Nederlands tijdschrift voor geneeskunde
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Ned Tijdschr Geneeskd · Jan 2013
Review[Tetanus prophylaxis after an injury; check the need for vaccination and immunoglobulin].
Tetanus can occur after an injury and is caused by the exotoxin of Clostridium tetani. Characteristics of generalised tetanus include spasms in the back and other muscles, trismus, risus sardonicus and difficulty in breathing caused by laryngospasms. Vaccination through the National Vaccination Programme of the Netherlands has resulted in 94% of the population being protected against tetanus; certain groups, however, have a low rate of vaccination. ⋯ Of these 5 patients, 3 did not receive post-exposure-prophylaxis (PEP) after their injuries, or received it incompletely. PEP may be comprised of 1 or more vaccinations with the tetanus toxoid and/or the administration of tetanus immunoglobulin. Patients who have sustained an injury should be evaluated in accordance with the guideline 'Tetanus' by the Landelijke Coördinatie Infectieziekten (National Coordination Centre for communicable disease control), and to assess whether PEP is indicated.
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Transfusion-related acute lung injury (TRALI) is a major complication of blood transfusions. The pathogenesis of TRALI is thought to occur in 2 phases: the 'double-hit theory'. The first phase is an underlying condition present in the patient, such as a surgical procedure or sepsis, which leads to priming, i.e. the activation of endothelium and subsequent sequestration of neutrophils in the lungs. ⋯ The incidence of TRALI in patients with an underlying condition is high; up to 15% of transfused patients are at risk. Anti-HLA and anti-HNA antibodies are highly prevalent in multiparous female donors. The exclusion of female donors for plasma and thrombocyte products has led to a 33-66% reduction in the incidence of TRALI.
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Ned Tijdschr Geneeskd · Jan 2013
Case Reports[Palliative sedation in a man with oral cancer; the Royal Dutch Medical Association guidelines not always sufficient].
Palliative sedation is an effective treatment option in patients with refractory symptoms in the last phase of life. In 2009 the Royal Dutch Medical Association (KNMG) published revised guidelines. The dosage of propofol recommended in these guidelines is, however, based on one single study. ⋯ In our opinion the advised starting dose of propofol is too low, especially in comparison with sedation in regional anaesthesia described in the literature. Furthermore, we advocate that administration of drugs from step 2, midazolam and levomepromazine, is not discontinued when propofol sedation is commenced in step 3.
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Ned Tijdschr Geneeskd · Jan 2013
Case Reports[Maternal pulmonary oedema due to the use of atosiban in cases of multiple gestation].
Nifedipine is used as a first choice tocolytic agent in many Dutch hospitals, but its use is discouraged in multiple gestations. Atosiban, a selective oxytocin receptor antagonist that rarely causes systemic side effects, is used as an alternative. ⋯ Every patient with multiple gestation is at increased risk of pulmonary oedema. Any tocolytic agent may elicit that response, even the relatively safe atosiban.
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Ned Tijdschr Geneeskd · Jan 2013
Comparative Study[The simulated setting for testing competencies; task shifting in outpatient anaesthesia].
Pre-anaesthesia evaluation is a complex task requiring integration of information obtained from the patient's history, physical examination and the proposed surgery. This task, traditionally performed by physicians, is increasingly being executed by specialised nurses or physician assistants in daily practice. ⋯ Simulation to test competencies requires properly described competencies within an adequate and validated simulation model, a suitable and validated assessment system, and an understanding of the causes of errors in measurement. A simulation study with an adequate sample size to detect a given sensitivity of physician assistants of 80% to identify significant comorbidity during pre-anaesthesia evaluation would require simulation of 1,000 to 1,500 consults.