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Patients treated with direct oral anticoagulants (DOACs) may require urgent procedures. Managing these patients is challenging due to different bleeding risks and may include laboratory testing, procedural delays, or haemostatic/reversal agent administration.We evaluated management strategies and outcomes of urgent, non-haemostatic invasive procedures in patients treated with DOACs.In a descriptive cohort study, we prospectively evaluated 478 patients in the GIHP-NACO registry, from June 2013 to November 2015. Hospitalised patients receiving dabigatran (n = 160), rivaroxaban (n = 274), or apixaban (n = 44) requiring urgent, procedural interventions were evaluated, of which 384/478 (80 %) were surgical procedures. Orthopaedic surgery included 216/384 patients (56 %), while gastrointestinal surgery included 75/384 (20 %) patients. On admission, the median age was 79 (70-85), and creatinine clearance was60 mL·minIn the GIHP-NACO registry, before specific antidotes were available, DOAC treated patients undergoing urgent invasive procedures were delayed in nearly half of the cases, and showed a low rate of excessive bleeding, suggesting that most urgent procedures can be performed safely without DOAC reversal.www.gov. Identifier: NCT02185027.

Contexte et problématique: En plein essor, le jeu sérieux est un jeu vidéo à visée pédagogique, c’est à dire un dispositif de simulation virtuelle sur un matériel numérique associant des éléments de jeu et un objectif pédagogique. Cet outil pédagogique permet un apprentissage expérientiel; de ce fait, il peut être exploité pour la formation des professionnels de santé au raisonnement clinique et à la prise de décision. Objectif: En s’appuyant sur des arguments de nature théorique et sur une revue narrative ciblée de la littérature, la présente contribution dresse un inventaire des impacts documentés de l’efficacité des jeux sérieux pour la formation des professionnels de la santé et formule quelques perspectives pédagogiques. Exégèse : Les jeux sérieux permettent d’opérationnaliser quatre conditions favorisant l’apprentissage: l’attention, l’engagement cognitif actif, la rétroaction et la consolidation. Bien qu’hétérogènes, les données de la littérature montrent que, sous certaines conditions, les jeux sérieux permettent de soutenir des apprentissages qui améliorent la prise de décision, d’une manière comparable aux dispositifs traditionnels. Certaines incertitudes demeurent quant à leur place exacte par rapport à d’autres dispositifs utilisant des ressources numériques ou à d’autres méthodes pédagogiques. Des travaux de recherche pédagogique sont à poursuivre dans certains domaines tels que la motivation et les modalités pédagogiques. Conclusion: Les jeux sérieux font partie des outils pédagogiques à disposition des enseignants lorsqu’ils souhaitent proposer à leurs étudiants des opportunités d’apprentissage actif et expérientiel, par exemple dans le cadre de formations centrées sur la prise de décision.

To compare two teaching methods of a forearm cast in medical students through simulation, the traditional method (Trad) based on a continuous demonstration of the procedure and the task deconstruction method (Decon) with the procedure fragmenting into its constituent parts using videos.During simulation training of the below elbow casting technique, 64 medical students were randomized in two groups. Trad group demonstrated the entire procedure without pausing. Decon group received step-wise teaching with educational videos emphasizing key components of the procedure. Direct and video evaluations were performed immediately after training (day 0) and at six months. Performance in casting was assessed using a 25-item checklist, a seven item global rating scale (GRS Performance), and a one item GRS (GRS Final Product).Fifty-two students (Trad n = 24; Decon n = 28) underwent both day zero and six month assessments. At day zero, the Decon group showed higher performance via video evaluation for OSATS (p = 0.035); GRS performance (p 0.001); GRS final product (p 0.001), and for GRS performance (p 0.001) and GRS final product (p = 0.011) via direct evaluation. After six months, performance was decreased in both groups with ultimately no difference in performance between groups via both direct and video evaluation. Having done a rotation in orthopaedic surgery was the only independent factor associated to higher performance.The modified video-based version simulation led to a higher performance than the traditional method immediately after the course and could be the preferred method for teaching complex skills.

The most recent recommendations support learning of external cardiac massage (ECM) through feedback devices.The objective was to compare the effects on immediate and 3-month retention of ECM technical skills when using feedback devices compared with training without feedback as part of a half-day training session in medical students.This randomized study was performed using the Resusci Anne QCPR manikin in 64 medical students. We compared the quality of ECM with nonfeedback training in the control group (group 1) vs. 2 feedback learning methods (group 2, PocketCPR and group 3, Skill Reporter each used with visual display available to the trainee). At the end of the training session and 3 months later, students performed chest compressions blindly during a 2-min assessment session. The median compression score was the primary outcome for assessing immediate and long-term retention.Regarding immediate retention, the median compression score was significantly lower in group 1 (23%) than in groups 2 (81%) and 3 (72%) (p 0.05) with no difference between the 2 feedback methods. At 3 months, mean compression scores remained high but not significantly different between the 2 feedback groups.The use of a feedback device used for ECM training improves the quality of immediate retention of technical ECM skills compared with traditional teaching in medical students. At 3 months, the 2 groups with feedback retained a high level of performance. No significant difference could be demonstrated between the 2 feedback methods.

Background: An observer tool (OT) dedicated to technical skills could improve learning of medical knowledge during simulation. However, it remains uncertain whether non-technical skills learning outcomes might be improved by using an OT.Methods: After consent, anesthesia residents enrolled to a crisis management training simulation were randomized to use an observer tool (OT +) (based on non-technical skills) or not (OT-) when not role-playing. The main outcome parameter was non-technical skills learning outcomes assessed by the global score of non-technical skills learning after the training (self-assessment using the 15 items of 4 categories of the Anaesthetists’ Non-Technical Skills (ANTS); 0 to 10 Likert scale; /40). The perceived stress level, satisfaction and the score of medical knowledge were also assessed. Results: All anesthesia residents were randomized (n = 48; OT+ group, n = 37; OT- group). At the end of the session, the global score of ANTS learning and the medical knowledge score were similar in the two groups: 31 ± 4 (OT+) and 31 ± 5 / 40 (OT-) (p = 0.55) and 12 ± 2 (OT+) and 12 ± 2 / 20 (OT-) (p=0.47). The 2 groups had a positive and similar perception of learning stress management, improvement of crisis skills management, satisfaction and changes in professional practice after the training session.Conclusions: This study has shown a positive perception of ANTS learning after crisis training without difference between using or not an OT in anesthesia residents. More studies are necessary to define the place of this educational tool. Trial registration: researchregistry.com. Registration number: researchregistry7055. Retrospectively registered August 13, 2021.

INTRODUCTION The growing number of learners implies that all of them cannot play an active role during high-fidelity scenarios. Studies suggest a positive educational value when learners are observers only, but it remains uncertain whether learning outcomes might be improved by using an observer tool (OT). METHODS Eighty-nine anesthesia residents were randomized to use an OT (n = 44, OT+; based on a cognitive aid) or not (n = 45, OT-) when not role-playing. The main outcome parameter was the learning outcomes assessed by comparing the change (before-after) in the response score to a questionnaire dedicated to medical knowledge obtained in the OT+ and OT- groups. The impact of using the OT was also assessed by measuring the perceived stress level and the change of the Anesthetists' Non-Technical Skill items values. RESULTS At the end of the session, the mean medical knowledge score (mean ± SD) was higher in the OT+ group than in the OT- group (11.4 ± 2.7 vs. 9.6 ± 2.4, respectively, P = 0.0008). The mean Anesthetists' Non-Technical Skill score and level of stress perceived did not differ between groups. Trainees rated similarly the learning value and satisfaction related to the simulation course. CONCLUSIONS This study suggests that observing high-fidelity simulation scenarios using an OT based on a cognitive aid increases the medical knowledge gain when compared with that seen in passive observers. This study suggests that the use of an OT improves the educational value of simulation.

Resume L’intelligence humaine produit constamment des erreurs, mais dispose egalement d’une grande capacite a les detecter et a les corriger. Le travail en equipe implique des competences non techniques (communication, leadership, prise de decision) qui peuvent egalement etre a l’origine d’erreurs. Les situations critiques sont responsables d’un stress qui decuple la production d’erreurs et la difficulte a mobiliser les connaissances. Les progres pour la securite des patients ont conduit a la mise en place d’outils de type aides cognitives (AC) (ou check-lists, fiches urgences…) : face a une situation de crise, les informations sont structurees, pas a pas, au plus pres de l’evenement, avec l’objectif d’ameliorer la performance de l’equipe medicale et paramedicale en guidant le raisonnement, listant l’enchainement des actions et evitant l’oubli d’etapes. Un des membres de l’equipe a pour role de la lire a haute voix pour guider les actions du reste de l’equipe. La litterature montre que l’utilisation de ces outils est efficace en simulation pour ameliorer la prise en charge d’une crise au bloc par l’equipe d’anesthesie, comme dans d’autres champs d’activites medicales. Ces AC sont des outils dont la conception (simple et claire), la mise en place (formation et simulation), la disponibilite (toujours disponible), le support, le format et l’appropriation sont essentiels. L’enseignement de leur utilisation en simulation est fondamental. La SFAR, via le Comite d’analyse et maitrise du risque (CAMR), participe a cette evolution en produisant ses AC sur la gestion des situations critiques en anesthesie et en reanimation (disponibles sur le site : https://sfar.org/espace-professionel-anesthesiste-reanimateur/outils-professionnels/boite-a-outils/aides-cognitives-en-anesthesie-reanimation/ , et sur l’application mobile de la SFAR).

Background A serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses’ ability to detect patient clinical deterioration. Methods The SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick’s framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis). Results The content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups’ high rating of the game’s realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study. Conclusion While it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool. Trial registration ClinicalTrials.gov ID: NCT03092440

Summary Skills other than technical or clinical competences are also recognized as essential in surgery. Most serious adverse events in health care are related to non-technical skill (NTS) failures. This has fostered interest in teaching surgeons about NTS. Reproducible evaluation scales, inspired by management strategies in the air transportation industry have been created in health care and some have been fashioned and validated specifically for surgeons. The list of NTS varies according to authors but one usually finds the same division into two main categories: social skills (communication, teamwork, leadership) and cognitive competences (situational awareness, decision-making). Stress and fatigue affect the implementation of these skills. Simulation is an efficient manner to teach NTS. The goals and exact modalities of how to teach NTS remains to be defined.

In medicine, a communicating virtual patient or doctor allows students to train in medical diagnosis and develop skills to conduct a medical consultation. In this paper, we describe a conversational virtual standardized patient system to allow medical students to simulate a diagnosis strategy of an abdominal surgical emergency. We exploited the semantic properties captured by distributed word representations to search for similar questions in the virtual patient dialogue system. We created two dialogue systems that were evaluated on datasets collected during tests with students. The first system based on hand-crafted rules obtains $92.29\%$ as $F1$-score on the studied clinical case while the second system that combines rules and semantic similarity achieves $94.88\%$. It represents an error reduction of $9.70\%$ as compared to the rules-only-based system.

Aim The increasing use of high-fidelity simulation is limited by the imbalance between the growing number of students and the human resources available in such a way that all residents cannot play a role during scenarios. The learning outcomes of observers need to be studied. Methods This prospective randomised study was approved by the institutional review board. Anaesthesia residents attending a one-day training session were enrolled. In each of the four scenarios, three residents played an active role while others observed in a separate room. All participants attended debriefing sessions. Residents were randomised between active participant-observer group (AP-O group) and observer group (O group). A similar questionnaire was distributed before, immediately after the session and after three months and included self-reported assessment of satisfaction, medical knowledge (noted 0–16), and non-technical skills. Results A hundred and four questionnaires were analysed. Immediately after the simulation, a significant increase in medical knowledge was recorded but was higher in the AP-O group (6 [5–8] to 10 [8–11]/16) than in the O group (7 [5–8] to 9 [7–10]/16). High scores for non-technical skills were similarly observed in both groups. Satisfaction was high in both groups but was higher in the AP-O group (9 [8–9] versus 8 [8–9]/10, P = 0.019). Decay of knowledge was observed for most main outcomes at three months. Conclusion This study suggests an immediate improvement of learning outcomes for both roles after immersive simulation but some learning outcomes may be better for residents engaged as players in scenarios.

Resume En anesthesie pediatrique, la simulation a un interet certain pour l’apprentissage de la gestion des complications frequentes ou rares, mais aussi pour la formation continue. Elle est egalement utile pour la pratique de l’anesthesie-reanimation pediatrique soit reguliere soit peu frequente. Selon l’experience de l’anesthesiste-reanimateur qui y participe, elle permet l’apprentissage et l’amelioration des competences medicales et non techniques de la gestion d’une situation de crise.

Introduction. The use of cognitive aids (CAs) during critical events is thought to be useful. However, whether CAs are known and used by French and Canadian anaesthesia providers is not clear. Methods. A survey was emailed to French and Canadian anaesthesia providers in 2017 through their respective national societies. It consisted of 23 questions about the participants’ demographics and their knowledge, use, and impact of CAs. A second survey was sent to French simulation centres. Results. 912 responses were recorded in France and 278 in Canada (overall response rate: 7% and 11%, respectively). Among the respondents, 700/899 in France (78%) versus 249/273 (91%) in Canada were familiar with the concept of cognitive dysfunction during a crisis and 501/893 (56%) in France versus 250/271 (92%) in Canada knew the concept of CAs. Amongst those respondents who knew about CAs, 189/492 (38%) in France versus 108/244 (44%) in Canada stated that they had already used a CA in real life and 225/493 (45%) in France versus 126/245 (51%) in Canada had received training in their use. Simulation was the principal modality for training in 150/225 (67%) of cases in France versus 47/126 (37%) in Canada. Among the 28/50 French simulation centres which responded (2018 January), 27 organised sessions in anaesthesia and 22 used CAs. Conclusion. CAs were better known in Canada than in France, but their actual use in real life was low in both countries. Simulation appears to play a potentially important role training anaesthesia providers in the use of CAs.

In this prospective observational study, we compared changes in cardiac index (CI) during fluid challenge using photoplethysmography (PPG; Nexfin™) (CIPPG) versus esophageal Doppler (ED) (CIED) in major noncardiac surgery patients.Measurements were obtained when the attending anesthesiologist decided to perform a fluid challenge. Correlations with linear regression, Bland-Altman analysis, and analysis of covariance were performed. Trending ability was studied using 2 different methods: a 4-quadrant plot and a polar plot.Forty-three patients were analyzed with a total of 111 fluid challenges. There was a significant linear relationship between CI PPG and CI ED (r2 = 0.34; P0.001). The bias between the ED and the PPG measurements of CI was -0.114 (95% confidence interval [CI95], -1.9 to 1.7) L/min/m2, with a mean percentage error of 55%. The correlation between the changes in CI during a fluid challenge was significant (r2 = 0.25; P = 0.002). The concordance rate of directional changes (increase or decrease) of CI PPG and CI ED during fluid challenge was 67% (CI95, 57-75) for the whole data set and 85% (CI95, 70-94) with an exclusion zone of 15%. When considering ED as a reference, the sensitivity and specificity to give an additional bolus with PPG (increase in CI PPG ≥ 15%) were 35% (CI95, 19-55) and 90% (CI95, 81-96), respectively, with a positive predictive value of 58% (CI95, 33-80) and a negative predictive value of 78% (CI95, 68-86).In major noncardiac surgery patients, the evaluation of CI using PPG is not interchangeable with the evaluation of CI using ED. When considering the ED as an accurate device to assess changes in CI, PPG is not appropriate to assess the need for additional fluid administration. These results clearly indicate the limitations of PPG as an accurate device to track changes in CI compared with ED.

Les « simulations relationnelles » sont assurées par un docteur en psychologie sociale et un médecin ; menées dans un cabinet de médecine générale spécialement recréé pour les étudiants médecins. Les séquences avec patients simulés sont regardées en direct, débriefées et ré visionnées. La formation est réalisée sur quatre promotions de 180 futurs médecins répartis en groupes (9 à 14 étudiants) de 4e ou 5e année. L’objectif est de produire une analyse réflexive et rétrospective sur l’activité du médecin généraliste tout en protégeant les apprenants. La formation exposée ici est réalisée pour quatre promotions de 180 futurs médecins répartis en groupes (9 à 14 étudiants) de 4ème ou 5ème année. L’objectif est, tout en protégeant les apprenants, de susciter une analyse réflexive et rétrospective de l’activité du médecin (avec la production d’une synthèse collective écrite sur les situations abordées). In Switzerland, men predominate in higher education science courses. However, biology courses are attended primarily by women. The little success of affirmative actions targeting girls and women in science invites us to re-examine the way these subjects are taught in Geneva primary school. We will show that only biology seems to occupy a proper place in the real curriculum. Put science back in the general knowledge could be a way to attract women in science.

Hyperfibrinolysis is observed during and immediately after major orthopedic surgery. The kinetics and duration of this phase should be defined to adjust the duration of antifibrinolytic treatment with tranexamic acid (TXA).We aimed to quantify the duration of postoperative fibrinolysis and to assess the biological impact of TXA administration.Fourteen patients undergoing total hip replacement (THR) and 10 patients undergoing total knee replacement (TKR) with tourniquet were included in an observational, prospective, single-center study. Among these patients, 7 THR patients and 5 TKR patients received TXA (15mg/kg IV intraoperatively, followed by continuous infusion of 15mg/kg/h until end of surgery, then every 4hours until 16±2hours after surgery). D-dimers, euglobulin lysis time (ELT), and thrombin generation time (TGT) were measured prior to surgery as well as 6, 18 and 24hours (H) after.No significant difference in ELT was observed between the groups. In contrast, D-dimers significantly increased postoperatively in patients not treated with TXA (p0.001), while such an increase was prevented in patients receiving TXA, as measured at H0, H6, H18 and H24 after THR, and at H6 and H18 after TKR (p0.001). No significant between-group change in TGT, was observed (peak thrombin and endogenous thrombin potential) all along the study.This study shows that fibrinolysis peaked 6hours after end of surgery and maintained about 18hours after surgery, as evidenced by an increase in D-dimers. When administered for up to 16±2hours after surgery, TXA reduced postoperative fibrinolysis.

Introduction L’AFGSU2 est une formation aux gestes d’urgence obligatoire chez les etudiants en medecine. Dans notre Faculte, elle est organisee avec une journee initiale en 2 e annee (DFGSM2) puis un rappel en 4 e annee (DFASM2). L’objectif est d’evaluer l’efficacite de la formation AFGSU2 chez les etudiants en medecine et le niveau de retention a 1 et 2 ans. Patients et methodes Tous les etudiants de DFGSM2 ont ete inclus dans cette etude monocentrique lors de la formation AFGSU2. Un meme questionnaire comportant 12 questions a choix simple et/ou multiple a ete rempli avant (T1) puis apres (T2) la formation initiale en 2 e annee puis a ete rempli a 1 an (T3) puis a 2 ans (T4) apres la formation. Les resultats sont rapportes comme mediane [espace interquartile] ou pourcentage. Les statistiques etaient non parametriques. Resultats En janvier 2013, 131 etudiants de 2 e annee ont participe a l’AFGSU2 avec 128 reponses au questionnaire a T1 et 131 reponses a T2. En janvier 2014, 119 etudiants en 3 e annee ont repondu au meme questionnaire a T3 et en janvier 2015, 129 etudiants en 4 e annee a T4. La mediane des notes s’ameliore significativement de T1 a T2 ( p p p Pour la question sur le numero du SAMU, on retrouve un tres fort taux de bonne reponse a T1, T2, T3 et T4 (96 % ; 86 %, 96 % et 97 %, respectivement). Concernant les questions sur la prise en charge de l’arret cardiaque ( Fig. 1 ), on observe systematiquement une forte amelioration entre T1 et T2 (Q2 : 74 a 97 %, Q3 : 44 a 82 %, Q4 : 16 a 60 %, Q5 : 18 a 97 %, Q6 : 20 a 89 %, Q7 : 3 a 42 % et Q8 : 10 a 82 %, p p p p p Discussion Cette etude montre une forte amelioration des reponses immediatement apres la formation AFGSU2 puis une diminution partielle de la retention des connaissances a 1 ans qui s’ameliore a nouveau a 2 ans. La retention reste globalement satisfaisante probablement due a la poursuite de la formation des etudiants a la fois theorique (examen de cardiologie avant T4) et pratique (stages). La formation relative a l’arret cardiaque semble satisfaisante alors que celle sur l’obstruction des voies aeriennes pourrait etre amelioree lors du rappel a 2 ans.

After traumatic brain injury (TBI), lesions are anatomically heterogeneous, but the spatial heterogeneity of the post-traumatic brain's vulnerability to hypoxia-hypotension (HH) has been poorly studied. Our objective was to compare the effect of HH after TBI on brain energy metabolism into two regions: the frontal lobe and the thalamus. Twenty-eight Sprague-Dawley rats were randomized into four groups: sham, TBI (brain trauma alone, impact acceleration, 450-g weight drop from 1.8 m), HH (blood depletion to mean arterial pressure 40 mm Hg, FiO(2) 10%, 15 min), and TBI-HH (TBI followed by HH, 45-min delay). Cerebral perfusion pressure (CPP) was continuously measured. Brain microdialysis and brain tissue oxygen partial pressure (PtiO(2)) probes were both inserted stereotaxically into the right thalamus and frontal lobe. Except during the HH period, CPP was always above 60 mm Hg. During the hour following the HH period, significant increases in cerebral lactate-pyruvate ratio, glycerol, and glutamate were observed, and were always higher in the frontal lobe than in the thalamus (p0.001). In the TBI-HH group and in the frontal lobe, increases in glutamate and glycerol were significantly higher than in the HH group (p0.001). During the 30 min following the HH phase (reperfusion), an increase in PtiO(2) was observed. In the TBI-HH group, this increase was significantly lower in the frontal lobe than in the thalamus. These findings demonstrate that in the early post-traumatic period, the metabolic cerebral response to HH is higher in the frontal lobe than in the thalamus, and is worsened by TBI, suggesting a higher vulnerability for the frontal lobes.

Urgent tracheal intubations are common in intensive care units (ICU), and succinylcholine is one of the first-line neuromuscular blocking drugs used in these situations. Critically ill patients could be at high risk of hyperkalemia after receiving succinylcholine because one or more etiologic factors of nicotinic receptor upregulation can be present, but there are few data on its real risk. Our objectives in this study were to determine the factors associated with arterial potassium increase (ΔK) and to assess the occurrence of acute hyperkalemia ≥6.5 mmol/L after succinylcholine injection for intubation in the ICU.In a prospective, observational study, all critically ill patients intubated with succinylcholine in an ICU were screened. Only intubations with arterial blood gases and potassium measurements before and after (K(after)) a succinylcholine injection were studied.During 18 months, 131 critically ill patients were intubated after receiving succinylcholine with arterial potassium before and after intubation (K(after)) for a total of 153 intubations. After multivariate analysis, the only factor associated with ΔK was the length of ICU stay before intubation (ρ = 0.561, P0.001). The factors associated with K(after) ≥6.5 mmol/L (n = 11) were the length of ICU stay (P0.001) and the presence of acute cerebral pathology (P = 0.047). The threshold of 16 days was found highly predictive of acute hyperkalemia ≥6.5 with 37% (95% confidence interval: 19%-58%) of K(after) ≥6.5 after the 16th day compared with only 1% (95% confidence interval: 0%-4%) of K(after) ≥6.5 when succinylcholine was injected during the first 16 days.This study shows that the risk of ΔK after succinylcholine injection is strongly associated with the length of ICU stay. The risk of acute hyperkalemia ≥6.5 mmol/L is highly significant after 16 days.

BACKGROUND: The aim of this study was to reevaluate the efficacy of tramadol for postoperative analgesia and to determine its ED 80 (the clinical dose for which 80% of the patients had their pain adequately relieved) using the Continual Reassessment Method. Because the preliminary results of the first 24 patients were contradictory to the literature, we performed a second trial to verify and validate our data. METHODS: The study was double-blind and prospective. Participants were allocated to a dose of tramadol by 3-patient cohorts, in order of inclusion. The dose of tramadol received in each cohort was determined by the reaction of all previous patients. Five doses were chosen before beginning, with a probability of a positive reaction associated with each: 60 (0.4), 100 (0.55), 140 (0.7), 190 (0.8), and 260 mg (0.9). Tramadol was considered effective if the numeric pain scale was ≥3/10 at T30. RESULTS: The effective dose in 80% of patients was 260 mg for both trials. The probability of success of the 260 mg dose was 0.699 (95% credibility interval, 0.471-0.874) and 0.657 (95% credibility interval, 0.437-0.853) for trial 1 and trial 2, respectively. CONCLUSION: Tramadol used as a sole drug cannot be considered the drug of choice after moderately painful surgery. The doses needed to relieve pain in 80% of patients are much larger than the usual dose of 100 mg. The Continual Reassessment Method allowed us to determine the ED 80 of tramadol with a limited number of patients.

Introduction Compte tenu du nombre important d’internes DESAR, chaque interne ne peut passer qu’une seule fois de maniere active sur un scenario (acteur) puis assiste en tant que spectateur aux autres scenarios lors d’une journee de formation par simulation haute fidelite. Notre objectif etait d’evaluer l’impact du role (acteur ou spectateur) sur l’apprentissage des connaissances medicales des internes. Materiel et methodes Une journee de simulation haute fidelite avec 4 scenarios differents a ete organisee pour les internes DESAR d’Ile-de-France (5e semestre a 7e semestre). Pour chaque scenario, il y avait 3 internes acteurs et les autres etaient spectateurs dans une salle adjacente grâce a une retransmission audio-video en direct. Le debriefing apres chaque scenario etait commun pour l’ensemble des apprenants. Au debut (pretest) puis en fin de journee de simulation (posttest), un test de connaissances medicales a ete rempli par les internes (16 questions soit 4 questions par scenario). Les resultats correspondant au scenario ou ils etaient acteurs « test acteur » (note sur 4) ont ete compares a ceux ou ils etaient spectateurs « test spectateur » (note sur 4). Les resultats on ete exprimes en mediane [espace interquartile] et analyses statistiquement avec un test de Wilcoxon (p Resultats Parmi les 62 internes (70 % en 6e semestre) inclus sur 5 jours de simulation, 3 n’ont pas ete inclus du fait de leur retard. Au total, 59 « tests acteurs » ont ete compares a 189 « tests spectateurs » ( Fig. 1 ). Avant la formation par simulation, il n’existait pas de difference significative entre les resultats du « pretest acteur » et du « pretest spectateur (2 [0–3] vs 2 [1–3], p = 0,50, respectivement) ( Fig. 1 ). Apres la journee de simulation, il n’existait pas de difference significative entre les resultats du « posttest acteur » et du « posttest spectateur » (3 [2–3] vs 3 [2–3], p = 0,48, respectivement) ( Fig. 1 ). En revanche, une amelioration significative des resultats entre avant et apres la simulation pour les deux sous groupes (acteurs et spectateurs) a ete observee (p Fig. 1 ). Discussion Notre etude preliminaire a montre une amelioration similaire des connaissances medicales que l’apprenant soit acteur ou spectateur. Une evaluation de la retention de ces connaissances est prevue a 6 mois par le meme test. Du moins en ce qui concerne les connaissances techniques, le role de spectateur dans une seance de simulation haute fidelite semble aussi benefique sur l’apprentissage des connaissances medicales que celui d’acteur.