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Warwick E, Yoon S, Ahmad I. Awake Tracheal Intubation: An Update. Int Anesthesiol Clin 2024; 62:59-71. [PMID: 39233572 DOI: 10.1097/aia.0000000000000458] [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: 09/06/2024]
Abstract
Awake tracheal intubation (ATI) remains the "gold standard" technique in securing a definitive airway in conscious, self-ventilating patients with predicted or known difficult airways and the procedure is associated with a low failure rate. Since its inception a variety of techniques to achieve ATI have emerged and there have been accompanying advancements in pharmaceuticals and technology to support the procedure. In recent years there has been a growing focus on the planning, training and human factors involved in performing the procedure. The practice of ATI, does however, remain low around 1% to 2% of all intubations despite an increase in those with head and neck pathology. ATI, therefore, presents a skill that is key for the safety of patients but may not be practised with regularity by many anesthetists. In this article we therefore aim to highlight relevant guidance, recent literature and provide an update on the practical methods fundamental for successful ATI. We also discuss the crucial aspects of a safe airway culture and how this can help to embed training and maintenance of skills.
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Ravindran B. Innovations in the Management of the Difficult Airway: A Narrative Review. Cureus 2023; 15:e35117. [PMID: 36945260 PMCID: PMC10024956 DOI: 10.7759/cureus.35117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/19/2023] Open
Abstract
The difficult airway (DA) remains a perpetual challenge and its implications have led to multiple advances, technological and otherwise in this area. This article investigates the latest developments in the definition, prediction tools and diagnostics like airway and neck Ultrasonography (USG), Magnetic Resonance Imaging (MRI) and Computed tomography (CT) scans, preoperative Virtual endoscopy (VE) and 3D printing. Innovations in airway devices and adjuncts are analysed. Difficult airway society (DAS) guidelines, American Society of Anaesthesiologists (ASA) Practice Guidelines and Vortex approach for the management of DA are explored. Other breakthroughs include novel oxygen supplementation techniques throughout airway management and tools like Anaesthesia Information Management Systems (AIMS) and Clinical Decision Support (CDS) systems. The delivery of DA training and patient counselling has also undergone vast changes with emerging technology like Virtual Reality (VR), mobile applications and toolkits. The enormous, ever-evolving and endless possibilities in this area have only helped improve clinical standards and enhance patient safety.
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Affiliation(s)
- Binu Ravindran
- Anaesthesiology, Dartford and Gravesham NHS Trust, Dartford, GBR
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O'Carroll J, Endlich Y, Ahmad I. Advanced airway assessment techniques. BJA Educ 2021; 21:336-342. [PMID: 34447580 PMCID: PMC8377241 DOI: 10.1016/j.bjae.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- J. O'Carroll
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Y. Endlich
- Royal Adelaide Hospital and Women's & Children Hospital, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - I. Ahmad
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
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4
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Batuwitage BT, Hanlon R, Charters P. Imaging in head and neck cancers. BJA Educ 2021; 21:2-9. [PMID: 33456968 DOI: 10.1016/j.bjae.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- B T Batuwitage
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - R Hanlon
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - P Charters
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Guarnizo A, Glikstein R, Tsehmaister-Abitbul V, Busca I, El-Sayed S, Odell M. Comparison of diagnostic accuracy of computed tomography virtual endoscopy and flexible fibre-optic laryngoscopy in the evaluation of neck anatomic structures and neoplasms. Neuroradiol J 2020; 34:8-12. [PMID: 32940129 DOI: 10.1177/1971400920957232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Computed tomography virtual endoscopy (CT-VE) is a non-invasive technique which allows visualisation of intraluminal surfaces by tridimensional reconstruction of air/soft tissues. The aim of this study was to compare the diagnostic accuracy of CT-VE and flexible fibre-optic laryngoscopy (FFL) in identifying normal neck anatomic structures and pharyngeal and laryngeal lesions. METHODS Forty-two patients with a history of neck cancer were assessed by two ENT surgeons using FFL and by one neuroradiologist using CT-VE in order to evaluate the visualisation of the epiglottis, vallecula, glossoepiglottic folds, pyriform sinuses, vocal cords and mass pathology. The visualisation of the structures in both modalities was assessed according to the following score: 0 = not visualised, 1 = partial visualisation, 2 = complete and clear visualisation. A weighted kappa coefficient was used to evaluate the inter-observer agreement. McNemar's test was performed to compare the two diagnostic tests. RESULTS The inter-observer agreement between FFL and CT-VE was fair in the assessment of the vocal cords (k = 0.341); moderate in the assessment of the glossoepiglottic folds (k = 0.418), epiglottis (k = 0.513) and pyriform sinuses (k = 0.477); and substantial in the assessment of the vallecula (k = 0.618) and the tumour (0.740). McNemar's test showed no significant difference between the two tests (p<0.05). CONCLUSION CT-VE is a non-invasive technique with a diagnostic accuracy comparable to FFL in terms of visualisation of anatomical structures and pharyngeal and laryngeal lesions.
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Affiliation(s)
- Angela Guarnizo
- Department of Radiology, Division of Neuroradiology, University of Ottawa, Canada
| | - Rafael Glikstein
- Department of Radiology, Division of Neuroradiology, University of Ottawa, Canada
| | | | - Ionut Busca
- Department of Radiation Oncology, Cancer Centre, University of Ottawa, Canada
| | - Samy El-Sayed
- Department of Radiation Oncology, Cancer Centre, University of Ottawa, Canada
| | - Michael Odell
- Department of Otolaryngology - Head and Neck Surgery, University of Ottawa, Canada
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Ormandy D, Kolb B, Jayaram S, Burley O, Kyzas P, Vallance H, Vassiliou L. Difficult airways: a 3D printing study with virtual fibreoptic endoscopy. Br J Oral Maxillofac Surg 2020; 59:e65-e71. [PMID: 33358011 DOI: 10.1016/j.bjoms.2020.08.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
Head and neck cancer patients present unique airway challenges, and oropharyngeal, laryngeal, and hypopharyngeal tumours considerably distort and narrow the anatomy of the airway. We describe the use of 3D augmented reality software combined with 3D printed models to assess the anatomy of difficult airways and to assist in the formulation of the most optimal airway management strategy in such patients. The reported patients had computed tomograms (CT) of the neck prior to their anaesthetic and surgical management. DICOM files of the respective scans were imported to 3D rendering software (OsiriX, Pixmeo). We constructed volume rendered models for initial assessment of the airway then generated serial surface rendered models to create a virtual endoscopic path of the airway to simulate the fibreoptic approach. To further facilitate the study of difficult airways we have subsequently printed 3D models of those that were most difficult using rapid prototyping. Head and neck tumours significantly distort the airway. Thorough study of the relevant anatomy prior to airway management for operating reasons enhances communication between the surgeon and anaesthetist, and aids selection of the most appropriate intubation approach. In conclusion, this paper highlights a useful and novel pre-assessment strategy that allows a virtual, visual, 3-dimensional assessment of the airway anatomy combined with 3D modelling and 3D printing. This enables the airway specialist, anaesthetist, and head and neck surgeon to anticipate any critical steps and adjust the plan accordingly.
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Affiliation(s)
- D Ormandy
- Department of Anaesthetics, North Manchester General Hospital/ Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
| | - B Kolb
- Department of Anaesthetics, North Manchester General Hospital/ Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
| | - S Jayaram
- Department of ENT, North Manchester General Hospital/Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
| | - O Burley
- Department of OMFS, North Manchester General Hospital/Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
| | - P Kyzas
- Department of OMFS, North Manchester General Hospital/Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
| | - H Vallance
- Department of Anaesthetics, North Manchester General Hospital/ Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
| | - L Vassiliou
- Department of OMFS, North Manchester General Hospital/Pennine Acute Hospitals NHS Trust, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom.
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Zhou Z, Zhao X, Zhang C, Yao W. Preoperative four-dimensional computed tomography imaging and simulation of a fibreoptic route for awake intubation in a patient with an epiglottic mass. Br J Anaesth 2020; 125:e290-e292. [PMID: 32654748 DOI: 10.1016/j.bja.2020.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Zhiqiang Zhou
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xu Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuanhan Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenlong Yao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Affiliation(s)
- Taylor Sawyer
- Department of Pediatrics, Division of Neonatology, and
| | - Kaalan Johnson
- Department of Otolaryngology, Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
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10
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Airway assessment in the obstetric patient – are we there yet? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jain K, Gupta N, Yadav M, Thulkar S, Bhatnagar S. Radiological evaluation of airway - What an anaesthesiologist needs to know! Indian J Anaesth 2019; 63:257-264. [PMID: 31000888 PMCID: PMC6460969 DOI: 10.4103/ija.ija_488_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Airway management forms the foundation of any anaesthetic management. However, unanticipated difficult airway (DA) and its sequelae continue to dread any anaesthesiologist. In spite of development of various clinical parameters to judge DA, no single parameter has proved to be accurate in predicting it. Radiological evaluation may help assess the aspects of patient's airway not visualised through the naked eye. Starting from traditional roentgenogram to ultramodern three-dimensional printing, imaging may assist the anaesthesiologists in predicting DA and formulate plan for its management. Right from predicting DA, it has been used for estimating endotracheal tube sizes, assessing airway pathologies in paediatric patients and planning extubation strategies. This article attempts to provide exhaustive overview on radiological parameters which can be utilised by anaesthesiologists for prediction of DA.
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Affiliation(s)
- Kinshuki Jain
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH AIIMS, New Delhi, India
| | - Mukesh Yadav
- Department of Radiology, Dr. BRAIRCH AIIMS, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiology, Dr. BRAIRCH AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Oncoanaesthesia and Palliative Medicine, Dr. BRAIRCH AIIMS, New Delhi, India
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12
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Williams UU, Hagberg CA. Preoperative airway assessment and strategies. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kulkarni KS, Karnik PP, Dave NM, Agrawal B. Radiological images through an anaesthesiologists' looking glass: Airway management in cervical lipomatosis in an infant. Indian J Anaesth 2017; 61:846-847. [PMID: 29242660 PMCID: PMC5664893 DOI: 10.4103/ija.ija_678_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ketan Sakharam Kulkarni
- Department of Anaesthesiology, Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Priyanka Pradeep Karnik
- Department of Anaesthesiology, Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Nandini M Dave
- Department of Anaesthesiology, Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Barkha Agrawal
- Department of Anaesthesiology, Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra, India
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14
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Affiliation(s)
- J Lynch
- Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - S M Crawley
- Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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Ahmad I, Keane O, Muldoon S. Enhancing airway assessment of patients with head and neck pathology using virtual endoscopy. Indian J Anaesth 2017; 61:782-786. [PMID: 29242648 PMCID: PMC5664881 DOI: 10.4103/ija.ija_588_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Studies have demonstrated that poor assessment and planning contribute to airway complications and that current airway assessment strategies have a poor diagnostic accuracy in predicting difficult intubation in the general population. Patients with head and neck pathology are at higher risk for difficulties during airway management and are more likely to need emergency surgical access. Therefore, thorough assessment of this group of patients is mandatory. The addition of virtual endoscopy (VE) to clinical history and computerised tomography imaging has been shown to improve diagnostic accuracy for supraglottic, glottic and infraglottic lesions and has a positive influence in formulating a more cautious and thorough airway management strategy in this high-risk group of patients. This article reviews whether VE can enhance airway assessment in patients with head and neck pathology and help reduce airway complications.
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Affiliation(s)
- Imran Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Oliver Keane
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Sarah Muldoon
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
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Varvinskiy A, Hinde T. 21st Annual Scientific Meeting of the Difficult Airway Society: lessons learned and glimpses of the future. Br J Anaesth 2017; 119:345-347. [DOI: 10.1093/bja/aex194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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The effect of virtual endoscopy on diagnostic accuracy and airway management strategies in patients with head and neck pathology: a prospective cohort study. Can J Anaesth 2017; 64:1101-1110. [PMID: 28702818 DOI: 10.1007/s12630-017-0929-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/02/2017] [Accepted: 07/05/2017] [Indexed: 12/19/2022] Open
Abstract
PURPOSE There is growing evidence to suggest a deficiency in anesthesiologists' diagnosis of airway pathology and subsequent airway management planning, and conventional instruments have not shown increases in safety. Virtual endoscopy (VE) is a tool that can detail intraluminal anatomical "fly-through" information in a format visually similar to the flexible endoscopic views familiar to anesthesiologists. We aimed to determine the effect of VE on diagnostic accuracy and airway management strategies when compared with conventional tools. METHODS Clinical scenarios, along with computerized tomography (CT) imaging, were presented to 20 anesthesiologists, and structured questions were asked regarding diagnosis of airway pathology and airway management strategy. Virtual endoscopy videos were then provided and the questions were repeated. Following the CT and VE presentations, the anesthesiologists' responses involving diagnostic accuracy and airway management strategy were compared between the CT and VE techniques. Answers relating to the utility of VE were also sought. RESULTS Diagnostic accuracy was 54.1% with CT alone and increased to 67.7% when VE was added (P = 0.007). In 48% of cases, the addition of VE to clinical history and CT led to changes in airway management strategy (P < 0.001), and 90.6% of these changes were deemed more cautious (P < 0.001). CONCLUSION Virtual endoscopy improves the accuracy in diagnosis of airway pathology when compared with CT alone. Furthermore, it leads to more conservative and potentially safer airway management strategies in patients with head and neck pathology.
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Pearson KL, McGuire BE. Anaesthesia for laryngo-tracheal surgery, including tubeless field techniques. BJA Educ 2017. [DOI: 10.1093/bjaed/mkx004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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19
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Affiliation(s)
- S Bala Bhaskar
- Department of Anaesthesiology, VIMS, Ballari, Karnataka, India E-mail:
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20
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Accuracy and reliability of oral maxillofacial radiologists when evaluating cone-beam computed tomography imaging for adenoid hypertrophy screening: a comparison with nasopharyngoscopy. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 121:e168-74. [DOI: 10.1016/j.oooo.2016.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/23/2016] [Accepted: 03/09/2016] [Indexed: 11/19/2022]
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Affiliation(s)
- I Ahmad
- Department of Anaesthesia, Guys and St. Thomas' Hospitals, London, UK.
| | - C R Bailey
- Department of Anaesthesia, Guys and St. Thomas' Hospitals, London, UK
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