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Vawda DO, King C, Toit LD, Dyer RA, Masuku NJ, Bishop DG. Agreement between three noninvasive temperature monitoring devices during spinal anaesthesia for caesarean delivery: a prospective observational study. J Clin Monit Comput 2024:10.1007/s10877-024-01154-1. [PMID: 38687415 DOI: 10.1007/s10877-024-01154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/14/2024] [Indexed: 05/02/2024]
Abstract
Hypothermia during obstetric spinal anaesthesia is a common and important problem, yet temperature monitoring is often not performed due to the lack of a suitable, cost-effective monitor. This study aimed to compare a noninvasive core temperature monitor with two readily available peripheral temperature monitors during obstetric spinal anaesthesia. We undertook a prospective observational study including elective and emergency caesarean deliveries, to determine the agreement between affordable reusable surface temperature monitors (Welch Allyn SureTemp® Plus oral thermometer and the Braun 3-in-1 No Touch infrared thermometer) and the Dräger T-core© (using dual-sensor heat flux technology), in detecting thermoregulatory changes during obstetric spinal anaesthesia. Predetermined clinically relevant limits of agreement (LOA) were set at ± 0.5 °C. We included 166 patients in our analysis. Hypothermia (heat flux temperature < 36 °C) occurred in 67% (95% CI 49 to 78%). There was poor agreement between devices. In the Bland-Altman analysis, LOA for the heat flux monitor vs. oral thermometer were 1.8 °C (CI 1.7 to 2.0 °C; bias 0.5 °C), for heat flux monitor vs. infrared thermometer LOA were 2.3 °C (CI 2.1 to 2.4 °C; bias 0.4 °C) and for infrared vs. oral thermometer, LOA were 2.0 °C (CI 1.9 to 2.2 °C; bias 0.1 °C). Error grid analysis highlighted a large amount of clinical disagreement between methods. While monitoring of core temperature during obstetric spinal anaesthesia is clinically important, agreement between monitors was below clinically acceptable limits. Future research with gold-standard temperature monitors and exploration of causes of sensor divergence is needed.
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Affiliation(s)
- D O Vawda
- Department of Anaesthesia, School of Clinical Medicine, College of Health Sciences, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, 3201, South Africa
| | - Christopher King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, MO, USA
| | - L du Toit
- Department of Anesthesiology, Washington University School of Medicine in St Louis, MO, USA
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - R A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - N J Masuku
- Department of Anaesthesia, School of Clinical Medicine, College of Health Sciences, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, 3201, South Africa
| | - D G Bishop
- Department of Anaesthesia, School of Clinical Medicine, College of Health Sciences, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, 3201, South Africa.
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Nascimento ASD, Lemos CDS, Biachi FB, Lyra FRSD, Gnatta JR, Poveda VDB. Evaluation of different body temperature measurement methods for patients in the intraoperative period. Rev Lat Am Enfermagem 2024; 32:e4143. [PMID: 38655937 DOI: 10.1590/1518-8345.6873.4143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/01/2023] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES this study aimed at estimating and comparing the reliability of temperature measurements obtained using a peripheral infrared temporal thermometer, a central cutaneous thermometer ("Zero-Heat-Flux Cutaneous thermometer") and an esophageal or nasopharyngeal thermometer among elective surgical patients in the intraoperative period. METHOD a longitudinal study with repeated measures carried out by convenience sampling of 99 patients, aged at least 18 years old, undergoing elective abdominal cancer surgeries, with anesthesia lasting at least one hour, with each patient having their temperature measured by all three methods. RESULTS the intraclass correlation coefficient showed a low correlation between the measurements using the peripheral temporal thermometer and the central cutaneous (0.0324) and esophageal/nasopharyngeal (-0.138) thermometers. There was a high correlation (0.744) between the central thermometers evaluated. CONCLUSION the data from the current study do not recommend using infrared temporal thermometers as a strategy for measuring the body temperature of patients undergoing anesthetic-surgical procedures. Central cutaneous thermometers and esophageal/nasopharyngeal thermometers are equivalent for detecting intraoperative hypothermia.
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Affiliation(s)
- Ariane Souza do Nascimento
- Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP, Brazil
- Scholarship holder at the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
| | - Cassiane de Santana Lemos
- Universidade Estadual de São Paulo Júlio de Mesquita Filho, Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
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Pedersen C, Munch P, Kjaergaard J, Grønlykke L, Bräuer A. Accuracy of a zero-heat-flux thermometer in cardiac surgery, a prospective, multicentre, method comparison study. Sci Rep 2024; 14:3169. [PMID: 38326589 PMCID: PMC10850058 DOI: 10.1038/s41598-024-53647-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/03/2024] [Indexed: 02/09/2024] Open
Abstract
Accurate measurement of core temperature is of utmost importance during on-pump cardiac surgery, for detection of hypothermia before cardiopulmonary bypass (CPB), guidance of temperature management on CPB, active rewarming on CPB and guidance of warming therapy after CPB. Most temperature measurement methods are known to become inaccurate during rapid changes in core temperature and suffer from delayed detection of temperature changes. Zero-heat-flux temperature (ZHF) measurement from the lateral forehead may be an alternative, non-invasive method quantifying the core temperature. A prospective, observational, multicentre study was conducted in one hundred patients scheduled for on-pump coronary artery bypass grafting. Core temperatures were measured every minute by two zero-heat-flux thermometer (SpotOn™) and a bladder thermometer and a pulmonary artery catheter (PAC) in the period after induction of anesthesia until CPB. Accuracy and precision of both methods were compared against core temperature measured in the pulmonary artery using the method of Bland and Altman. A high accuracy (around 0.1 °C) and a very good precision (Limits of agreement (LoA) - 0.6; 0.4 °C) were found between zero-heat-flux thermometer and core temperature measured by PAC. Among the two ZHF thermometers the bias was negligible (- 0.003 °C) with narrow LoA of - 0.42 °C and 0.41 °C. In contrast, bias between bladder temperature and PAC temperature was large (0.51 °C) with corresponding LoA of - 0.06 °C and 1.1 °C. ZHF thermometers are in contrast to bladder temperature a reliable core temperature monitor in cardiac surgery during the period after induction of anestesia until CPB. The zero-heat-flux method can provide clinicians reliably with continuous and non-invasive measurements of core temperature in normothermic and mild hypothermic temperature ranges and therefore can be helpful to guide temperature management.
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Affiliation(s)
- Carsten Pedersen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, 2100, Copenhagen, Denmark.
| | - Peter Munch
- Department of Cardiothoracic Anesthesiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Anselm Bräuer
- Department of Anesthesiology, University Hospital Göttingen, Göttingen, Germany
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Brodshaug I, Reine E, Raeder J. Maternal hypothermia during elective caesarean delivery: A prospective observational study. Acta Anaesthesiol Scand 2024; 68:247-253. [PMID: 37876139 DOI: 10.1111/aas.14340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Patients undergoing caesarean delivery are at risk of developing unintended perioperative hypothermia, defined as a core temperature <36.0°C. Most previous studies of core temperature in caesarean delivery patients have not been conducted with accurate measurements for the complete perioperative period. Therefore, we conducted a prospective observational study to identify the incidence and duration of pre- and post-operative maternal hypothermia with a high accuracy continuous temperature monitoring system. METHODS Women ≥18 years old presenting for elective caesarean delivery under spinal anaesthesia were invited to participate in the study. The primary outcomes were the incidence and duration of perioperative maternal hypothermia (<36.0°C). Maternal core temperatures were measured with the non-invasive zero-heat-flux thermometer (Bair Hugger Temperature Monitoring System, 3M) throughout the perioperative course. RESULTS A total of 40 participants were recruited to the study. The incidence of perioperative hypothermia was 32.5%, with a duration of 77 ± 40 min (mean ± standard deviation). The hypothermic patients had similar core temperature as the normothermic patients at baseline preoperatively, but significantly lower temperature at operating room arrival and during the remaining study period. Forty percent of all patients reported thermal discomfort and felt cold on admission to post anaesthesia care unit, whereas 33% had shivering. Neither thermal discomfort nor shivering were associated with hypothermia. CONCLUSION In the present study almost a third of the women undergoing elective caesarean delivery developed perioperative hypothermia with a core temperature <36.0°C. The mean duration of maternal hypothermia was 77 min, lasting well into the postoperative period for many patients. These data should remind healthcare professionals of the importance of measuring core temperature in all phases of the perioperative setting and to consider optimal warming measures to avoid and treat hypothermia.
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Affiliation(s)
- Irene Brodshaug
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Elizabeth Reine
- Department of Nurse Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Johan Raeder
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Liang H, Wang JY, Liang Y, Shao XF, Ding YL, Jia HQ. Agreement of zero-heat-flux thermometry with the oesophageal and tympanic core temperature measurement in patient receiving major surgery. J Clin Monit Comput 2024; 38:197-203. [PMID: 37792140 PMCID: PMC10879315 DOI: 10.1007/s10877-023-01078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
To identify and prevent perioperative hypothermia, most surgical patients require a non-invasive, accurate, convenient, and continuous core temperature method, especially for patients undergoing major surgery. This study validated the precision and accuracy of a cutaneous zero-heat-flux thermometer and its performance in detecting intraoperative hypothermia. Adults undergoing major non-cardiac surgeries with general anaesthesia were enrolled in the study. Core temperatures were measured with a zero-heat-flux thermometer, infrared tympanic membrane thermometer, and oesophagal monitoring at 15-minute intervals. Taking the average value of temperature measured in the tympanic membrane and oesophagus as a reference, we assessed the agreement using the Bland-Altman analysis and linear regression methods. Sensitivity, specificity, and predictive values of detecting hypothermia were estimated. 103 patients and one thousand sixty-eight sets of paired temperatures were analyzed. The mean difference between zero-heat-flux and the referenced measurements was -0.03 ± 0.25 °C, with 95% limits of agreement (-0.52 °C, 0.47 °C) was narrow, with 94.5% of the differences within 0.5 °C. Lin's concordance correlation coefficient was 0.90 (95%CI 0.89-0.92). The zero-heat-flux thermometry detected hypothermia with a sensitivity of 82% and a specificity of 90%. The zero-heat-flux thermometer is in good agreement with the reference core temperature based on tympanic and oesophagal temperature monitoring in patients undergoing major surgeries, and appears high performance in detecting hypothermia.
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Affiliation(s)
- Hao Liang
- Department of Anesthesiology, The Fourth Hospital Of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jing-Yan Wang
- Department of ENT, Affiliated Hospital Of Hebei University, Baoding, Hebei, China
| | - Yan Liang
- Department of Obstetrics, The NO.1 Central Hospital Of Baoding City, Baoding, Hebei, China
| | - Xin-Feng Shao
- Department of Anesthesiology, The NO.1 Central Hospital Of Baoding City, Baoding, Hebei, China
| | - Yan-Ling Ding
- Department of Anesthesiology, The NO.1 Central Hospital Of Baoding City, Baoding, Hebei, China
| | - Hui-Qun Jia
- Department of Anesthesiology, The Fourth Hospital Of Hebei Medical University, Shijiazhuang, Hebei, China.
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Engelbart G, Brandt S, Scheeren T, Tzabazis A, Kimberger O, Kellner P. Accuracy of non-invasive sensors measuring core body temperature in cardiac surgery ICU patients - results from a monocentric prospective observational study. J Clin Monit Comput 2023; 37:1619-1626. [PMID: 37436599 PMCID: PMC10651547 DOI: 10.1007/s10877-023-01049-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Temperature monitoring in the perioperative setting often represents a compromise between accuracy, invasiveness of probe placement, and patient comfort. Transcutaneous sensors using the Zero-Heat-Flux (ZHF) and Double-Sensor (DS) technology have been developed and evaluated in a variety of clinical settings. The present study is the first to compare the performance of both sensors simultaneously with temperature measured by a Swan-Ganz catheter (PAC) in patients admitted to the intensive care unit (ICU) after cardiac surgery. METHODS In this monocentric prospective observational study patients were postoperatively transferred to the ICU and both sensors were placed on the patients' foreheads. Core body temperature measured by intraoperatively placed PAC served as gold standard. Measurements were recorded at 5-minute intervals and up to 40 data sets per patient were recorded. Bland and Altman's method for repeated measurements was used to analyse agreement. Subgroup analyses for gender, body-mass-index, core temperature, airway status and different time intervals were performed. Lin's concordance correlation coefficient (LCCC) was calculated, as well as sensitivity and specificity for detecting hyperthermia (≥ 38 °C) and hypothermia (< 36 °C). RESULTS Over a period of six month, we collected 1600 sets of DS, ZHF, and PAC measurements, from a total of 40 patients. Bland-Altman analysis revealed a mean bias of -0.82 ± 1.27 °C (average ± 95% Limits-of-Agreement (LoA)) and - 0.54 ± 1.14 °C for DS and ZHF, respectively. The LCCC was 0.5 (DS) and 0.63 (ZHF). Mean bias was significantly higher in hyperthermic and hypothermic patients. Sensitivity and specificity were 0.12 / 0.99 (DS) and 0.35 / 1.0 (ZHF) for hyperthermia and 0.95 / 0.72 (DS) and 1.0 / 0.85 (ZHF) for hypothermia. CONCLUSION Core temperature was generally underestimated by the non-invasive approaches. In our study, ZHF outperformed DS. In terms of agreement, results for both sensors were outside the range that is considered clinically acceptable. Nevertheless, both sensors might be adequate to detect postoperative hypothermia reliably when more invasive methods are not available or appropriate. TRIAL REGISTRATION German Register of Clinical Trials (DRKS-ID: DRKS00027003), retrospectively registered 10/28/2021.
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Affiliation(s)
- Georg Engelbart
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Sebastian Brandt
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, D-23538, Lübeck, Germany
- Department of Anesthesiology and Intensive Care Medicine, Städtisches Klinikum Dessau, Brandenburg Medical School Theodore Fontane, Dessau, Germany
| | - Tobias Scheeren
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Alexander Tzabazis
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Oliver Kimberger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Patrick Kellner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, D-23538, Lübeck, Germany.
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Park C, Kim T, Oh S, Bang YS. Prospective comparative analysis of zero-heat-flux thermometer (SpotOn®) compared with tympanic thermometer and bladder thermometer in extremely aged patients undergoing lower extremity orthopedic surgery. Medicine (Baltimore) 2023; 102:e35593. [PMID: 37861486 PMCID: PMC10589526 DOI: 10.1097/md.0000000000035593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/20/2023] [Indexed: 10/21/2023] Open
Abstract
Thermoregulation is important for maintaining homeostasis in the body. It can be easily broken under anesthesia. An appropriate method for measuring core body temperature is needed, especially for elderly patients, because the efficiency of thermoregulation gradually decreases with age. Zero-heat-flux (ZHF) thermometry (SpotOn) is an alternative, noninvasive method for continuous temperature monitoring at the skin surface. The aim of this study was to examine the accuracy and feasibility of using the SpotOn sensor in lower extremity orthopedic surgery in elderly patients aged over 80 years by comparing a SpotOn sensor with 2 other reliable minimally invasive methods: a tympanic membrane thermometer and a bladder thermometer. This study enrolled 45 patients aged over 80 years who were scheduled to undergo lower extremity surgery. Body temperature was measured using a SpotOn sensor, a tympanic membrane thermometer and a bladder thermometer. Agreements between the SpotOn sensor and the other 2 methods were assessed using Bland and Altman plots for repeated measures adjusted for unequal numbers of measurements per patient. Compared with bladder temperature, bias and limits of agreement for SpotOn temperature were 0.07°C ± 0.58°C. Compared with tympanic membrane temperature, bias and limits of agreement for SpotOn temperature were -0.28°C ± 0.61°C. The 3M SpotOn sensor using the ZHF method for patients aged over 80 years undergoing lower extremity surgery showed feasible measurement value and sensitivity.
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Affiliation(s)
- Chunghyun Park
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Taeyeon Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Soojeong Oh
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Yun-Sic Bang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
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Guo L, Shi J, Liu D, Wang Y, Tong H, Feng Y, Yu P, Lv Y, Li E, Wang C. Measurement of exhaled breath temperature in patients under general anesthesia: A feasibility study. Biomed Rep 2023; 18:18. [PMID: 36776785 PMCID: PMC9912139 DOI: 10.3892/br.2023.1600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/09/2023] [Indexed: 01/21/2023] Open
Abstract
The aim of the present study was to investigate the respiratory parameters that influence the exhaled breath temperature (EBT) and the feasibility of using the latter to monitor the core temperature under general endotracheal anesthesia. A total of 20 patients undergoing abdominal surgery were included in the present study. At the first stage of the experiment, the respiratory rate was adjusted, while the other respiratory parameters [tidal volume, inspiratory and expiratory time ratio (TI:TE), and positive end expiratory pressure (PEEP)] were maintained at a constant level. At the second stage, the tidal volume was adjusted, while the other respiratory parameters were maintained at a constant level. At the third stage, the TI:TE was adjusted, while the other parameters were maintained at a constant level. At the fourth stage, PEEP was adjusted, while the other parameters were maintained at a constant level. In each experiment, the EBT, the maximum temperature of exhaled air in each min, the inhaled air temperature and the nasopharyngeal temperature (T nose) were recorded every min. During the first stage of the experiment, no significant difference was noted in the EBT at different levels of respiratory rate. During the second, third and fourth stage, no significant difference was noted in the EBT at different tidal volumes, TI:TE and PEEP, respectively. The EBT was significantly correlated with the T nose. Overall, the present study demonstrated that the EBT of patients undergoing abdominal surgery under general endotracheal anesthesia was not affected by the examined respiratory parameters and that it could be considered a feasible method of monitoring core temperature.
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Affiliation(s)
- Libo Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Jinghui Shi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Desheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yue Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Hongshuang Tong
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yue Feng
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Pulin Yu
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yanji Lv
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Enyou Li
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Changsong Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China,Correspondence to: Professor Changsong Wang, Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang, Harbin, Heilongjiang 150001, P.R. China
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