Emergency reversal of anticoagulation: from theory to real use of prothrombin complex concentrates. A retrospective Italian experience.

BACKGROUND: Prothrombin Complex Concentrates (PCC) are administered to normalise blood coagulation in patients receiving oral anticoagulant therapy (OAT). Rapid reversal of OAT is essential in case of major bleeding, internal haemorrhage or surgery.The primary end-point was to evaluate whether PCC in our hospital were being used in compliance with international and national guidelines for the reversal of OAT on an emergency basis. The secondary end-point was to evaluate the efficacy and safety of PCC. MATERIALS AND METHODS: All patients receiving OAT who required rapid reversal anticoagulation because they had to undergo emergency surgery or urgent invasive techniques following an overdose of oral anticoagulants were eligible for this retrospective observational study. RESULTS: Forty-seven patients receiving OAT who needed rapid reverse of anticoagulation were enrolled in our study. The patients were divided in two groups: (i) group A (n=23), patients needed haemostatic treatment before neurosurgery after a head injury and (ii) group B (n=24), patients with critical haemorrhage because of an overdose of oral anticoagulants. The International Normalised Ratio (INR) was checked before and after infusion of the PCC. The mean INR in group A was 2.7 before and 1.43 after infusion of the PCC; in group B the mean INR of 6.58, before and 1.92 after drug infusion. The use of vitamin K, fresh-frozen plasma and red blood cells was also considered. During our study 22 patients died, but no adverse effects following PCC administration were recorded. DISCUSSION: In our study three-factor-PCC was found to be effective and safe in rapidly reversing the effects of OAT, although it was not always administered in accordance with international or national guidelines. The dose, time of administration and monitoring often differed from those recommended. In the light of these findings, we advocate the use of single standard protocol to guide the correct use of PCC in each hospital ward.

Lung ultrasound: a new tool for the emergency physician.

Patients with dyspnea are routinely assessed with physical examination, lung auscultation and chest X-rays. Auscultation and bedside radiography have a low accuracy in the critically ill. Chest X-ray images remain suboptimal in more than one-third of cases and are poorly correlated to lung CT images. Lung ultrasound is invaluable as a bedside diagnostic tool of the dyspneic patient since, in a few minutes, it may help distinguish the typical features of most common causes of dyspnea. The lung has been improperly considered to be poorly accessible using ultrasound, because air prevents the progression of the ultrasound beam with production of reverberation artifacts under the lung surface. This article reviews the scanning technique, and the normal and pathological findings of lung ultrasound, and underscores its utility in providing the emergency physician with a new, fast and reliable diagnostic tool.