Four-day antithrombin therapy does not seem to attenuate hypercoagulability in patients suffering from sepsis

INTRODUCTION: Sepsis activates the coagulation system and frequently causes hypercoagulability, which is not detected by routine coagulation tests. A reliable method to evaluate hypercoagulability is thromboelastography (TEG), but this has not so far been used to investigate sepsis-induced hypercoagulability. Antithrombin (AT) in plasma of septic patients is decreased, and administration of AT may therefore reduce the acquired hypercoagulability. Not clear, however, is to what extent supraphysiologic plasma levels of AT decrease the acute hypercoagulability in septic patients. The present study investigates the coagulation profile of septic patients before and during four day high-dose AT therapy. METHODS: Patients with severe sepsis were randomly assigned to receive either 6,000 IU AT as a bolus infusion followed by a maintenance dose of 250 IU/hour over four days (n = 17) or placebo (n = 16). TEG, platelet count, plasma fibrinogen levels, prothrombin time and activated partial thromboplastin time were assessed at baseline and daily during AT therapy. RESULTS: TEG showed a hypercoagulability in both groups at baseline, which was neither reversed by bolus or by maintenance doses of AT. The hypercoagulability was mainly caused by increased plasma fibrinogen, and to a lesser extent by platelets. Plasmatic coagulation as assessed by the prothrombin time and activated partial thromboplastin time was similar in both groups, and did not change during the study period. CONCLUSION: The current study shows a distinct hypercoagulability in patients suffering from severe sepsis, which was not reversed by high-dose AT treatment over four days. This finding supports recent data showing that modulation of coagulatory activation in septic patients by AT does not occur before one week of therapy. Trial registration: Current Control Trials ISRCTN2293102

Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial

Objective To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity

Factors associated with success in the oral part of the European Diploma in Intensive Care

Introduction: The oral part of European Diploma in Intensive Care diploma examinations changed in 2013 into an objective structured clinical examination-type exam. This step was undertaken to provide a fair and reproducible clinical exam. All candidates face identical questions with predefined correct answers simultaneously in seven high throughput exam centres on the same day. We describe the factors that are associated with success in part 2 European Diploma in Intensive Care exam. Methods: We prospectively collected self-reported data from all candidates sitting European Diploma in Intensive Care part 2 in 2015, namely demographics, professional background and attendance to a European Diploma in Intensive Care part 2 or generic objective structured clinical examination preparatory courses. After testing association with success (with cutoff at p < 0.10) and co-linearity of these factors as independent variables, we performed a multivariate logistical analysis, with binary exam outcome (pass/fail) as the dependent variable. Structural equation modelling was used to gain further insight into relations among determinants of success in the oral part of the European Diploma in Intensive Care. Results: Out of 427 candidates sitting the exam, completed data from 341 (80%) were available for analysis. The following candidates' factors were associated with increased chance of success: English as native language (odds ratio 4.3 (95% CI 1.7–10.7)), use of Patient-centred Acute Care Training e-learning programme module (odds ratios 2.0 (1.2–3.3)), working in an EU country (odds ratios 2.5 (1.5–4.3)), and better results in the written part of the European Diploma in Intensive Care (for each additional SD of 6.1 points odds ratios 1.9 (1.4–2.4)). Chance of success in the European Diploma in Intensive Care 2 decreased with increased candidates ‘age (for each additional SD of 5.5 years odds ratios 0.67 (0.51–0.87)). Exam centres (7 in total) could be clustered into 3 groups with similar success rates. There were significant differences in exam outcomes among these 3 groups of exam centres even after adjustment to known candidates' factors (G1 vs G2 odds ratios 2.4 (1.4–4.1); G1 vs G3 odds ratios 9.7 (4.0–23.1) and G2 vs G3 odds ratios 3.9 (1.7–9.2)). A short data collection period (only one year) and 20% of missing candidates' data are the main limitations of this study. Conclusions: Younger age, English as native language, better results in written part of the exam, working at a European country and the use of PACT for preparation, were factors associated with success in the oral part of the European Diploma in Intensive Care exam. Despite the limitations of this study, the differences in outcome among the exam centres will need further investigation