Chest
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Direct oral anticoagulants (DOACs) are the treatment of choice for most patients with atrial fibrillation and/or noncancer-associated venous thromboembolic disease. Although routine monitoring of these agents is not required, assessment of anticoagulant effect may be desirable in special situations. The objective of this review was to summarize systematically evidence regarding laboratory assessment of the anticoagulant effects of dabigatran, rivaroxaban, apixaban, and edoxaban. ⋯ An ideal test, offering both accuracy and precision for measurement of any DOAC is not widely available. We recommend a dilute TT or ecarin-based assay for assessment of the anticoagulant effect of dabigatran and anti-Xa assays with drug-specific calibrators for direct Xa inhibitors. In the absence of these tests, TT or APTT is recommended over PT/INR for assessment of dabigatran, and PT/INR is recommended over APTT for detection of factor Xa inhibitors. Time since last dose, the presence or absence of drug interactions, and renal and hepatic function should impact clinical estimates of anticoagulant effect in a patient for whom laboratory test results are not available.
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Widespread use of critical care ultrasonography (CCUS) for the management of patients in the ICU requires an effective training program. The effectiveness of national and regional CCUS training courses is not known. This study describes a national-level, simulation-based, 3-day CCUS training program and evaluates its effectiveness. ⋯ Learners demonstrated a significant improvement in written test scores that assessed cognitive and image interpretation abilities. In addition, they demonstrated acquisition of practical skills as evidenced by high scores during hands-on testing. Further studies are needed to determine if a simulation-based CCUS course will translate into effective clinical practice and to measure the durability of training. This 3-day course is an effective method to train large groups of critical care clinicians in the skills requisite for CCUS (image acquisition and image interpretation).
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Meta Analysis
Prophylaxis against atrial fibrillation after general thoracic surgery: Trial sequential analysis and network meta-analysis.
Postoperative atrial fibrillation/flutter (POAF) is associated with significant morbidity and mortality after general thoracic surgery, but the need for and the best agent for prophylaxis remains obscure. ⋯ The current literature supports the effectiveness and tolerability of medical prophylaxis and the superiority of β-blockers in preventing POAF after general thoracic surgery. β-Blockers are recommended, taking into consideration the status of the bronchopulmonary system.