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Wiesmann T, Steinfeldt T, Schubert AK. [Peripheral Regional Anesthesia Techniques - Standards in Flux?!]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:180-189. [PMID: 38513642 DOI: 10.1055/a-2065-7696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
This review article provides an overview of current developments in peripheral regional anaesthesia (RA). The authors present a subjective compilation based on discussions at professional events and inquiries to the Working Group on Regional Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI). The article addresses several relevant topics, including the handling of antithrombotic medication in peripheral blockades with reference to European guidelines, the debate on the discharge timing after plexus anaesthesia, and the consideration of rebound pain as an independent pain entity following RA.Furthermore, the contentious discussion regarding the administration of peripheral nerve blockades under general anaesthesia is illuminated. The authors express no fundamental concerns in this regard but emphasize the importance of preoperative evaluation and individual patient needs. The question of mixing local anaesthetics is also addressed, with the authors critically questioning this tradition and recommending the use of individual, long-acting substances.Another focal point is the application of peripheral nerve blockades in emergency medicine, both in preclinical and emergency room settings. The authors highlight the necessity for high-quality studies and discuss the complex organizational issues associated with the preclinical application of RA techniques.
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Boselli E, Hopkins P, Lamperti M, Estèbe JP, Fuzier R, Biasucci DG, Disma N, Pittiruti M, Traškaitė V, Macas A, Breschan C, Vailati D, Subert M. European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia. Eur J Anaesthesiol 2021; 38:219-250. [PMID: 33186303 DOI: 10.1097/eja.0000000000001383] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.
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Affiliation(s)
- Emmanuel Boselli
- From the Department of Anaesthesiology, Pierre Oudot Hospital, Bourgoin-Jallieu, University Claude Bernard Lyon I, University of Lyon, France (EB), Leeds Institute of Medical Research at St James's School of Medicine, University of Leeds, Leeds, UK (PH), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Anaesthesiology, Intensive Care and Pain Medicine, University hospital of Rennes, Rennes, France (JPE), Department of Anaesthesiology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France (RF), Intensive Care Unit, Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (DGB), Department of Anaesthesiology, IRCCS Istituto Giannina Gaslini, Genova, Italy (ND), Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (MP), Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania (VT, AM), Department of Anaesthesia, Klinikum Klagenfurt, Austria (CB), Anaesthesia and Intensive Care Unit, Melegnano Hospital (DV) and Department of Surgical and Intensive Care Unit, Sesto San Giovanni Civic Hospital, Milan, Italy (MS)
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Schittek GA, Schwantzer G, Simonis H, Heschl S, Sandner-Kiesling A, Bornemann-Cimenti H. Randomised controlled pilot trial of concepts for analgesia and sedation during placement of peripheral regional anaesthesia before operations. Eur J Anaesthesiol 2021; 38:183-184. [PMID: 33394784 DOI: 10.1097/eja.0000000000001296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gregor A Schittek
- From the Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Graz (GAS, HS, HB-C), Institute for Medical Informatics, Statistics and Documentation (GS), Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine (SH) and Division of the Special Anaesthesiology, Pain and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria (AS-K)
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Luedi MM, Upadek V, Vogt AP, Steinfeldt T, Eichenberger U, Sauter AR. A Swiss nationwide survey shows that dual guidance is the preferred approach for peripheral nerve blocks. Sci Rep 2019; 9:9178. [PMID: 31235760 PMCID: PMC6591381 DOI: 10.1038/s41598-019-45700-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 06/12/2019] [Indexed: 11/09/2022] Open
Abstract
Ultrasound has significantly increased safety and effectiveness in regional anesthesia. However, little is known about its clinical use. We studied clinical approaches currently used by anesthesiologists, conducted a nationwide survey, and analyzed data collected in ordered logistic regression models. All active members of the Swiss Society for Anaesthesiology and Resuscitation (SSAR/SGAR) were asked to participate. Reported practice in nerve localization, safety, and techniques used for peripheral nerve blocks (PNB) were main outcome measures. Experience ranged from 3 to >30 years. The mean number of block techniques mastered was 11.5 ± 5.9. Standard monitoring was regularly used, whereas sterile coats were less frequently used by anesthesiologists who self-estimated a higher level of expertise in PNB (ordered logit coefficient −0.05, 95% CI −0.07 to −0.02, P < 0.001; pseudo r2 = 0.019; probability > Chi2 = 0.02). The more self-estimated expertise anesthesiologists had, the less likely they were to use nerve stimulation in combination with ultrasound (dual guidance) (ordered logit coefficient −0.31; 95% CI −0.85 to −0.03: P = 0.03; pseudo r2 = 0.007; probability > Chi2 = 0.05). The high share of reported standard monitoring meets the recommendations of the Helsinki Patient Safety Declaration. Dual guidance appears to be the preferred approach for safely localizing nerves for PNB in Switzerland.
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Affiliation(s)
- Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vanessa Upadek
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas P Vogt
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thorsten Steinfeldt
- Department of Anaesthesiology, Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Germany
| | - Urs Eichenberger
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Axel R Sauter
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Division of Emergencies and Critical Care, Department of Anaesthesiology and Department of Research and Development, Oslo University Hospital, Oslo, Norway.
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Büttner B, Schwarz A, Mewes C, Kristof K, Hinz J, Quintel M, Mansur A, Bergmann I. Subparaneural Injection in Popliteal Sciatic Nerve Blocks Evaluated by MRI. Open Med (Wars) 2019; 14:346-353. [PMID: 31157299 PMCID: PMC6534099 DOI: 10.1515/med-2019-0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 03/25/2019] [Indexed: 11/30/2022] Open
Abstract
Intraneural injection of a local anesthetic can damage the nerve, yet it occurs frequently during distal sciatic block with no neurological sequelae. This has led to a controversy about the optimal needle tip placement that results from the particular anatomy of the sciatic nerve with its paraneural sheath. The study population included patients undergoing lower extremity surgery under popliteal sciatic nerve block. Ultrasound-guidance was used to position the needle tip subparaneurally and to monitor the injection of the local anesthetic. Sonography and magnetic resonance imaging were used to assess the extent of the subparaneural injection. Twenty-two patients participated. The median sciatic cross-sectional area increased from 57.8 mm2 pre-block to 110.8 mm2 immediately post-block. An intraneural injection according to the current definition was seen in 21 patients. Two patients had sonographic evidence of an intrafascicular injection, which was confirmed by MRI in one patient (the other patient refused further examinations). No patient reported any neurological symptoms. A subparaneural injection in the popliteal segment of the distal sciatic nerve is actually rarely intraneural, i.e. intrafascicular. This may explain the discrepancy between the conventional sonographic evidence of an intraneural injection and the lack of neurological sequelae.
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Affiliation(s)
- Benedikt Büttner
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Alexander Schwarz
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen Germany
| | - Caspar Mewes
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Katalin Kristof
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - José Hinz
- Department of Anesthesiology, Emergency and Intensive Care Medicine, Klinikum Region Hannover, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Ashham Mansur
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Ingo Bergmann
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
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Schwemmer U. [54-year-old male after bicycle accident with elbow luxation fracture : Preparation for the medical specialist examination: Part 14]. Anaesthesist 2019; 68:140-145. [PMID: 30989303 DOI: 10.1007/s00101-019-0551-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Kliniken des Landkreises Neumarkt/Opf., Nürnberger Str. 12, 91318, Neumarkt in der Oberpfalz, Deutschland.
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Micro Air Bubble in Psoas Muscle: Is It Psoas Muscle Abscess or Nerve Block? Anesthesiology 2019; 130:354. [PMID: 30688790 DOI: 10.1097/aln.0000000000002539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bomberg H, Wetjen L, Wagenpfeil S, Schöpe J, Kessler P, Wulf H, Wiesmann T, Standl T, Gottschalk A, Döffert J, Hering W, Birnbaum J, Kutter B, Winckelmann J, Liebl-Biereige S, Meissner W, Vicent O, Koch T, Bürkle H, Sessler DI, Volk T. Risks and Benefits of Ultrasound, Nerve Stimulation, and Their Combination for Guiding Peripheral Nerve Blocks. Anesth Analg 2018; 127:1035-1043. [DOI: 10.1213/ane.0000000000003480] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ultrasound standard of peripheral nerve block for shoulder arthroscopy: a single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. Br J Anaesth 2016; 116:574-5. [DOI: 10.1093/bja/aev459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Vassiliou T, Müller HH, Limberg S, De Andres J, Steinfeldt T, Wiesmann T. Risk evaluation for needle-nerve contact related to electrical nerve stimulation in a porcine model. Acta Anaesthesiol Scand 2016; 60:400-6. [PMID: 26666693 DOI: 10.1111/aas.12664] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/06/2015] [Accepted: 10/19/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND For performing peripheral nerve blocks, the risk for needle-nerve contact (NNC) as an adverse event for low and high current thresholds has not yet been clearly defined when nerve stimulator guided techniques were applied. This experimental study aimed to investigate the risk of NNCs when applying stimulation currents between 0.1 and 2 mA (in increments of 0.1 mA). METHODS Brachial plexus nerves were exposed surgically in five anesthetized pigs. An insulated needle connected to a nerve stimulator was placed at 10 mm distance to the targeted nerves. Current intensity was adjusted according to randomization (0.1-2.0 mA, increments of 0.1 mA). The needle tip was advanced toward the nerve until a motor response was elicited. The frequencies of NNCs for each of the adjusted current intensities were noted. Risks of NNCs were calculated according to the analysis of 95% confidence intervals (95% CI). RESULTS We executed 2000 needle placements with stimulation currents ranging from 0.1 to 2.0 mA. The risks for NNC at low current intensities were 0.85 (95% CI, 0.77-0.91) for 0.3 mA and 0.5 (95% CI, 0.4-0.6) for 0.5 mA, respectively. For high current intensities, risks of 0.13 (95% CI, 0.07-0.21) for 0.9 mA and 0.01 (95% CI, 0-0.05) for 1.1 mA were calculated. CONCLUSIONS In this experimental animal study, a relevant reduction in the risk of NNCs could be observed when high current intensities (0.9-1.1 mA) were applied compared to low current intensities (0.3-0.5 mA).
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Affiliation(s)
- T Vassiliou
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
| | - H-H Müller
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany
| | - S Limberg
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
| | - J De Andres
- Department of Anaesthesiology and Critical Care, University General Hospital Valencia, Valencia, Spain
| | - T Steinfeldt
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
| | - T Wiesmann
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
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Lin JA, Chuang TY, Yao HY, Yang SF, Tai YT. Ultrasound standard of peripheral nerve block for shoulder arthroscopy: a single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. Br J Anaesth 2016; 115:932-4. [PMID: 26582855 DOI: 10.1093/bja/aev384] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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A comparison of motor stimulation threshold in ultrasound-guided interscalene brachial plexus block for arthroscopic shoulder surgery: a randomized trial. Can J Anaesth 2015; 63:461-7. [DOI: 10.1007/s12630-015-0553-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 10/10/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022] Open
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Histological confirmation of needle tip position during ultrasound-guided interscalene block: a randomized comparison between the intraplexus and the periplexus approach. Can J Anaesth 2015; 62:1295-302. [PMID: 26335906 DOI: 10.1007/s12630-015-0468-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 07/20/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Ultrasound-guided interscalene block can be performed using either periplexus or intraplexus needle placement. In this novel study, we histologically examined the needle tip position in relation to the neural tissues with the two techniques. Our objective was to investigate the variable risk of subepineurial needle tip placement resulting from the two ultrasound-guided techniques. METHODS In an embalmed cadaveric model, periplexus or intraplexus interscalene injections were performed with the side, order, and technique assigned randomly. Under real-time ultrasound guidance, the block needle was placed next to the hyperechoic layer of the plexus (periplexus) or between the hypoechoic nerve roots (intraplexus). Once positioned, 0.1 mL of black acrylic ink was injected. The brachial plexus tissues were then removed and histology sections were prepared and then coded in order to blind two reviewers to group allocation. The area of ink staining was used to determine needle tip location, and the groups were compared for the presence of subepineurial ink. RESULTS Twenty-six cadavers had each of the blocks performed on either brachial plexus (i.e., 52 injections). No subepineurial ink deposits were observed in the periplexus group (0%), but subepineurial ink deposition was observed in 3/26 (11.5%) intraplexus injections (odds ratio, 0; 95% confidence interval, 0 to 2.362; P = 0.235). Furthermore, in the intraplexus group, two (of the three) subepineurial ink deposits were observed under the perineurium. CONCLUSION Although our study was somewhat underpowered due to a lower than previously reported rate of subepineurial needle tip positioning, our results suggest that there may be an increased likelihood of subepineurial needle tip position with the intraplexus approach. The periplexus technique resulted in no subepineurial spread of ink, suggesting that this approach may be less likely to result in mechanical trauma to nerves from direct needle injury.
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Wiesmann T, Wallot P, Nentwig L, Beermann AV, Wulf H, Zoremba M, Al-Dahna T, Eschbach D, Steinfeldt T. Separation of stimulating catheters for continuous peripheral regional anesthesia during their removal - two case reports and a critical appraisal of the use of steel-coil containing stimulating catheters. Local Reg Anesth 2015; 8:15-9. [PMID: 26170716 PMCID: PMC4492648 DOI: 10.2147/lra.s82362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Stimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia. The incidence of reported complications is somewhat similar to that for non-stimulating catheters. However, as many stimulating catheters contain a coiled steel wire for optimal stimulation, they may cause specific complications. Clinical features In this report, we present two cases of complicated removals of stimulating catheters. During both removals, a part of the metal wire was left “decoiled” next to the supraclavicular and interscalene plexus, respectively. The strategies used to determine steel wire localization and a description of the successful removal of these steel wires are included in this report. Conclusion Catheter separation and problems with residual metal wire components of stimulating catheters seem to be a rare but specific problem during removal. Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer’s instructions, and take care during catheter removal. Manufacturers should focus on technical solutions to avoid rare but relevant complications such as catheter tip decoiling and separation of stimulating catheters during removal.
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Affiliation(s)
- Thomas Wiesmann
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Pascal Wallot
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Laura Nentwig
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Alisha-Viktoria Beermann
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Martin Zoremba
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Turfa Al-Dahna
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Daphne Eschbach
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Marburg, Marburg, Germany
| | - Thorsten Steinfeldt
- Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
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