératures:
Evolution Favorables Défavorables
Littératures
Notre série 98% 2%

Moyikoua et al [1] 1993 Congo 95,25% 4,75%
Sidibe [6] 2014 Mali 99% 1%
Belgassi [14] 2014 Maroc 95,25% 4,75%
Camara [15] 2011 Mali 83,33% 16,67%
▪ Durée moyenne d’hospitalisation:
Comparaison de durée moyenne d’hospitalisation aux autres
séries:
Littératures Durée moyenne
d’hospitalisation
Notre série à Battambang 23,7 jours

Garba et al [10] 2018 Niger 69 jours
Moyikoua et al [1] 1993 Congo 64 jours
Sidibe [6] 2014 Mali 41 jours
Randriambololona et al [21]2017 27 jours
Madagascar
CONCLUSION
L’infection du site opératoire en chirurgie orthopédique et traumatologique
constitue une complication catastrophique.
Dans notre étude, nous avons obtenu 3% de la prévalence des infections post-
opératoires en chirurgie orthopédique et traumatologique.
Le diagnostic confirmait par les signes cliniques, les biologiques et les
bactériologiques. Les microorganismes isolés dans notre série prédominaient avec
69% de Staphylococcus aureus.
Le traitement a réalisé par le débridement large, le lavage, drainage, séquestrectomie
et l’ablation de matérielle ostéosynthèse plus des antibiotiques sensiblement aux
résultats d’antibiogramme.
L’évolution était favorable dans 98% et défavorable dans 2% des cas. Aucun de
décès de nos patients.
RECOMMENDATION
Aux médecins hospitaliers :
- Faire l’antibiogramme avant toute antibiothérapie.
- Antibioprophylaxie.
- Corriger les risques infectieux avant toute l’intervention chirurgicale.
Aux autorités :
- Consolider la commission de la lutte contre les infections nosocomiales et IPC (Infection Prevention
Control).
Aux administrateurs et gestionnaire des hôpitaux :
- Respecter les règles asepsies aux circuits du bloc opératoire et préopératoires.
- Pratiquer le 5 S (Sort, Set, Shine, Standard et Sustainable).
- Hygiène de la main.
- Veillez à la dotation du service en produit servant à la lutte contre les infections postopératoire.
REFERENCE
1- MOYIKOUA A., KAYA J.M., ONDZOTO J.M., PENA-PITRA B
Complications septiques des ostéosynthèses des membres. A propos de 402 interventions.
Médecine d'Afrique Noire : 1993, 40 (12): 722- 726.
2- Nora Renza, Thomas Hubacherb, Christian Klebera,c, Andrej Trampuza
Infections après traitement par ostéosynthèse d’une fracture.
Forum Médical Suisse 2016;16(4):85–91.
3- WJ. Metsemakersa, R. Kuehlb, TF. Moriartyc, RG. Richardsc, M. Verhofstadd, O. Borense, S.
Katesf, M. Morgensterng
Infection after fracture fixation: Current surgical and microbiological concepts
Injury, Int. J. Care Injured xxx (2016) xxx–xxx.
http://dx.doi.org/10.1016/j.injury.2016.09.019
4- Nicole Desplaces
Infections nosocomiales en chirurgie orthopédique.
EMC Appareil locomoteur [14-016-B-10]
© 2000 Elsevier, Paris
https://www.em-consulte.com/article/8131/infections-nosocomiales-en-chirurgie-orthopedique
5- Samuel Rounds Mayo
Infections in Orthopaedic Trauma: A Review.
https://www.researchgate.net/publication/303250070
Submitted December 15th, 2015
6- Rokiatou SIDIBE
Les infections post- opératoires dans le service de traumatologie et d’orthopédie du CHU Gabriel
TOURE.
Thèse de Médecine 2014
7- Rémi CHARVET
Les infections du site opératoire (ISO) en orthopédie et traumatologie.
Mémoire de fin d’étude de DESC NANCY 2010
8- Nitin Kimmatkar, Jaya T. Hemnani
Incidence of Surgical site infections in IPD Orthopedics patients undergoing implant surgery.
International Archives of BioMedical and Clinical Research | Oct – Dec 2017| Vol 3| Issue 4: 135-
138
9- D-P MUTOMBO, Y. KRUBWA et M. KALUNDA
INFECTIONS POST-OPERATOIRES PRECOCES EN CHIRURGIE OSTEO- ARTICULAIRE A
KINSHASA.
Etude préliminaire de facteurs pathogéniques. A propos de 189 interventions.
Médecine d'Afrique Noire : 1993, 40 (7) : 430-3
10- Idé Garba, Abdoul Wahab Mohamed, Hama Younssa, DMM Habibou, Hans-Moevi Aristote.
L’Infection du Site Opératoire en Chirurgie Ortho-Traumatologique Propre au CNHU-HKM de
Cotonou.
Health Sci. Dis: Vol 19 (2) April – May – June 2018: 108- 111
11- Noel Oizerovici Foni, Felipe Augusto Ribeiro Batista, Luís Henrique Camargo Rossato, José
Octavio Soares Hungria, Marcelo Tomanik Mercadante, Ralph Walter Christian.
Postoperative infection in patients undergoing inspection of orthopedic damage due to external
fixation.
Rev Bras Orthop . 2015; 50(6):625–630
12- Yong-Qing Xu, Yue-Liang Zhu, Xin-Yv Fan, Tao Jin, Yang Li, and Xiao-Qing He.
Implant-Related Infection in the Tibia: Surgical Revision Strategy with Vancomycin Cement.
Hindawi Publishing Corporation
The Scientific World Journal Volume 2014, Article ID 124864, 6 pages
13- S. SAID, F. GALUIA
Prévention et prise en charge des infections post-opératoires en traumato- orthopédie à l'hôpital
militaire Avicenne de Marrakech.
14- BELGASSI Kaoutar
Prise en charge des infections ostéo- articulaires sur matériel orthopédique et leurs complications :
Analyse et évaluation.
Thèse de Médecine No. 59/ 2014
15- Chaka CAMARA
Complications post-opératoires dans le service de chirurgie ortho-traumatologie du C.H.U GABRIEL
TOURE. A propos de 30 cas.
16- OGOBARA KODIO
Etude des complications des ostéosynthèses dans le service de chirurgie orthopédique et
traumatologique du CHU Gabriel TOURE. A propos de 111 cas.
17- DENNIS RAAHAVE
Postoperative Wound Infection After Implant and Removal of Osteosynthetic Material.
Acta Orthopaedica Scandinavica 2009; 47:1, 28-35
18- Amaradeep G, Shiva Prakah SS and Manjappa CN
Surgical site infections in orthopedic implant surgery and its risk factors: A prospective study in
teaching hospital.
International Journal of Orthopaedics Sciences 2017; 3(3): 169-172.
19- Sanjay Kumar, Mallika Sengupta, Vivek Hada, Soma Sarkar, Ranajit Bhatta, Manideepa
Sengupta.
Early Post-operative Wound Infection in Patients Undergoing Orthopaedic Surgery with Implant.
International Journal of Scientific Study 2017;Vol 5 (8): 44- 48
20- Zerouki A, Abada S, Bouzitouna M, Zoughailech D, Naim M
Surveillance des infections du site opératoire en chirurgie orthopédique et Traumatologique à
l'hôpital militaire de Constantine.
19ème Congrès de la Société Algérienne de Chirurgie Orthopédique et Traumatologique
21- Randriambololona VH, Razafimahatratra R, Rakotomaharo A, Solofomalala GD
Les infections du site opératoire en chirurgie orthopédique et traumatologique au CHU Ampefiiloha
HJRA ANTANANARIVO. Madagascar
Revue de Chirurgie Orthopédique et de Traumatologie Malgache, volume 1 : 8 pages
Management for Preterm babies
Presented by: CHIV Sothearath, MD

Directed by: Assist. Prof. CHEA Peuv, MD
Pediatric Department, Battambang Provincial Referral Hospital
នងៃគ្េហសបត្ិ៍ ៩ខោច ខេទ្ុតិយាសាឍ ឆ្នាំខ ោះ បញ្ច ស័ក េ.ស ២៥៦៧

ាំ ០២៣
2
CONTENTS
• Definition
• Classification
• Complication
• Management
• Discharge home
• Case scenario
3
Newborn Admission
4
DEFINITION
A baby born before the end of the 37th week following onset of the last menstrual period
(LMP).
5
CLASSIFICATION
• Gestation age
• Extremely preterm (<28weeks)
• Very preterm (28–31weeks)
• Moderately preterm (32–33weeks)
• Late preterm(34-36weeks)
• Preterm (<37weeks)
• Birth weight
• Low Birth Weight(LBW): <2500g
• Very Low Birth Weight(VLBW):<1500g
• Extremely Low Birth Weight(ELBW):<1000g
6
GA assessment
Criteria for evaluation of premature babies:

• Last menstrual period
• Echography antenatal(1st trimesters)
• New Ballard score
7
COMPLICATION
C. Other Complications:
A. Respiratory:
Hemodynamic: PDA
RDS/Apnea/PPHN
Hepatic: Jaundice
Metabolic: Hypothermia, Hypocalcemia,
Hypoglycemia, Hyperglycemia
Renal: Tubulopathy
Hematology: Anemia
B. Digestive: Immunologic: Immaturity (risk of infection)
Simple enteropathy/NEC/GERD/Immaturity Neurologic: IVH, PVL, Compartmental-
of sucking and swallowing psychomotor development trouble
Sensory: Deafness, ROP
8
MANAGEMENT
• Antenatal corticosteroids
• Monitoring oxygenation and ventilation
• Assisted ventilation of the neonate
• Exogenous surfactant therapy
• Supportive care including thermoregulation, nutritional support, fluid and electrolyte
management, antibiotic therapy, KMC etc.
9
DISCHARGE HOME
Your baby is ready to go home when he or she:

• Can breathe without support
• Can maintain a stable body temperature
• Can breast or bottle feed
• Is gaining weight steadily
• Is free of infection
10
CASE SCENARIO
11
CASE SCENARIO
I. Patient identification
Name: TSM Sex/Age: F/4hours

DOB: 01/01/23 Admission date: 01/01/23/ at 5h45mn
II. Chief Complain

Preterm Birth and very low birth weight
III. Medical past history

1st child born at 28week GA to a 17yrs old mother (unplanned pregnancy and no follow-up, low
education)
A/S 6-8-8, BW 1060g by Vaginal delivery at Pailin Provincial hospital
Maternal history: P1G0A0, HT/DM/Tbc/Hepatitis (-/-/-/-), No maternal fever>38C,

No Prolong rupture of membrane, No meconium stained
12
CASE SCENARIO
IV. History present illness
A newborn baby girl born at 28weeksGA,Vaginal delivery, Birthweight 1060g,

Apgar score 6-8-8. She was transferred form Paillin provincial hospital to Pediatric ward
RHBTB due to Preterm birth and VLBW on 01/01/23 at 5h45mn.
PHYSICAL EXAMINATION AT THE ARRIVAL: 13
ON 01/01/23 AT 5:45AM
• Weak, hypotonia, No cyanosis, SpO2: 99% (room air), To: 36.9 C

• RR: 56/min, No retraction, and grunting with stethoscope (Silverman score: 2)
• HR 148 bpm without murmur.
• No Sucking. Moro and Grasping reflex are very weak.
• Morphology:
• Breast: barely perceptible
• Eye/ear: lip open pina flat stay fold
• Plantar surface: No creases
• Genitals: clitoris prominent and labia flat.
=> Ballard score correspond to 28WGA.
Dx: Very premature 28weeks GA

Very low birth weight 1060g
Hyaline membrane disease
14
INVESTIGATION
Laboratory test:
• CBC
• CRP
• RBS
15
TREATMENT
1. Radiant warmer
2. Clear airway
3. Incubator care
4. CPAP supply (Peep:6CmH2O ,Flow:6, FiO2:28% )
5. PIV D10% 4ml/h (TFV: 80ml/kg/day)
6. Ampicillin (1g) : 53mg x 2times/day (IV)
7. Gentamycin (80mg) : 3mg x 1time/day (IV)
8. Aminophylline (240mg/5ml) : 0.2mg x 1 (IV) loading dose, after24h
0.1mgx2 (IV) maintenance dose
9. Vitamin K1: 1mg x 1 (IV)
10. Regime: NPO
11. Vital sign check every 4hours
16
EVOLUTION ON 02/01/23 (DAY2)
Evolution Management
• GA: ill looking • PIV D10% 4ml/h (TFV:100ml/kg/day)

• Ampicillin (1g) : 53mg x 2times/day (IV)
• Coloration: Pink • Gentamycin (80mg): 3mg x 1time/day (IV)
• Hypotonia • Aminophylline (240mg/5ml)
0.1mg x 2time/day (IV)
• No sucking, very poor reflex • Insert OGT for feeding
• Mild dyspnea • CPAP supply(Peep:6,Flow:6, FiO2:28%)
• Incubator care
• Normal Lung and heart sound • Start regime: Formular milk 1ml 12times per
• Abdominal soft day by OGT
• Vital sign check every4h
• Normal defecation and urination • Control CBC, CRP, RBS
17
LABORATORY RESULT
Date 01/01/23 02/01/03

Lab WBC=13.7 WBC=17.8
RBC=5.38 RBC=5.3
Hb=17.7 Hb=17.0
Ht=52.2 Ht=50.6
Neu: 9.41 Neu: 8.31

Lym:6.77 Lym:7.07
Mono: 1.75 Mono: 1.85
Eosi: 0.35 Eosi: 0.34
Baso: 0.32 Baso: 0.23
CRP= Negative
RBS: 65mg/dl RBS: 89mg/dl
18
• GA: looking better • PIV D1/3s 4ml/h (TFV:120ml/kg/day)
• Consciousness: Alert • Gentamycin (80mg): 3mg x 1time/day (IV)
• Coloration: Yellowish • Aminophylline (240mg/5ml)
• Feeding by OGT, No residual • Calcium gluconate (500mg/10ml)
• Poor reactivity 80mg x1time/day (IV)
• CPAP supply(Peep:6 ,Flow:5,FiO2:24%)
• No contraction • Incubator care
• Hyper secretion • Formular milk 2ml 12times per day by OGT
• Normal Lung and heart sound
• Normal defecation and urination
19
• Ampicillin(1g): 53mg x 2times/day (IV)
• Consciousness: Alert • Gentamycin (80mg):3mg x1time/day (IV)
• Coloration: Yellowish • Aminophylline (240mg/5ml)
• Poor reactivity 80mg x1time/day (IV)
• Phototherapy
• No contraction • Aspiration
• Hyper secretion • CPAP supply(Peep:6,Flow:5, FiO2:24%)
• Incubator care
• Normal Lung and heart sound • Formular milk 3ml 12times per day by OGT
• Normal defecation and urination • Vital sign check every4h
20
• GA: looking better • PIVD1/3s 4ml/h (TFV:150ml/kg/day)
• Consciousness: Alert • Gentamycin (80mg) : 3mg x 1time/day (IV)
• Coloration: Pink • Aminophylline (240mg/5ml)
• Reactivity (+) 80mg x1time/day (IV)
• Vitamin k1 1mg x 1 (IV)
• No contraction • Aspiration
• Hypersecretion • Stop Phototherapy
• CPAP supply(Peep:5,Flow:5, FiO2:21%)
• No other symptom report • Incubator care
• Normal defecation and urination • Formular milk 6ml 12times per day by OGT
21
• Ampicillin (1g) 53mg x 3 (IV)
• Consciousness: Alert • Aminophylline (240mg/5ml)
• Coloration: Pink 0.1mg x 2time/day (IV)
• Calcium gluconate (500mg/10ml)
• Feeding well by OGT, No residual 80mg x1time/day (IV)
• Normal tone and reflex • Stop Gentamycin
• Stop CPAP
• No neurological sign • O2 supply 1L/min (nasal canular)
• No other symptom report • Try to feed by mouth before remove OGT
7ml 12times per day
• Normal defecation and urination • Incubator care
22
• GA: looking better • Stop IVF
• Consciousness: Alert • Stop Antibiotic
• Coloration: Pink • Stop aminophylline
• Feeding by OGT • Stop O2 supply
• Normal tone and reflex • Stop Calcium gluconate
• No neurological sign • Incubator care
• No other symptom report • Breastmilk 13ml12times per day by OGT
• Normal defecation and urination • Vital sign check every6h
23
• GA: looking better • Stop warmer
• Consciousness: Alert • Stop incubator
• Coloration: Pink • Stop OGT
• Feeding well • KMC
• Normal tone and reflex • Breastmilk 15ml 12times per day
• No neurological sign • Vital sign check every6h
• No other symptom report
• Normal defecation and urination
24
DISCHARGE HOME ON 17/01/23 (DAY17)
• GA: Stable
• Good reactivity
• Feeding well
• No neurological deficit
• Other physical examination: Unremarkable
Parents Education:
• Exclusive breastfeeding, keeping the baby warm, keep hygiene, KMC at home.
• Please return the baby to the hospital immediately if there are danger signs: Convulsion, any
bleeding, severe diarrhea or vomiting, baby appears unresponsive, severe breathing problems,
baby feels cold, refuses feeds, baby feels abnormally hot, Jaundice.
25
NUTRITIONAL STATUS
26
FOLLOW UP
1month after discharge:

Physical Examination
• Good general condition
• Normal feeding
• No neurological deficit
• Other physical examination: Unremarkable
27
REFERENCE
T‐L. GOMELLA et al. Neonatology: Management, procedures, on‐call Problems, Diseases, and
Drugs. Gestational age and birth weight classification. 7th and 8th edition. P29‐42.
28
THANKS YOU FOR YOUR ATTENTION !
Management of tetanus in ICUM
Presented by: PHON SOTHEA, MD,

Vice chief of ICUM Department, Battambang Referral Hos[ital

ាំ ០២៣
2
CONTENTS
• Introduction
• Pathogenesis
• How to diagnose tetanus
• Type of tetanus
• Characteristic features
• Management & Treatment of tetanus
• Prognosis
• Case scenario
Introduction
• Tetanus is an acute infectious disease caused by spores of the bacterium

clostridium tetani, anaerobic conditions.
• It is also called tetanospasmin toxin.
• Spores of tetanus bacteria are everywhere in the environment, including
soil, dust, and manure. The spores develop into bacteria when they
enter the body. Unlike other vaccine-preventable diseases, tetanus is not
spread from person to person.
4
Pathogenesis
• Tetanospasmin is transported from the site of production to the central nervous system along motor
nerves and also via circulation.
• Circulating toxin attaches to motor nerve endings of alpha motor neurons and gains access to the central
nervous system by retrograde axonal transport.
• It finally reaches inhibitory interneurons in the spinal cord and brainstem where it binds to
synaptobrevin, a protein that is required for neuro-exocytosis, a process that results in the release of
neurotransmitters at nerve endings.
• Its selectivity for inhibitory interneurons that produce gamma-aminobutyric acid (GABA) and glycine
results in loss of inhibition and spontaneous excessive discharge of motor and autonomic nerve
impulses as well as exaggerated responses to stimuli manifesting as tonic muscle contraction,
intermittent muscle spasms, and autonomic overactivity.
• Since tetanospasmin reaches the motor nuclei of the shortest motor axons first by retrograde axonal
transport, muscles innervated by motor cranial nerves are affected first, followed by trunk muscles, and
finally limb muscles.
5
How to diagnose tetanus
Doctors can diagnose tetanus by asking about recent history of cuts

• Scrapes
• Punctures
• Trauma
• Examining someone for certain signs and symptoms.
• There are no hospital lab tests that can confirm tetanus.
6
Type of tetanus
There are four forms of tetanus based on clinical findings:

1.Generalized tetanus
2.Neonatal tetanus
3.Localized tetanus
4.Cerebral tetanus
Generalized tetanus is the most common form of tetanus occurring in

approximately 80% of cases.
7
Characteristic features
• The average time from infection to appearance of signs and symptoms

(incubation period) is 8-10 days. The incubation period can range from
3 to 21 days.
• Risus sardonicus (a rigid smile)
• Trismus (commonly known as lock-jaw)
• Opisthotonus (rigid, arched back).
• Difficulty swallowing
• Rigid abdominal muscles
8
Characteristic features
9
Management
• The first step is to assess the severity of the disease and risk of progression to
severe tetanus over the next few days.
• An incubation period of fewer than 7 days and a period of onset less than 48 h
predict rapid progression to severe disease.
• These patients should be managed in a hospital with good intensive care
facilities including invasive hemodynamic monitoring, mechanical
ventilation, and good infection control practices.
• The severity of the disease can be assessed by using Ablett classification
10
Ablett Classification of tetanus Severity
11
Prognosis
• Mild tetanus : mortality below 10%

• Moderate tetanus : mortality of 10-20%
• Severe tetanus : mortality of 20-40%
• Very severe tetanus: mortality above 50%Jan 18, 2019
12
Prognosis
• The prognosis in severe tetanus depends on the experience of the treating

center and the availability of intensive care facilities.
• Mortality due to non-neonatal tetanus in resource-limited countries ranges
from 5% to 53%, and is much lower in developed countries with better
intensive care facilities.
• Poor prognostic features include age > 60 years, period of onset < 48 h,
incubation period < 7 days, severe tetanus requiring neuromuscular blockade
and mechanical ventilation, and severe autonomic dysfunction.
• Deaths are commonly due to nosocomial infections or severe autonomic
dysfunction with cardiac arrhythmias.
13
Tetanus clinical cases
In ICU medicine at RHBTB from 09/09/2022 to 17/05/2023 there are:

• 9 cases of tetanus were died, 3 cases are alive.
• All is male
• Age: 36-54yrs
• Incubation: <10days
• Range of death: 2-8days of admission days
14
Treatment on admission
• Isolate room( not standard)

• IV fluid replacement
• SAT (besreka’s method 1a(1500ui) test then 6a IM)
• AB follow guideline
• Muscle relaxation(diazepam) 5amp+NSS or D5% run in 15drop/min
• Airway protection (oxygen)
• Pain killer (Morphine, Perfalgon)
• Wound dressing
• Vital signs
15
Treatment
• Treatment of tetanus is best performed in the intensive care unit in consultation

with an anesthesiologist or critical care specialist trained in the management of
the complications of this disease, including early and aggressive airway
management. The goals of treatment include:
• Halting the toxin production
• Neutralization of the unbound toxin
• Airway management
• Control of muscle spasms
• Management of dysautonomia
• General supportive management
16
Halting toxin production
• Wound management
• Antimicrobial therapy:
▪ Penicillin G (2 to 4 million units IV every four to six hours) is a
safe and effective alternative . We suggest a treatment duration of 7
to 10 days.
▪ Metronidazole (500 mg intravenously, every six to eight hours)
17
Neutralization of unbound toxin
• Intramuscular antitoxin – Human tetanus immune globulin (HTIG) is

the antitoxin of choice to neutralize unbound toxin. Recommended dose
range was 3000 to 6000 units..
• Equine anti-tetanus serum 10,000–20,000 units IV after skin sensitivity
testing
18
Control of muscle spasms
• Benzodiazepines and other sedatives:

starting dose of diazepam for an adult is 10 to 30 mg IV and repeated as
needed every 1 to 4 hours. When higher doses of the IV formulation of
diazepam are used, the vehicle, propylene glycol, may produce
hyperosmolarity and an anion gap metabolic (lactic) acidosis.
• Neuromuscular blocking agents are used when sedation alone is inadequate
19
Management of autonomic dysfunction
• Produce adrenergic blockade and suppress autonomic hyperactivity

• Magnesium sulfate:(loading dose 40 mg/kg over 30 minutes, followed by
continuous infusion of either 2 g per hour for patients over 45 kg or 1.5 g per
hour for patients ≤45 kg)
• Beta blockade: Labetalol (0.25 to 1 mg/min) has frequently been
administered because of its dual alpha- and beta-blocking properties
• Morphine sulfate (0.5 to 1 mg/kg per hour by continuous intravenous
infusion) is commonly used to control autonomic dysfunction as well as to
induce sedation
20
Airway management and other supportive measures
• In patients with severe tetanus, prolonged immobility in the intensive

care unit is common, much of which is on mechanical ventilation and
may last for weeks.
• Such patients are predisposed to nosocomial infections, decubitus
ulcers, tracheal stenosis, gastrointestinal hemorrhage(sucralfate) and
thromboembolic disease(LMWH, Heparin).
• Tetanus Immunization
21
Considerations in resource limited settings
• Critical care services are often unavailable or rudimentary in many resource limited countries.
• When ICUs are not available, acute respiratory failure is a leading cause of death from tetanus.
• In the absence of an ICU, ideally a separate ward or room should be designated for patients
with tetanus, and sensory stimuli should be kept to a minimum since loud noises, physical
contact, and light can trigger tetanic spasms .
• Other options include eye shades and ear plugs to reduce stimuli.
• Nondepolarizing paralytic agents, such as vecuronium and pancuronium, are not safe to use in
the absence of ventilatory support.
• However, benzodiazepines and baclofen can be used in such situations if doses are carefully
titrated to avoid respiratory depression.
• Magnesium sulfate may be used to manage autonomic dysfunction and as an adjunctive for
muscle spasm.
22
CASE SCENARIO
23
CASE SCENARIO
• អ្នកជាំងឺ ត្បុស ២៨ឆ្ន ាំ ហៅត្សុកហោងឬសស ី បារ់ដាំបង
• គារ់មកសាំ រាកហពទយហៅថ្ងៃ១៧.០៥.២០២៣ ហោយោនអាការៈ Trismus, abdominal muscle contraction.
• អ្នកជាំងោ
ឺ នអាការៈ រងថ្គ
ឹ ា ម សពឹក ត្ាញថ្ដហជើង ហៅផ្ទះពរី បថ្ី ងៃ បន្ទទប់មកាច់ញារបា
ិ នយកហៅគ្លន
ី ក
ិ មួយ
កខនលងហដើមបព
ី ាបាលរយៈហពល៥ថ្ងៃហោយហរាគ្វន
ិ ច
ិ យ
ឆ័ រលាកហត្ាមែួរកាល។
• ហោយអាការៈមន
ិ បានធូរត្ាលត្កុមត្គ្ួារហសនើរបនតពាបាលហៅភ្នហាំ ពញ ហ យ
ើ ការពាបាលបានខរមួយថ្ងៃ ាច់
ញារយ ាំ ងវញ។
ិ កមកមនទរី ហពទយហែរតបារ់ដប ិ
24
CASE SCENARIO
ហោងតាមការពិនរ
ិ យនង
ិ ាកសួ រ: ការពិនរ
ិ យទូហៅ:
ិ ធ្លលប់ោនជាំងឺ រ ឺ ោនត្បរិកម្ថ្គនហាំ ទ
•មន •ាានភាពា្ររី: ដង
ឹ ធម្តា ខរចាញ់ ពនលន
ឺ ង
ិ សាំ ហលង
•ាានភាពជាំងឺធៃនធ
់ ៃរ •ាច់ដាំហ ះរង,
ឹ រងឆ្អ
ឹ ង ឹ ែនងហកាង, ខបកហញើសហត្ចន
ើ
•ត្បកាច់ រងថ្គ
ឹ ាម •ត្បព័នធរ ាំលាយអាហារ៖ ាច់ដាំហ ះរងខ្
ឹ លងាំ
•សញ្ញាជវី រ:
ិ BP:100/60mmHg, • ត្បព័នធផ្ូ វដហងហ
ល ម
ើ ៖ សាំ ហលងធម្តា
Pulse:110pbm, RR: 28/min, To: •ត្បព័នធរបរ់ឈាមហបះដូង៖ ហដរើ ញាប់ហស្ើ
36.9 C, SpO2: 96%. •ត្បព័នធាច់ដាំ នង
ិ ត្បាទ៖ កន្ត្ន្ទតក់ជាប់រ ូរជា
ពិហសសោនសាំ ហលងខ្លង
ាំ
25
Investigation
• CBC: WBC 29000, Neu 86%

• Electrolyte: Normal
• Calcium: Normal
• AST: 278 IU (<37)
• Glucose: Normal
• Urea & Creatinine: Normal
• Hep B&C: Normal
26
Diagnostic
• Tetanus Declaration
• Epilepsy
27
Management
17/05/23
• PIV NSS0.9% 1000ml in30drop/min
• Diazepam10mg (ivl) as need
• PIV D5% 500ml + Diazepam 5amp in 15drop/min
• PNC 1M : 2amp x 3 (ivl) for 7days
• SAT : 1500IU for 6amp (IM) and 1amp test
• Oxygen supply
• Foley catheter
• Isolated room
• Vital signs q2h
28
Evolution
18/05/23
• GA: Look alteration • PIV NSS0.9% 1000ml in 30drop/min
• Trismus • Diazepam10mg IVL as need
• Opisthotonos • PIV D5% 500ml + Diazepam 5apm in
15drop/min
• Abdominal muscle contraction
• PNC 1M: 2amp x 3 (ivl)
• Abdominal pain
• Buscopan 20mg: 1amp x 3 (ivl)
• Sweating++
• Omeprazole 40mg (ivl)
• BP:110/60mmHg, Pulse:105bpm,
• Oxygen supply
RR: 28/min, Spo2 98%
• Vital signs q2h
29
Evolution
19-21/05/23
• GA: Look stationary • PIV NSS0.9% 1000ml in 30drop/min
• Contraction repeated induce by voice and • Diazepam 10mg (ivl) as need
light • PIV D5% 500ml + Diazepam 5amp in
• Abdominal muscle contraction/pain 15drop/min
• Vital signs: BP:100/70mmHg, • PNC 1M: 2amp x 3 (ivl)
Pulse: 110bpm, RR:34/min, Spo2: 96%. • Buscopan 20mg: 1amp x 3 (ivl)
• Omeprazole: 40mg (ivl)
• Oxygen supply
• Vital signs q2h
30
Evolution
22/05/23 - 02/06/23
• GA: Look alteration • All is keep the same plan
• Agitation • PNC 1M: 2amp x 3 (ivl) stop on 26/05/23
• Repeat Contraction • Magnesium sulphate 5g Piv
• Abdominal muscle contraction and pain • Morphine10mg: 3mg (ivl) as need
• Opisthotonos • Heparin 5000IU (ivl)
• Trismus induce by sound
• Profuse sweating
• Rapid breathing, tachycardia
• Vital signs: BP: 100/70mmHg, Pusle: 120bpm,
RR:36/min,Spo2:94%
31
Evolution
03-09/06/23
• GA: Look improved • IV medication as need
• Trismus reduce • Diazepam10mg (BID)
• Abdominal contraction reduce
• Spasm induce by voice and light reduce
• Vital signs are stable
32
Evolution
10/06/2023
The patient condition is getting improved and Discharged home.
33
Home message
• បនតហលបថ្គនហាំ ៅផ្ទះ ហធវច

ើ លន្ទ នង
ិ ោ៉ាសា
• តាមោនអាការៈហបោ
ើ នការខត្បត្បួល សូ មត្រលប់មកមនទរី ហពទយវញជាបន្ទ
ិ ទ ន់
• រាល់ការមរ របួស សូ មហៅចាក់វ៉ាក់ាាំងការ រជមៃហឺ រតាណូស
 មន្ទីរពេទ្យបង្អែកពេត្តបាត្់ដំបអ
ង្នែកជំអឺសពរ្គោះបន្ទទន្់ទ្ូពៅមន្ុសសចាស់


34
Reference
HTTPS://WWW.UPTODATE.COM/CONTENTS/TETANUS
UPTODATE (HTTPS://WWW.UPTODATE.COM/CONTENTS/TETANUS)
TETANUS - UPTODATE
TETANUS IS A NERVOUS SYSTEM DISORDER CHARACTERIZED BY
MUSCLE SPASMS THAT IS CAUSED BY THE TOXIN-PRODUCING
ANAEROBECLOSTRIDIUM TETANI, WHICH IS FOUND IN THE SOIL
35
03/06/2023
36
06/06/2023
37
09/06/2023
្ូមអរគុណ
38
ើ ទី១៩ វេត្តបាត្់ដប
1
Complete Blood Count Processing and Results Interpretation in

Laboratory of Battambang Referral Hospital
Presented by: PHAI Sophanan, PharmD

Medical Laboratory Quality Manager
Laboratory Department, Battambang Provincial Referral Hospital
នងៃគ្េហសបត្ិ៍ ៩ខោច ខេទ្ុតិយាសាឍ ឆ្នាំខ ោះ បញ្ច ស័ក េ.ស ២៥៦៧

ាំ ០២៣
Contents
2
1. Objectives
2. Laboratory processing
2.1 Criteria for Rejection (EDTA)
2.2 Equipment Maintenance
2.3 Internal Quality Control
3. Result interpretation
4. Criteria for blood smear review
5. Data analyze on smear review.
1. Objectives
3
❖ Introduce the implementation of LQMS in BTB Lab

❖ Accurate and reliable of CBC testing
❖ Benefit of Blood Smear Examination
❖ Understanding and interpretation of CBC result.
2. Laboratory processing
4
Post-Analytical phase: Pre-Analytical phase:

- Review result (critical, alarm…) - Order test by authorizer
- Result transcription - Samples labeling
- Result reporting (CamLIS) - Samples collection
- Samples storage
- Sample transportation
Analytical phase:
- Sample preparation
- Preventive maintenance
- IQC in range
- Testing
2.1 Criteria for Rejection (EDTA)
5
7.2.4.2 Information for pre-collection activities

The laboratory shall provide information and instructions for pre-collection
activities with sufficient detail to ensure that the integrity of the sample is not
compromised.
This shall include:
a) preparation of the patient (e.g. instructions to caregivers, sample collectors
and patients);
b) type and amount of the primary sample to be collected with descriptions of the
containers and any necessary additives, and when relevant the order of collecting
samples;
c) special timing of collection, where relevant;
d) provision of clinical information relevant to, or affecting sample collection,
examination performance or result interpretation (e.g. history of administration
of drugs);
e) sample labelling for unequivocal identification of the patient, as well as source
and site of sample, and labelling, when several samples from the same patient are
to be collected, including multiple pieces of tissue or slides;
f) the laboratory’s criteria for acceptance and
rejection of samples specific to the examinations
requested.
2.2 Equipment Maintenance
6
‍15ISO 15189:2022(E)
6.4.5 Equipment maintenance and repair
a) The laboratory shall have preventive maintenance
programmes, based on manufacturer’s instructions. Deviations
from the manufacturer's schedules or instructions shall be
recorded.
b) Equipment shall be maintained in a safe working condition and
working order. This shall include electrical safety, any emergency
stop devices and the safe handling and disposal of hazardous
materials by authorized personnel.
c) Equipment that is defective or outside specified requirements,
shall be taken out of service. It shall be clearly labelled or marked
as being out of service, until it has been verified to perform
correctly. The laboratory shall examine the effect of the defect or
deviation from specified requirements and shall initiate actions ▪ Equipment maintenance
when non-conforming work occurs (see 7.5).
d) When applicable, the laboratory shall decontaminate
▪ Reagent management
equipment before service, repair or decommissioning, provide ▪ Procedure for testing (SOP)
suitable space for repairs and provide appropriate personal ▪ Training and Competency.
protective equipment.
2.3 Internal Quality Control
7
ISO 15189:2022(E) 205.50 USD

3.12
interlaboratory comparison
organization, performance and evaluation of
measurements or examinations (3.8) on the same or
similar materials by two or more independent
laboratories in accordance with pre-determined
conditions
[SOURCE: ISO/IEC 17043:2010 3.4, modified — "tests"
has been replaced by "examinations". "items" has been
replaced by "materials". "laboratories" has been
replaced by "independent laboratories".]
3.13
internal quality control IQC Westgard rules
quality control QC
internal procedure which monitors the testing process
to verify the system is working correctly and gives
confidence that the results are reliable enough to be
released
[SOURCE: ISO/TS 22583:2019 3.9, modified — “decide”‍
has been replaced by “verify”. Note 1 to entry has been
removed. ]
2.4 Complete Blood Count Testing Processing
8
❖ Good in maintenance equipment

❖ Run daily IQC (3 Levels)
❖ IQC evaluation passed (LJ chart and Westgard rule)
❖ Staff competent in testing and using machine
❖ Good quality specimen and right labeling
Do you think the results are accurate and reliable yet?
3. Result interpretation
9
4. Criteria for blood smear review
10
❖ISLH (International Society for Laboratory for

Hematology) Consensus Guidelines:
total of 41 Rules
▪ Neonate and first time
▪ WBC (<4, >30)
▪ HGB (<7, >2 upper ref range)
▪ MCV (<60*, >105)
▪ PLT (<100, >1000)
▪ RDW-CV >22
▪ PLT*
▪ WBC*….
❖Using CamLIS for delta check
5. Data analyze on smear review
11
Starting Ending #CBC ករណីត្រូវធ្វ ើ

% បានធ ើលភ្នាស? % បានកកកត្ែ %
Date Date requested Smear?
14-Oct-22 19-Oct-22 424 231 54% 134 58% 99 74%

20-Oct-22 25-Oct-22 459 242 53% 126 52% 83 66%
20-Feb-23 26-Feb-23 470 115 24% 60 52% 18 30%
▪ Smear review is manual technique
▪ Time consumption
▪ Provide more accurate results
6.Reference
12
▪ INTERNATIONAL STANDARD ISO 15189 Fourth edition 2022-12
▪ International Society for Laboratory Hematology (ISLH)
▪ The International Consensus Group for Hematology Review.
Thanks you
13
SEALAB project mentorship toward accreditation ISO 15189


បទបង្ហាញCPDខេត្តបាត់ដំបង10 08 23

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

បទបង្ហាញCPDខេត្តបាត់ដំបង10 08 23

Transféré par

Droits d'auteur :

Formats disponibles

ី ៈវវជាសាស្រ្តបន្តវ

ទិវាអភិវឌ្ឍវិជ្ជាជវ ក ំ ង ឆ្ន ំ២០២៣

ថ្ងៃព្រហ្បត្ិ៍ ៩វោច ខេទុត្ិយាសាឍ ឆ្ន ំវ ោះ បញ្ច ្័ក រ.្ ២៥៦៧

Rupture prématurée des membranes(RPM) រឺ

Chorion ម្ុនដេលឈឺដ ោះសបោល។

▪ RPM base : La rupture au pôle inférieur de l’oeuf

▪ RPM Haute : La rupture des membranes dans la cavité

utérine la poche des eaux avant la tête foetale est encore

intact( tête mobile).

▪ RPM Prolongée: Cas de rupture des membranes avant le

travail > 18 heurs,

La rupture base des

▪ 5- 10 % ( Pan Afri Med 2017)

1-Fragilitisation ▪ Infection endo -cervacale et

2-Traumatisme TV, cerclage , amnioscope……

3-Maladie des ▪ Malinutrion: Vit.C, Cu, Zn..,

Le traitement propose sera choisi en fonction:

▪ 50 %des cas, l’accouchement survient dans les

Longeur du Col(en cm) >3 1-3 <1

Effacement(en %) 0-30 40-50 60-70

Consistance Ferme Moyenne Molle

Position du Col Postérieur Médiane Antérieur

▪ Score < 6 défavorable,

ស្តសរីដ្មោះ តូច សុផា,​៤០ឆ្ែប,​G2P0

- Amoxicilline 500mg 2cps x 3 po/J

2-3.Résultats du J1 (16/03/2023 à 14H00)

- TA 120/80, pouls: 78/mn. T:37.2C, RR: 24/mn

▪ Score de Bishop: 6 points,

▪ Antibiothérapie, et antipyrétique continue

* ការសនែិោានរលីនិច៖ “RPM prolongée, au début du

The 19th Continuing Professional Development Symposium Battambang Province

Etude rétrospective des aspects épidémio-cliniques et thérapeutiques

Prof. Asst. Dr. HUOT SOCHEAT

ថ្ងៃព្រហ្បត្ិ៍ ៩វោច ខេទុត្ិយាសាឍ ឆ្ន ំវ ោះ បញ្ច ្័ក រ.្ ២៥៦៧

Etude rétrospective des aspects épidémio-cliniques

Prof. Asst. Dr. HUOT SOCHEAT

Durant 3 ans, concernant 1694 patients

Sex-ratio: H/F était de 7,6 en

▪ Répartition des patients selon le membre atteint:

Radiographie osseuse: 7 cas (13%)

ABS Chloramphénicol Amox/Clav Ceftazidime

Note: Un cas de complication était de

Notre série à Battambang 3%

Moyikoua et al [1] 1993 Congo 5,2%

Sidibe R [6] 2014 Mali 5,7%

Rémi CHARVET [7] 2010 France 0.77%

Kimmatkar et al [8] 2017 Inde 6,15%

Mutombo et al [9] 1993 Zaïre 19%

Notre série à Battambang 46 6 7,6

Garba et al [10] 2018 Niger 67 21 3,1

Moyikoua et al [1] 1993 Congo 19 2 9,5

Foni et al [11] 2015 Brésil 13 8 1,6

Littératures Âge moyen des patients

Notre série à Battambang 36,56 ans

Garba et al [10] 2018 Niger 33 ans

Quing Xu et al [12] 2014 Chine 35,6%

Moyikoua et al [1] 1993 Congo 34,5 ans

Said et al [13] 2013 Maroc 27 ans

Nous avons trouvé les signes cardinaux des infections

Littératures Membre Membre

Foni et al [11] 2015 Brésil 6,25% 93,75%

Littératures Notre série Belgassi Kimmatk Amarade

Diabète + HTA 11,53% 4,8% 25% 45,45%

ស្តសរីដ្មោះ តូច សុផា,៤០ឆ្ែប,G2P0