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Littlejohns A, Savic L. Management and treatment of perioperative hypersensitivity. Curr Opin Allergy Clin Immunol 2024; 24:210-217. [PMID: 38814699 DOI: 10.1097/aci.0000000000001000] [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: 05/31/2024]
Abstract
PURPOSE OF REVIEW Perioperative hypersensitivity reactions are rare but potentially catastrophic events. This review acts to summarize recent recommendations for both immediate and poststabilization management of suspected reactions, alongside practical advice for anaesthetists who may be faced with these events. RECENT FINDINGS Prompt treatment is essential but may be hampered by delay in recognition. This can occur because there are multiple differential diagnoses for the observed clinical signs as well as variations in clinical presentation. Resuscitation is dependent on the use of adrenaline and fluids. Adrenaline should be administered in small, titrated intravenous boluses. Low-dose infusions should be commenced early if the response to boluses is poor. Large volume fluid resuscitation may be required to maintain adequate circulating volume. Chest compressions are recommended when there is evidence of inadequate perfusion, rather than waiting until cardiac arrest is confirmed. Antihistamines and corticosteroids are no longer recommended in the immediate management phase. Once the patient has been stabilized, it is important to obtain serial tryptase concentrations to aid the subsequent clinic investigation. The decision to proceed or abandon surgery will be based on an individual risk-benefit analysis. All cases of suspected perioperative hypersensitivity, including fatal cases, must be referred for formal investigation. SUMMARY There have been recent updates to management guidelines in perioperative hypersensitivity. Treatment algorithms, treatment packs and referral packs can all help the anaesthetist manage these complex cases, aid the subsequent investigation and ensure patient safety in the future.
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Affiliation(s)
- Anna Littlejohns
- Anaesthetic Department, Leeds Teaching Hospitals Trust, Leeds, UK
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Harris DE. Rocuronium-Induced Anaphylaxis in the Perioperative Period: A Clinical Review. AORN J 2024; 119:47-58. [PMID: 38149896 DOI: 10.1002/aorn.14053] [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: 07/14/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 12/28/2023]
Abstract
Rocuronium, a nondepolarizing neuromuscular blocking agent used for muscle relaxation especially during endotracheal intubation, can cause hypersensitivity reactions. This article provides an overview of anaphylactic reactions; risk factors; and the pathophysiology, presentation, diagnosis, treatment, and nursing implications associated with rocuronium-induced anaphylaxis. Life-threatening anaphylaxis can be immunoglobulin E-mediated or non-immunoglobulin E-mediated and usually occurs after the first dose. Anaphylaxis can present with hypotension and bronchospasm; cutaneal symptoms, such as erythema, may not be obvious. Diagnosis is initially presumptive and may require a transesophageal echocardiogram to rule out other causes of hypotension (eg, pulmonary embolus). Emergency treatment begins with epinephrine administration and fluid boluses; cardiac support devices may be needed. Definitive diagnosis requires early measurement of histamine and tryptase levels and skin testing after the patient recovers from the reaction. Perioperative nurses should be prepared to participate in emergency treatment of anaphylaxis and advocate for testing for a definitive diagnosis.
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Ghimire A, Olbrecht VA, Tobias JD. Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports. Paediatr Anaesth 2022; 32:706-715. [PMID: 35212434 DOI: 10.1111/pan.14424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/01/2022]
Abstract
Allergic reactions are generalized hypersensitivity processes triggered by different antigenic stimuli, resulting in the end effect of mast cell degranulation and adverse physiologic effects. During the perioperative period, the most commonly identified agents include antibiotics, neuromuscular blocking agents (rocuronium and succinylcholine), chlorhexidine, and iodinated dyes for radiologic imaging. Sugammadex is a novel agent for the reversal of neuromuscular blockade achieved with rocuronium or vecuronium. Its unique mechanism of action, whereby it encapsulates and forms a one-to-one complex with rocuronium, has led to its anecdotal use as an adjunct in the treatment of anaphylactic and anaphylactoid reactions following rocuronium. The current manuscript discusses the potential use of sugammadex in the treatment of allergic reactions following the administration of rocuronium, reviews previous anecdotal reports of its use in these scenarios, and provides recommendations for future care.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Harper N, Cook T, Garcez T, Lucas D, Thomas M, Kemp H, Kong KL, Marinho S, Karanam S, Ferguson K, Hitchman J, Torevell H, Warner A, Egner W, Nasser S, McGuire N, Bellamy M, Floss K, Farmer L, Farooque S. Anaesthesia, surgery, and life-threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6). Br J Anaesth 2018; 121:172-188. [DOI: 10.1016/j.bja.2018.04.015] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/08/2018] [Accepted: 04/16/2018] [Indexed: 12/20/2022] Open
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Kuric V, Zaza KJ, Algazlan SS. Atypical presentation to rocuronium allergy in a 19-year-old female patient. J Clin Anesth 2017; 37:163-165. [PMID: 28235514 DOI: 10.1016/j.jclinane.2016.11.007] [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: 07/19/2015] [Revised: 10/18/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
Abstract
The danger of anaphylaxis, a rare but life threatening complication of general anesthesia (GA) can be summarized in two: 1. General Anesthesia masks the typical early signs of allergy which can be seen in an awake patient. 2. Anaphylaxis during GA manifests mostly as circulatory/ventilatory failures which can be interpreted as adverse effects of anesthetics or surgery and this can lead to critical delay of effective therapy. A 19-year-old female admitted for posterior spinal fusion and instrumentation (the 5th surgery in patient's life) desaturated seconds after intubation. Cardiopulmonary resuscitation (CPR) was started and the absence of cutaneous signs along with a loud holosystolic murmur were questioned. The patient was promptly resuscitated and allergy to rocuronium was confirmed by intradermal tests 6weeks later. Factors influencing decision making and potential etiology of the newly heard holosystolic murmur during anaphylaxis are discussed.
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Affiliation(s)
- Vladimir Kuric
- Department of Anesthesiology, King Faisal Specialist Hospital and Research Center (KFSH & RC), P.O. Box 3354, Riyadh 11211, Saudi Arabia.
| | - Khaled J Zaza
- Department of Anesthesiology, King Faisal Specialist Hospital and Research Center (KFSH & RC), P.O. Box 3354, Riyadh 11211, Saudi Arabia; College of Medicine, Alfaisal University, P.O. Box 50927, Riyadh 11533, Saudi Arabia.
| | - Sulaiman S Algazlan
- Department of Medicine, King Faisal Specialist Hospital and Research Center (KFSH & RC), P.O. Box 3354, Riyadh 11211, Saudi Arabia.
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Schaller SJ, Lewald H. Clinical pharmacology and efficacy of sugammadex in the reversal of neuromuscular blockade. Expert Opin Drug Metab Toxicol 2016; 12:1097-108. [DOI: 10.1080/17425255.2016.1215426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heidrun Lewald
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Spoerl D, D'Incau S, Roux-Lombard P, Harr T, Czarnetzki C. Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism. Int Arch Allergy Immunol 2016; 169:256-62. [PMID: 27240836 DOI: 10.1159/000446182] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022] Open
Abstract
We present 3 cases of pseudoallergic (anaphylactoid) reactions to perioperatively administered rocuronium, which rapidly resolved after sugammadex injection. Allergological workup showed no evidence for immediate-type hypersensitivity to the drugs used for anesthesia, including rocuronium. However, rocuronium induced an irritative reaction in skin tests in all 3 patients and in 3 healthy individuals. This reaction was specifically suppressed by adding sugammadex at a 1:1 molecular proportion to rocuronium before the skin tests. This observation suggests that the patients suffered from a pseudoallergic reaction, and indicates that sugammadex might act via the inhibition of non-IgE mediated MRGPRX2 (Mas-related G-protein-coupled receptor member X2)-triggered mast cell degranulation induced by rocuronium.
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Affiliation(s)
- David Spoerl
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, Geneva University Hospital, Geneva, Switzerland
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Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth 2015; 30:290-7. [PMID: 26646837 PMCID: PMC4819478 DOI: 10.1007/s00540-015-2105-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
Abstract
Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan.
| | - Hiromasa Mitsuhata
- Department of Anesthesiology, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koto-Ku, Tokyo, 136-0075, Japan
| | - Paul Michel Mertes
- Service d'anesthésie-réanimation chirurgicale, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
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Platt PR, Clarke RC, Johnson GH, Sadleir PHM. Efficacy of sugammadex in rocuronium-induced or antibiotic-induced anaphylaxis. A case-control study. Anaesthesia 2015; 70:1264-7. [DOI: 10.1111/anae.13178] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- P. R. Platt
- Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - R. C. Clarke
- Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - G. H. Johnson
- Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - P. H. M. Sadleir
- Sir Charles Gairdner Hospital; Perth Western Australia Australia
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Baumüller E, Schaller S, Chiquito Lama Y, Frick C, Bauhofer T, Eikermann M, Fink H, Blobner M. Postoperative impairment of motor function at train-of-four ratio ≥0.9 cannot be improved by sugammadex (1 mg kg −1 ). Br J Anaesth 2015; 114:785-93. [DOI: 10.1093/bja/aeu453] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 12/17/2022] Open
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Raft J, Belhadj-Tahar N, Meistelman C. Slow recovery after sugammadex bolus after rocuronium-induced anaphylaxis. Br J Anaesth 2014; 112:1115-6. [PMID: 24829421 DOI: 10.1093/bja/aeu167] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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A new option for the treatment of anaphylaxis linked to steroidal neuromuscular blockers: How much value should we grant to case reports? Can J Anaesth 2014; 61:511-8. [DOI: 10.1007/s12630-014-0150-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 03/13/2014] [Indexed: 12/17/2022] Open
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Baldo BA, McDonnell NJ. Sugammadex and anaphylaxis in the operating theater. ACTA ACUST UNITED AC 2014; 61:239-45. [PMID: 24666509 DOI: 10.1016/j.redar.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- B A Baldo
- Retired. Formerly, Head, Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia.
| | - N J McDonnell
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women and School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
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Lobaz S, Clymer M, Sammut M. Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal. ACTA ACUST UNITED AC 2014. [DOI: 10.4137/cmt.s10241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium- or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I–III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.
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Affiliation(s)
- Steven Lobaz
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mark Clymer
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mario Sammut
- Department of Anaesthetics and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. CORE EVIDENCE 2013; 8:57-67. [PMID: 24098155 PMCID: PMC3789633 DOI: 10.2147/ce.s35675] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the "gold standard" muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.
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Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Heidrun Fink
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Development of New Neuromuscular Blocking Agents. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Silva-Obregón JA, Gamero-Donis D, Romo-Gonzales JE, Benito-Puncel C, Borrallo-Pérez JM, Marian-Crespo C. [Rocuronium-induced anaphylaxis. Potential off-label use of sugammadex]. Med Intensiva 2013; 38:58-9. [PMID: 23375690 DOI: 10.1016/j.medin.2012.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 11/05/2012] [Accepted: 11/27/2012] [Indexed: 10/27/2022]
Affiliation(s)
- J A Silva-Obregón
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - D Gamero-Donis
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - J E Romo-Gonzales
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - C Benito-Puncel
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - J M Borrallo-Pérez
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - C Marian-Crespo
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
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