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Pérez L, Sabate A, Gutierrez R, Caballero M, Pujol R, Llaurado S, Peñafiel J, Hereu P, Blasi A. Risk factors associated with blood transfusion in liver transplantation. Sci Rep 2024; 14:19022. [PMID: 39152310 PMCID: PMC11329499 DOI: 10.1038/s41598-024-70078-2] [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: 03/06/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024] Open
Abstract
To explore preoperative and operative risk factors for red blood cell (RBC) transfusion requirements during liver transplantation (LT) and up to 24 h afterwards. We evaluated the associations between risk factors and units of RBC transfused in 176 LT patients using a log-binomial regression model. Relative risk was adjusted for age, sex, and the model for end-stage liver disease score (MELD) (adjustment 1) and baseline hemoglobin concentration (adjustment 2). Forty-six patients (26.14%) did not receive transfusion. Grafts from cardiac-death donors were used in 32.61% and 31.54% of non-transfused and transfused patients, respectively. The transfused group required more reoperation for bleeding (P = 0.035), longer mechanical ventilation after LT (P < 0.001), and longer ICU length of stay (P < 0.001). MELD and hemoglobin concentrations determined RBC requirements. For each unit of increase in the MELD score, 2% more RBC units were transfused, and non-transfusion was 0.83-fold less likely. For each 10-g/L higher hemoglobin concentration at baseline, 16% less RBC transfused, and non-transfusion was 1.95-fold more likely. Ascites was associated with 26% more RBC transfusions. With an increase of 2 mm from the baseline in the A10FIBTEM measurement of maximum clot firmness, non-transfusion was 1.14-fold more likely. A 10-min longer cold ischemia time was associated with 1% more RBC units transfused, and the presence of post-reperfusion syndrome with 45% more RBC units. We conclude that preoperative correction of anemia should be included in LT. An intervention to prevent severe hypotension and fibrinolysis during graft reperfusion should be explored.Trial register: European Clinical Trials Database (EudraCT 2018-002,510-13) and ClinicalTrials.gov (NCT01539057).
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Grants
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
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Affiliation(s)
- Lourdes Pérez
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain
| | - Antoni Sabate
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain.
| | - Rosa Gutierrez
- Department of Anesthesiology, University Hospital of Cruces, Bilbao, Spain
| | - Marta Caballero
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain
| | - Roger Pujol
- Department of Anesthesiology, Clinic Hospital, University of Barcelona Health Barcelona, Spain Campus, IDIBAPS, Barcelona, Spain
| | - Sandra Llaurado
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain
| | - Judith Peñafiel
- UICEC, Biostatistics Unit (UBiDi), University of Barcelona Health Campus. IDIBELL, Barcelona, Spain
| | - Pilar Hereu
- UICEC, Biostatistics Unit (UBiDi), University of Barcelona Health Campus. IDIBELL, Barcelona, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Clinic Hospital, University of Barcelona Health Barcelona, Spain Campus, IDIBAPS, Barcelona, Spain
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Sabate A, Scarlatescu E. Treating periprocedural bleeding in patients with cirrhosis. J Thromb Thrombolysis 2024; 57:531-536. [PMID: 38281228 PMCID: PMC10961284 DOI: 10.1007/s11239-023-02941-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Abstract
Patients with cirrhosis are known to have an abnormal coagulation status, which is a particular concern when planning invasive procedures in which blood loss is possible or predictable. Careful consideration must be given to the bleeding risk for each individual patient and coagulation management strategies should be established in advance of procedural interventions, where possible. Perioperative clinical decision-making should utilize viscoelastic testing in addition to usual assessments, where possible, and focus on the well-established three pillars of patient blood management: optimization of erythropoiesis, minimization of bleeding and blood loss, and management of anemia. Restrictive transfusion policies, careful hemostatic monitoring, and a proactive approach to predicting and preventing bleeding on an individual patient basis should be central to managing perioperative bleeding in the fragile patient population with cirrhosis. This review discusses coagulation assessments and bleeding management techniques necessary before, during, and after surgical interventions in patients with cirrhosis, and provides expert clinical opinion and physician experience on the perioperative management of these patients.
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Affiliation(s)
- Antoni Sabate
- Anesthesia Department, Bellvitge University Hospital, University of Barcelona, Idibell, Barcelona, Spain
| | - Ecaterina Scarlatescu
- Anesthesia and Intensive Care Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.
- Department of Anesthesia and Intensive Care Medicine, Fundeni Clinical Institute, Bucharest, Romania.
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Lladó L, Abradelo de Usera M, Blasi A, Gutiérrez R, Montalvá E, Pascual S, Rodríguez-Laiz G. Consensus document from the Spanish Society for Liver Transplantation: Enhanced recovery after liver transplantation. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:206-217. [PMID: 38342510 DOI: 10.1016/j.gastrohep.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/09/2023] [Indexed: 02/13/2024]
Abstract
The goal of the Spanish Society for Liver Transplantation (Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses enhanced recovery after liver transplantation, dividing needed actions into 3periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.
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Affiliation(s)
- Laura Lladó
- Unidad de Cirugía HB y Trasplante Hepático, Servicio de Cirugía, Hospital Universitari Bellvitge, IDIBELL, Universidad de Barcelona, Barcelona, España.
| | - Manuel Abradelo de Usera
- Unidad de Cirugía HBP y Trasplante de Órganos, Servicio de Cirugía, Hospital Universitario 12 de Octubre, Imas12, Madrid, España
| | - Annabel Blasi
- Departamento de Anestesiología, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, España
| | - Rosa Gutiérrez
- Servicio de Anestesiología- Reanimación, Hospital Universitario de Cruces, Bilbao, España
| | - Eva Montalvá
- Unidad de Cirugía HBP y Trasplante, Hospital Universitario y Politécnico La Fe, Universitat de València. CIBERehd, ISCIII. IIS LaFe, Valencia, España
| | - Sonia Pascual
- Unidad Hepática, Servicio de Digestivo, CIBERehd. ISABIAL, Hospital General Universitario Alicante, Alicante, España
| | - Gonzalo Rodríguez-Laiz
- Unidad Hepática, Servicio de Cirugía, CIBERehd, ISABIAL, Hospital General Universitario Alicante, Alicante, España
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Lladó L, Usera MAD, Blasi A, Gutiérrez R, Montalvá E, Pascual S, Rodríguez-Laiz G. Consensus document from the Spanish Society for Liver Transplantation: enhanced recovery after liver transplantation. Cir Esp 2024; 102:104-115. [PMID: 38403385 DOI: 10.1016/j.cireng.2023.07.004] [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: 06/12/2023] [Accepted: 07/09/2023] [Indexed: 02/27/2024]
Abstract
The goal of the Spanish Society for Liver Transplantation (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses Enhanced Recovery After Liver Transplantation, dividing needed actions into three periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.
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Affiliation(s)
- Laura Lladó
- Unidad de Cirugía HB y Trasplante Hepático, Servicio de Cirugía, Hospital Universitari Bellvitge, IDIBELL, Universidad de Barcelona, Barcelona, Spain.
| | - Manuel Abradelo de Usera
- Unidad de Cirugía HBP y Trasplante de Órganos, Servicio de Cirugía, Hospital Universitario 12 de Octubre, Imas12, Madrid, Spain
| | - Annabel Blasi
- Departamento de Anestesiología, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Rosa Gutiérrez
- Servicio de Anestesiología-Reanimación, Hospital Universitario de Cruces, Bilbao, Spain
| | - Eva Montalvá
- Unidad de Cirugía HBP y Trasplante, Hospital Universitario y Politécnico La Fe, Universitat de València, CIBERehd, ISCIII, IIS LaFe, Valencia, Spain
| | - Sonia Pascual
- Unidad Hepática, Servicio de Digestivo, CIBERehd, ISABIAL, Hospital General Universitario Alicante, Alicante, Spain
| | - Gonzalo Rodríguez-Laiz
- Unidad Hepática, Servicio de Cirugía, CIBERehd, ISABIAL, Hospital General Universitario Alicante, Alicante, Spain
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Alhamar M, Uzuni A, Mehrotra H, Elbashir J, Galusca D, Nagai S, Yoshida A, Abouljoud MS, Otrock ZK. Predictors of intraoperative massive transfusion in orthotopic liver transplantation. Transfusion 2024; 64:68-76. [PMID: 37961982 DOI: 10.1111/trf.17600] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Although transfusion management has improved during the last decade, orthotopic liver transplantation (OLT) has been associated with considerable blood transfusion requirements which poses some challenges in securing blood bank inventories. Defining the predictors of massive blood transfusion before surgery will allow the blood bank to better manage patients' needs without delays. We evaluated the predictors of intraoperative massive transfusion in OLT. STUDY DESIGN AND METHODS Data were collected on patients who underwent OLT between 2007 and 2017. Repeat OLTs were excluded. Analyzed variables included recipients' demographic and pretransplant laboratory variables, donors' data, and intraoperative variables. Massive transfusion was defined as intraoperative transfusion of ≥10 units of packed red blood cells (RBCs). Statistical analysis was performed using SPSS version 17.0. RESULTS The study included 970 OLT patients. The median age of patients was 57 (range: 16-74) years; 609 (62.7%) were male. RBCs, thawed plasma, and platelets were transfused intraoperatively to 782 (80.6%) patients, 831 (85.7%) patients, and 422 (43.5%) patients, respectively. Massive transfusion was documented in 119 (12.3%) patients. In multivariate analysis, previous right abdominal surgery, the recipient's hemoglobin, Model for End Stage Liver Disease (MELD) score, cold ischemia time, warm ischemia time, and operation time were predictive of massive transfusion. There was a direct significant correlation between the number of RBC units transfused and plasma (Pearson correlation coefficient r = .794) and platelets (r = .65). DISCUSSION Previous abdominal surgery, the recipient's hemoglobin, MELD score, cold ischemia time, warm ischemia time, and operation time were predictive of intraoperative massive transfusion in OLT.
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Affiliation(s)
- Mohamed Alhamar
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ajna Uzuni
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Harshita Mehrotra
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jaber Elbashir
- Department of Anesthesia, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Dragos Galusca
- Department of Anesthesia, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Shunji Nagai
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Atsushi Yoshida
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Marwan S Abouljoud
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Zaher K Otrock
- Transfusion Medicine, Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Pérez-Calatayud AA, Hofmann A, Pérez-Ferrer A, Escorza-Molina C, Torres-Pérez B, Zaccarias-Ezzat JR, Sanchez-Cedillo A, Manuel Paez-Zayas V, Carrillo-Esper R, Görlinger K. Patient Blood Management in Liver Transplant—A Concise Review. Biomedicines 2023; 11:biomedicines11041093. [PMID: 37189710 DOI: 10.3390/biomedicines11041093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/07/2023] Open
Abstract
Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.
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Affiliation(s)
| | - Axel Hofmann
- Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth 6907, WA, Australia
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, 8057 Zurich, Switzerland
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, 28700 San Sebastián de los Reyes, Spain
- Department of Anesthesiology, European University of Madrid, 28702 Madrid, Spain
| | - Carla Escorza-Molina
- Departmen of Anesthesiology, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Bettina Torres-Pérez
- Department of Anesthesiology, Pediatric Transplant, Centro Medico de Occidente, Instituto Mexicano del Seguro Social, Guadalajara 44329, Mexico
| | | | - Aczel Sanchez-Cedillo
- Transplant Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Victor Manuel Paez-Zayas
- Gastroenterology Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | | | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45131 Essen, Germany
- TEM Innovations GmbH, 81829 Munich, Germany
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Caballero M, Sabate A, Gutierrez R, Beltran J, Pérez L, Pujol R, Viguera L, Costa M, Reyes R, Martinez A, Ojinaga G, Leon A, Navarro A, Barquero M, Alonso G, Puig G, Blasi A. Blood component requirements in liver transplantation: effect of 2 thromboelastometry-guided strategies for bolus fibrinogen infusion-the TROMBOFIB randomized trial. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:37-46. [PMID: 36695394 DOI: 10.1016/j.jtha.2022.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/28/2022] [Accepted: 10/18/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND A low plasma fibrinogen level influences blood component transfusion. Thromboelastometry provides clinical guidance for fibrinogen replacement in liver transplantation (LT). OBJECTIVES We hypothesized that infusions of fibrinogen concentrate to reach an A10FibTem value of 11 mm during LT could reduce red blood cell (RBC) and other component and fluid requirements in comparison to standard care. METHODS This randomized, blinded, multicenter trial in 3 hospitals enrolled 189 LT-scheduled patients allocated to an intervention target (A10FibTem, 11 mm) or a standard target (A10FibTem, 8 mm); 176 patients underwent LT with fibrinogen replacement. Data were analyzed by intention-to-treat (intervention group, 91; control group, 85). Blood was extracted, and fibrinogen kits were prepared to bring each patient's fibrinogen level to the assigned target at the start of LT, after portal vein clamping, and after graft reperfusion. The main outcome was the proportion of patients requiring RBC transfusion during LT or within 24 hours. RESULTS The proportion of patients requiring RBCs did not differ between the groups: intervention, 74.7% (95% CI, 65.5%-83.3%); control, 72.9% (95% CI, 62.2%-82.0%); absolute difference, 1.8% (95% CI, -11.1% to 14.78%) (P = .922). Thrombotic events occurred in 4% of the patients in both groups; reoperation and retransplantation rates and mortality did not differ. Nearly 70% of the patients in both groups required fibrinogen concentrate to reach the target. Using an 11-mm A10FibTem target increased the maximum clot firmness without affecting safety. However, this change provided no clinical benefits. CONCLUSION The similar low plasma fibrinogen concentrations could explain the lack of significant between-group outcomes.
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Affiliation(s)
- Marta Caballero
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Antoni Sabate
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain.
| | - Rosa Gutierrez
- Department of Anesthesiology, University Hospital of Cruces, Bilbao, Spain
| | - Joan Beltran
- Department of Anesthesiology, Clinic Hospital. University of Barcelona Health Campus, IDIBAPS, Barcelona, Spain
| | - Lourdes Pérez
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Roger Pujol
- Department of Anesthesiology, Clinic Hospital. University of Barcelona Health Campus, IDIBAPS, Barcelona, Spain
| | - Laura Viguera
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Marta Costa
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Raquel Reyes
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Alberto Martinez
- Department of Anesthesiology, University Hospital of Cruces, Bilbao, Spain
| | - Gorka Ojinaga
- Department of Anesthesiology, University Hospital of Cruces, Bilbao, Spain
| | - Ariadna Leon
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Antonio Navarro
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Marta Barquero
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Guillermo Alonso
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Guillermo Puig
- Department of Anesthesiology, University Hospital of Bellvitge. University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Clinic Hospital. University of Barcelona Health Campus, IDIBAPS, Barcelona, Spain
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