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Iqbal B, Rahman NM, Hallifax RJ. COVID-19-Related Pleural Diseases. Semin Respir Crit Care Med 2023; 44:437-446. [PMID: 37429295 DOI: 10.1055/s-0043-1769616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Coronavirus disease 2019 (COVID-19)-related pleural diseases are now well recognized. Since the beginning of the pandemic, increasing cases of pleural diseases including pneumothorax, pneumomediastinum, and pleural effusion with severe COVID-19 infection have attracted the attention of physicians and are not incidental or due to barotrauma. The complicated course of COVID-19 illness highlights the complex pathophysiological underpinnings of pleural complications. The management of patients with pneumothorax and pneumomediastinum is challenging as the majority require assisted ventilation; physicians therefore appear to have a low threshold to intervene. Conversely, pleural effusion cases, although sharing some similar patient characteristics with pneumothorax and pneumomediastinum, are in general managed more conservatively. The evidence suggests that patients with COVID-19-related pleural diseases, either due to air leak or effusion, have more severe disease with a worse prognosis. This implies that prompt recognition of these complications and targeted management are key to improve outcomes.
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Affiliation(s)
- Beenish Iqbal
- Respiratory Trials Unit, Oxford Centre for Respiratory Disease, Oxford University Hospital, Oxford Centre for Respiratory Medicine, Churchill Hospital, NHS Trust, Oxford, United Kingdom
| | - Najib M Rahman
- Respiratory Trials Unit, Oxford Centre for Respiratory Disease, Oxford University Hospital, Oxford Centre for Respiratory Medicine, Churchill Hospital, NHS Trust, Oxford, United Kingdom
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Rob J Hallifax
- Respiratory Trials Unit, Oxford Centre for Respiratory Disease, Oxford University Hospital, Oxford Centre for Respiratory Medicine, Churchill Hospital, NHS Trust, Oxford, United Kingdom
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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Khaire N, Deshmukh S, Agarwal E, Mahale N, Khaladkar S, Desai S, Kulkarni A. "Pneumomediastinum: A marker of severity in Covid-19 disease". Heliyon 2023; 9:e12981. [PMID: 36647393 PMCID: PMC9834123 DOI: 10.1016/j.heliyon.2023.e12981] [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: 02/10/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Objective The goal of this study was to look at the incidence, risk factors, clinical characteristics, and radiological aspects of COVID-19 patients who developed pneumomediastinum and compare these features between those who died and those who survived. Materials and methods This retrospective observational study included COVID-19 patients having pneumomediastinum on CT from May 2020 to May 2021 in a COVID-19 care hospital. 1st wave patients were considered between the period of May 2020 to January 2021 and those in the second wave between February 2021 to May 2021. The clinical details were analyzed by a consultant intensivist and CT scans were read by a team of 6 resident radiologists and 5 experienced radiologists. Demographic data, co-morbidities, clinical parameters, hemodynamic markers, radiological involvement and associated complications were analyzed. Results During the study period, 10,605 COVID-19 patients were admitted to our hospital of which 5689 underwent CT scan. 66 patients were detected to have pneumomediastinum on CT; 26 of them in the first wave and 40 in the second wave. Out of 66, 28 patients were admitted to ICU, 9 during the first wave and 18 during the second wave. The overall incidence of developing pneumomediastinum was 1.16%. Incidence in the 1st wave was 1.0% and in the 2nd wave was 1.29%. The overall mortality rate in admitted COVID-19 patients was 12.83% while it was 43.9% in COVID-19 patients who developed pneumomediastinum. Incidence of pneumomediastinum and pneumothorax was high in patients with extensive parenchymal involvement. 59/66 (89%) cases of pneumomediastinum had severe CT score on imaging. Conclusion We conclude that pneumomediastinum is a marker of poor prognosis. Timely diagnosis of interstitial emphysema or pneumomediastinum will aid in planning early protective ventilation strategies and timely intervention of complications.
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Affiliation(s)
- Nivedita Khaire
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Sonali Deshmukh
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Esha Agarwal
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Pune, India,Corresponding author. Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Near Mhatre Bridge, Erandawne, Pune, India.411004.
| | - Nilesh Mahale
- Department of Critical Care Medicine, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Sanjay Khaladkar
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Sanjay Desai
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Ashwini Kulkarni
- Department of Radiology, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Patel N, Nicolae R, Geropoulos G, Mandal P, Christou CD, Gavala M, Madouros N, Papapanou M, Mogal R, Giannis D, Kechagias KS, Panagiotopoulos N. Pneumomediastinum in the COVID-19 era: to drain or not to drain? Monaldi Arch Chest Dis 2022; 93. [PMID: 35904103 DOI: 10.4081/monaldi.2022.2338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/20/2022] [Indexed: 02/07/2023] Open
Abstract
Pneumomediastinum (PNM) is a rare clinical finding, usually with a benign course, which is managed conservatively in the majority of cases. However, during the COVID-19 pandemic, an increased incidence of PNM has been observed. Several reports of PNM cases in COVID-19 have been reported in the literature and were managed either conservatively or surgically. In this study, we present our institutional experience of COVID-19 associated PNM, propose a management algorithm, and review the current literature. In total, 43 Case Series were identified, including a total of 747 patients, of whom 374/747 (50.1%) were intubated at the time of diagnosis, 168/747 (22.5%) underwent surgical drain insertion at admission, 562/747 (75.2%) received conservative treatment (observation or mechanical ventilation. Inpatient mortality was 51.8% (387/747), while 45.1% of the population recovered and/or was discharged (337/747). In conclusion, with increased incidence of PNM in COVID-19 patients reported in the literature, it is still difficult to assign a true causal relationship between PNM and mortality. We can, however, see that PMN plays an important role in disease prognosis. Due to increased complexity, high mortality, and associated complications, conservative management may not be sufficient, and a surgical approach is needed.
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Affiliation(s)
- Nian Patel
- Department of General Surgery, University College London Hospitals, NHS Foundation Trust, London.
| | - Robert Nicolae
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.
| | - Georgios Geropoulos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London.
| | - Pallabhi Mandal
- Department of General Surgery, University College London Hospitals, NHS Foundation Trust, London.
| | | | | | | | | | - Rahul Mogal
- Respiratory Medicine Department, Watford General Hospital, West Hertfordshire Hospitals, NHS Foundation Trust, Hertfordshire.
| | | | - Konstantinos S Kechagias
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London.
| | - Nikolaos Panagiotopoulos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK..
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6
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Melhorn J, Achaiah A, Conway FM, Thompson EMF, Skyllberg EW, Durrant J, Hasan NA, Madani Y, Naran P, Vijayakumar B, Tate MJ, Trevelyan GE, Zaki I, Doig CA, Lynch G, Warwick G, Aujayeb A, Jackson KA, Iftikhar H, Noble JH, Ng AYKC, Nugent M, Evans PJ, Hastings RA, Bellenberg HR, Lawrence H, Saville RL, Johl NT, Grey AN, Ellis HC, Chen C, Jones TL, Maddekar N, Khan SL, Muhammad AI, Ghani H, Myint YMM, Rafique C, Pippard BJ, Irving BRH, Ali F, Asimba VH, Azam A, Barton EC, Bhatnagar M, Blackburn MP, Millington KJ, Budhram NJ, Bunclark KL, Sapkal TP, Dixon G, Harries AJE, Ijaz M, Karunanithi V, Naik S, Khan MA, Savlani K, Kumar V, Gallego BL, Mahdi NA, Morgan C, Patel N, Rowlands EW, Steward MS, Thorley RS, Wollerton RL, Ullah S, Smith DM, Lason W, Rostron AJ, Rahman NM, Hallifax RJ. Pneumomediastinum in COVID-19: a phenotype of severe COVID-19 pneumonitis? The results of the United Kingdom (POETIC) survey. Eur Respir J 2022; 60:2102522. [PMID: 35144988 PMCID: PMC8832377 DOI: 10.1183/13993003.02522-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 01/12/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is an emerging understanding that coronavirus disease 2019 (COVID-19) is associated with increased incidence of pneumomediastinum. We aimed to determine its incidence among patients hospitalised with COVID-19 in the United Kingdom and describe factors associated with outcome. METHODS A structured survey of pneumomediastinum and its incidence was conducted from September 2020 to February 2021. United Kingdom-wide participation was solicited via respiratory research networks. Identified patients had SARS-CoV-2 infection and radiologically proven pneumomediastinum. The primary outcomes were to determine incidence of pneumomediastinum in COVID-19 and to investigate risk factors associated with patient mortality. RESULTS 377 cases of pneumomediastinum in COVID-19 were identified from 58 484 inpatients with COVID-19 at 53 hospitals during the study period, giving an incidence of 0.64%. Overall 120-day mortality in COVID-19 pneumomediastinum was 195/377 (51.7%). Pneumomediastinum in COVID-19 was associated with high rates of mechanical ventilation. 172/377 patients (45.6%) were mechanically ventilated at the point of diagnosis. Mechanical ventilation was the most important predictor of mortality in COVID-19 pneumomediastinum at the time of diagnosis and thereafter (p<0.001) along with increasing age (p<0.01) and diabetes mellitus (p=0.08). Switching patients from continuous positive airways pressure support to oxygen or high flow nasal oxygen after the diagnosis of pneumomediastinum was not associated with difference in mortality. CONCLUSIONS Pneumomediastinum appears to be a marker of severe COVID-19 pneumonitis. The majority of patients in whom pneumomediastinum was identified had not been mechanically ventilated at the point of diagnosis.
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Affiliation(s)
- James Melhorn
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, UK
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- JM is the guarantor and takes responsibility for the integrity of the work from inception to published article
| | - Andrew Achaiah
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, UK
| | | | | | | | - Joseph Durrant
- Newham University Hospital, Barts Health NHS Trust, London, UK
| | - Neda A Hasan
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Yasser Madani
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Prasheena Naran
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Bavithra Vijayakumar
- Royal Brompton Hospital, National Heart and Lung Institute, London, UK
- Chelsea and Westminster Hospital, National Heart and Lung Institute, Imperial College London, UK
| | - Matthew J Tate
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Gareth E Trevelyan
- Royal Berkshire Hospital, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Irfan Zaki
- Royal Berkshire Hospital, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Catherine A Doig
- Southend University Hospital, Mid and South Essex NHS Foundation Trust, Southend, UK
| | - Geraldine Lynch
- Prince of Wales Hospital, Cwm Taf Morgannwg University Health Board, Bridgend, Wales, UK
| | - Gill Warwick
- The Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Wales, UK
| | - Avinash Aujayeb
- Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Karl A Jackson
- Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Hina Iftikhar
- Gloucester Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Jonathan H Noble
- Gloucester Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Anthony Y K C Ng
- Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Mark Nugent
- Glangwilli General Hospital, Hywel Dda University Health Board, Carmarthen, Wales, UK
| | - Philip J Evans
- Glangwilli General Hospital, Hywel Dda University Health Board, Carmarthen, Wales, UK
| | - Robert A Hastings
- Barnet General Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Harry R Bellenberg
- Barnet General Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Hannah Lawrence
- Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rachel L Saville
- Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nikolas T Johl
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Adam N Grey
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Huw C Ellis
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, UK
| | - Cheng Chen
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, UK
| | - Thomas L Jones
- Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Nadeem Maddekar
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Shahul Leyakathali Khan
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | | | - Hakim Ghani
- Watford General Hospital, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | - Cecillia Rafique
- University Hospital of North Tees, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Benjamin J Pippard
- University Hospital of North Tees, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Benjamin R H Irving
- Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Fawad Ali
- Bedford Hospital, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Viola H Asimba
- Nottingham University Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Aqeem Azam
- Royal Blackburn Teaching Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Eleanor C Barton
- The Grange University Hospital, Aneurin Bevan Health Board, Cwmbran, Wales, UK
| | - Malvika Bhatnagar
- Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Matthew P Blackburn
- Southport and Ormskirk District General Hospital, Southport and Ormskirk Hospital NHS Trust, Southport, UK
| | - Kate J Millington
- Great Western Hospital, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Nicholas J Budhram
- Great Western Hospital, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Katherine L Bunclark
- Norwich and Norfolk University Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Toshit P Sapkal
- Norwich and Norfolk University Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Giles Dixon
- Royal United Hospitals Bath, The Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Andrew J E Harries
- Royal Glamorgan Hospital, Llantrisant, Cwm Taf University Health Board, Wales, UK
| | - Mohammad Ijaz
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Samir Naik
- The Princess Alexandra Hospital, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Malik Aamaz Khan
- Luton & Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust, Luton, UK
| | - Karishma Savlani
- Luton & Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust, Luton, UK
| | - Vimal Kumar
- Kettering General Hospital, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Beatriz Lara Gallego
- University Hospital, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Noor A Mahdi
- Lister Hospital, East and North Hertfordshire NHS Trust Stevenage, UK
| | - Caitlin Morgan
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | - Neena Patel
- Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Elen W Rowlands
- Neville Hall Hospital, Aneurin Bevan University Health Board, Abergavenny, Wales, UK
| | - Matthew S Steward
- Royal Devon & Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Richard S Thorley
- The Royal Cornwall Hospital, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Sana Ullah
- Ysbyty Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Rhyl, Wales, UK
| | - David M Smith
- Integrated Critical Care Unit, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Wojciech Lason
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, UK
| | - Anthony J Rostron
- Integrated Critical Care Unit, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Najib M Rahman
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
- Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rob J Hallifax
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Umbrello M, Venco R, Antonucci E, Cereghini S, Filardo C, Guglielmetti L, Montanari G, Muttini S. Incidence, clinical characteristics and outcome of barotrauma in critically ill patients with COVID-19: a systematic review and meta-analysis. Minerva Anestesiol 2022; 88:706-718. [PMID: 35416463 DOI: 10.23736/s0375-9393.22.16258-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Barotrauma is rare in patients with acute respiratory distress syndrome undergoing mechanical ventilation. Its incidence seems increased among critically ill COVID-19 patients. We performed a systematic review and meta-analysis to investigate the incidence, risk factors and clinical outcomes of barotrauma among critically ill COVID-19 patients EVIDENCE ACQUISITION: PubMed was searched from March 1st, 2020 to August 31st, 2021; case series and retrospective cohort studies concerning barotrauma in adult critically ill COVID-19 patients, either hospitalized in the Intensive Care Unit (ICU) or invasively ventilated were included. Primary outcome was the incidence of barotrauma in COVID-19 versus non-COVID-19 patients. Secondary outcomes were clinical characteristics, ventilator parameters, mortality and length of stay between patients with and without barotrauma. EVIDENCE SYNTHESIS We identified 21 studies (six case series, 15 retrospective cohorts). The overall incidence of barotrauma was 11 [95% CI: 8-14]% in critically ill COVID-19 patients, vs. 2 [1-3]% in non-COVID-19, P<0.001; the incidence in mechanically ventilated patients was 14 [11-17]% vs. 4 [2-5]% non-COVID-19 patients, P<0.001. There were no differences in demographic, clinical, ventilatory parameters between patients who did and did not develop barotrauma, while, on average, protective ventilation criteria were always respected. Among COVID-19 patients, those with barotrauma had a higher mortality (60 [55-66] vs. 48 [42-54]%, P<0.001) and a longer ICU length of stay (20 [14-26] vs. 13 [10,5-16] days, P=0.03). CONCLUSIONS Barotrauma is a frequent complication in critically ill COVID-19 patients and is associated with a poor prognosis. Since lung protective ventilation was delivered, the ventilatory management might not be the sole factor in the development of barotrauma.
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Affiliation(s)
- Michele Umbrello
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy -
| | - Roberto Venco
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Edoardo Antonucci
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sergio Cereghini
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Clelia Filardo
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Luigi Guglielmetti
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Giulia Montanari
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Stefano Muttini
- Unit of Anesthesia and Resuscitation II, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
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