INR reduction after prothrombin complex concentrate (Co-Fact) administration.:Comparison of INR outcomes in different patient categories at the emergency department

BACKGROUND: Co-fact(©), prothrombin complex concentrate, is used for restoring the international normalized ratio (INR) in patients on vitamin K antagonists (VKA) presenting with acute bleeding. In this prospective cohort study, we evaluated whether adequate INR values were reached in ED patients using the Sanquin (Federation of Dutch Thrombosis Services) treatment protocol. METHODS: We evaluated this protocol for two target INR groups: group 1, target INR ≤ 1.5 (for life-threatening bleeding/immediate intervention); group 2, target INR 1.6-2.1 (in cases of a minor urgent surgery or serious overdosing of anticoagulant). We specifically wanted to identify both under- and over-treated patients. Reversing VKA anticoagulation therapy to unnecessarily low INR values may involve thrombotic risks. Apart from this risk, the patient is also administered an excess amount of the drug. This means unnecessary costs and may present problems with restoring an anticoagulated state at a later time. RESULTS: In our cohort, the Sanquin dosing protocol was followed for 45/60 patients. It appeared that out of the 41 patients in group 1 (target INR ≤ 1.5), 35 (85%) achieved the goal INR. This occurred more often than for the 19 patients in group 2 (target INR 1.6–2.1), where only 6 (32%) achieved the goal INR. Using the protocol resulted in a positive trend toward better INR reversal in group 1. In group 2, no relation between using the protocol and achieving the desired INR value was detected. Physicians ignoring the proposed dose of Co-fact(©) prescribed significantly less Co-fact(©) (even when correcting for patient weight). It appeared that patients in group 1 had a significantly lower baseline INR than patients in group 2. Group 2 patients, on the other hand, had a baseline INR > 7.5 in 53% of the cases. CONCLUSION: In our cohort, for most patients in INR group 2 treated with Co-fact(©), the achieved INR value was outside the desired range of 1.6-2.1. The supra-therapeutic range of baseline INR in group 2 may have contributed to the different kind of bleeding witnessed in this patient group. Our results support the idea that treatment of patients on vitamin K antagonists with Co-fact(©) could benefit from a slightly different approach, taking into account the INR value to which the patient needs to be reversed

Serious Games for Improving Technical Skills in Medicine:Scoping Review

BACKGROUND: Serious games are being used to train specific technical skills in medicine, and most research has been done for surgical skills. It is not known if these games improve technical skills in real life as most games have not been completely validated. OBJECTIVE: This scoping review aimed to evaluate the current use of serious games for improving technical skills in medicine and to determine their current validation state using a validation framework specifically designed for serious games. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A multidatabase search strategy was adopted, after which a total of 17 publications were included in this review. RESULTS: These 17 publications described five different serious games for improving technical skills. We discuss these games in detail and report about their current validation status. Only one game was almost fully validated. We also discuss the different frameworks that can be used for validation of serious games. CONCLUSIONS: Serious games are not extensively used for improving technical skills in medicine, although they may represent an attractive alternative way of learning. The validation of these games is mostly incomplete. Additionally, several frameworks for validation exist, but it is unknown which one is the best. This review may assist game developers or educators in validating serious games

Haemodynamic effects of a 10-min treatment with a high inspired oxygen concentration in the emergency department:A prospective observational study

Previous studies show that prolonged exposure to a high inspired oxygen concentration (FiO 2) is associated with unfavourable haemodynamic effects. Until now, it is unknown if similar effects also occur after oxygen therapy of limited duration in the emergency department (ED). Objectives To investigate the haemodynamic effects of a high FiO 2 administered for a limited duration of time in patients who receive preoxygenation for procedural sedation and analgesia (PSA) in the ED. Design, settings and participants In a prospective cohort study, cardiac output (CO), stroke volume (SV) and systemic vascular resistance (SVR) were measured using the Clearsight non-invasive CO monitoring system in patients who received preoxygenation for PSA in the ED. Measurements were performed at baseline, after 5 min of preoxygenation via a non-rebreathing mask at 15 /L min and after 5 min of flush rate oxygen administration. Outcomes measures The primary outcome was defined as the change in CO (L/min) from baseline after subsequent preoxygenation with 15 L/min and flush rate. Results Sixty patients were included. Mean CO at baseline was 6.5 (6.0-6.9) L/min and decreased to 6.3 (5.8-6.8) L/min after 5 min of oxygen administration at a rate of 15 L/min, and to 6.2 (5.7-6.70) L/min after another 5 min at flush rate (p=0.037). Mean SV remained relatively constant during this period, whereas mean SVR increased markedly (from 781 (649-1067), to 1244 (936-1695) to 1337 (988-1738) dyn/s/cm -5, p10% decrease in CO. Conclusion Exposure of patients to a high FiO 2 for 5-10 min results in a significant drop in CO in one out of four patients. Therefore, even in the ED and in prehospital care, where oxygen is administered for a limited amount of time, FiO 2 should be titrated based on deficit whenever this is feasible and high flow oxygen should not be given as a routine treatment