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Horejsek J, Balík M, Kunstýř J, Michálek P, Brožek T, Kopecký P, Fink A, Waldauf P, Pořízka M. Prediction of Fluid Responsiveness Using Combined End-Expiratory and End-Inspiratory Occlusion Tests in Cardiac Surgical Patients. J Clin Med 2023; 12:jcm12072569. [PMID: 37048651 PMCID: PMC10094769 DOI: 10.3390/jcm12072569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
End-expiratory occlusion (EEO) and end-inspiratory occlusion (EIO) tests have been successfully used to predict fluid responsiveness in various settings using calibrated pulse contour analysis and echocardiography. The aim of this study was to test if respiratory occlusion tests predicted fluid responsiveness reliably in cardiac surgical patients with protective ventilation. This single-centre, prospective study, included 57 ventilated patients after elective coronary artery bypass grafting who were indicated for fluid expansion. Baseline echocardiographic measurements were obtained and patients with significant cardiac pathology were excluded. Cardiac index (CI), stroke volume and stroke volume variation were recorded using uncalibrated pulse contour analysis at baseline, after performing EEO and EIO tests and after volume expansion (7 mL/kg of succinylated gelatin). Fluid responsiveness was defined as an increase in cardiac index by 15%. Neither EEO, EIO nor their combination predicted fluid responsiveness reliably in our study. After a combined EEO and EIO, a cut-off point for CI change of 16.7% predicted fluid responsiveness with a sensitivity of 61.8%, specificity of 69.6% and ROC AUC of 0.593. In elective cardiac surgical patients with protective ventilation, respiratory occlusion tests failed to predict fluid responsiveness using uncalibrated pulse contour analysis.
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Horejsek J, Kunstyr J, Michalek P, Porizka M. Novel Methods for Predicting Fluid Responsiveness in Critically Ill Patients—A Narrative Review. Diagnostics (Basel) 2022; 12:diagnostics12020513. [PMID: 35204603 PMCID: PMC8871108 DOI: 10.3390/diagnostics12020513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with acute circulatory failure, fluid administration represents a first-line therapeutic intervention for improving cardiac output. However, only approximately 50% of patients respond to fluid infusion with a significant increase in cardiac output, defined as fluid responsiveness. Additionally, excessive volume expansion and associated hyperhydration have been shown to increase morbidity and mortality in critically ill patients. Thus, except for cases of obvious hypovolaemia, fluid responsiveness should be routinely tested prior to fluid administration. Static markers of cardiac preload, such as central venous pressure or pulmonary artery wedge pressure, have been shown to be poor predictors of fluid responsiveness despite their widespread use to guide fluid therapy. Dynamic tests including parameters of aortic blood flow or respiratory variability of inferior vena cava diameter provide much higher diagnostic accuracy. Nevertheless, they are also burdened with several significant limitations, reducing the reliability, or even precluding their use in many clinical scenarios. This non-systematic narrative review aims to provide an update on the novel, less employed dynamic tests of fluid responsiveness evaluation in critically ill patients.
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Affiliation(s)
- Jan Horejsek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
| | - Jan Kunstyr
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
| | - Pavel Michalek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
- Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK
| | - Michal Porizka
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
- Correspondence: ; Tel.: +420-702-089-475
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Changes in the Plethysmographic Perfusion Index During an End-Expiratory Occlusion Detect a Positive Passive Leg Raising Test. Crit Care Med 2021; 49:e151-e160. [PMID: 33332814 DOI: 10.1097/ccm.0000000000004768] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The end-expiratory occlusion test for assessing preload responsiveness consists in interrupting mechanical ventilation for 15 seconds at end-expiration and measuring the cardiac index changes. The perfusion index is the ratio between the pulsatile and the nonpulsatile portions of the plethysmography signal and is, in part, determined by stroke volume. We tested whether the end-expiratory occlusion-induced changes in perfusion index could detect a positive passive leg raising test, suggesting preload responsiveness. DESIGN Observational study. SETTING Medical ICU. PATIENTS Thirty-one ventilated patients without atrial fibrillation. INTERVENTIONS We measured perfusion index (Radical-7 device; Masimo Corp., Irvine, CA) and cardiac index (PiCCO2; Pulsion Medical Systems, Feldkirchen, Germany) before and during a passive leg raising test and a 15-second end-expiratory occlusion. MEASUREMENTS AND MAIN RESULTS In 19 patients with a positive passive leg raising test (increase in cardiac index ≥ 10%), compared to the baseline value and expressed as a relative change, passive leg raising increased cardiac index and perfusion index by 17% ± 7% and 49% ± 23%, respectively, In these patients, end-expiratory occlusion increased cardiac index and perfusion index by 6% ± 2% and 11% ± 8%, respectively. In the 12 patients with a negative passive leg raising test, perfusion index did not significantly change during passive leg raising and end-expiratory occlusion. Relative changes in perfusion index and cardiac index observed during all interventions were significantly correlated (r = 0.83). An end-expiratory occlusion-induced relative increase in perfusion index greater than or equal to 2.5% ([perfusion index during end-expiratory occlusion-perfusion index at baseline]/perfusion index at baseline × 100) detected a positive passive leg raising test with an area under the receiver operating characteristic curve of 0.95 ± 0.03. This threshold is larger than the least significant change observed for perfusion index (1.62% ± 0.80%). CONCLUSIONS Perfusion index could be used as a reliable surrogate of cardiac index for performing the end-expiratory occlusion test. Confirming previous results, the relative changes in perfusion index also reliably detected a positive passive leg raising test.
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Ma GG, Xu LY, Luo JC, Hou JY, Hao GW, Su Y, Liu K, Yu SJ, Tu GW, Luo Z. Change in left ventricular velocity time integral during Trendelenburg maneuver predicts fluid responsiveness in cardiac surgical patients in the operating room. Quant Imaging Med Surg 2021; 11:3133-3145. [PMID: 34249640 PMCID: PMC8250022 DOI: 10.21037/qims-20-700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 03/03/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid responsiveness is an important topic for clinicians. We investigated whether changes in left ventricular outflow tract (LVOT) velocity time integral (VTI) during a Trendelenburg position (TP) maneuver can predict fluid responsiveness as a non-invasive marker in coronary artery bypass graft (CABG) surgery patients in the operating room. METHODS This prospective, single-center observational study, performed in the operating room, enrolled 65 elective CABG patients. Hemodynamic data coupled with transesophageal echocardiography monitoring of the LVOT VTI and the peak velocity were collected at each step [baseline 1, TP, baseline 2 and fluid challenge (FC)]. Patients whose VTI increased ≥15% after FC (500 mL of Gelofusine infusion within 30 min) were considered responders. RESULTS Twenty-eight (43.1%) patients were responders to fluid administration. VTI changes during the TP maneuver predicted fluid responsiveness with an area under the receiver operating characteristic curve (AUC) of 0.90 (95% CI, 0.79-0.96), with a sensitivity of 100%, and a specificity of 70% at a threshold of 10% (gray zone, 8-15%). The increase in VTI during the TP was correlated with the VTI changes induced by FC (r=0.61, P<0.0001). Changes in peak velocity and pulse pressure during the TP were poorly predictive of fluid responsiveness, with an AUC of 0.72 (95% CI: 0.60-0.82) and 0.66 (95% CI: 0.53-0.77), respectively. CONCLUSIONS An increase in VTI induced by the TP could predict fluid responsiveness in CABG patients in the operating room. However, changes in peak velocity and pulse pressure stimulated by the TP could not reliably predict fluid responsiveness.
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Affiliation(s)
- Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Center of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li-Ying Xu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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Mendes RDS, Pelosi P, Schultz MJ, Rocco PRM, Silva PL. Fluids in ARDS: more pros than cons. Intensive Care Med Exp 2020; 8:32. [PMID: 33336259 PMCID: PMC7746428 DOI: 10.1186/s40635-020-00319-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
In acute respiratory distress syndrome (ARDS), increased pulmonary vascular permeability makes the lung vulnerable to edema. The use of conservative as compared to liberal fluid strategies may increase the number of ventilator-free days and survival, as well as reduce organ dysfunction. Monitoring the effects of fluid administration is of the utmost importance; dynamic indexes, such as stroke volume and pulse pressure variations, outperform static ones, such as the central venous pressure. The passive leg raise and end-expiratory occlusion tests are recommended for guiding fluid management decisions. The type of intravenous fluids should also be taken into consideration: crystalloids, colloids, and human albumin have all been used for fluid resuscitation. Recent studies have also shown differences in outcome between balanced and non-balanced intravenous solutions. In preclinical studies, infusion of albumin promotes maintenance of the glycocalyx layer, reduces inflammation, and improves alveolar-capillary membrane permeability. Fluids in ARDS must be administered cautiously, considering hemodynamic and perfusion status, oncotic and hydrostatic pressures, ARDS severity, fluid type, volume and infusion rate, and cardiac and renal function. Of note, no guideline to date has recommended a specific fluid composition for use in ARDS; most physicians currently follow recommendations for sepsis.
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Affiliation(s)
- Renata de S Mendes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Hou JY, Zheng JL, Ma GG, Lin XM, Hao GW, Su Y, Luo JC, Liu K, Luo Z, Tu GW. Evaluation of radial artery pulse pressure effects on detection of stroke volume changes after volume loading maneuvers in cardiac surgical patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:787. [PMID: 32647712 PMCID: PMC7333092 DOI: 10.21037/atm-20-847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid responsiveness is defined as an increase in cardiac output (CO) or stroke volume (SV) of >10-15% after fluid challenge (FC). However, CO or SV monitoring is often not available in clinical practice. The aim of this study was to evaluate whether changes in radial artery pulse pressure (rPP) induced by FC or passive leg raising (PLR) correlates with changes in SV in patients after cardiac surgery. METHODS This prospective observational study included 102 patients undergoing cardiac surgery, in which rPP and SV were recorded before and immediately after a PLR test and FC with 250 mL of Gelofusine for 10 min. SV was measured using pulse contour analysis. Patients were divided into responders (≥15% increase in SV after FC) and non-responders. The hemodynamic variables between responders and non-responders were analyzed to assess the ability of rPP to track SV changes. RESULTS A total of 52% patients were fluid responders in this study. An rPP increase induced by FC was significantly correlated with SV changes after a FC (ΔSV-FC, r=0.62, P<0.01). A fluid-induced increase in rPP (ΔrPP-FC) of >16% detected a fluid-induced increase in SV of >15%, with a sensitivity of 91% and a specificity of 73%. The area under the receiver operating characteristic curve (AUROC) for the fluid-induced changes in rPP identified fluid responsiveness was 0.881 (95% CI: 0.802-0.937). A grey zone of 16-34% included 30% of patients for ΔrPP-FC. The ΔrPP-PLR was weakly correlated with ΔSV-FC (r=0.30, P<0.01). An increase in rPP induced by PLR (ΔrPP-PLR) predicted fluid responsiveness with an AUROC of 0.734 (95% CI: 0.637-0.816). A grey zone of 10-23% included 52% of patients for ΔrPP-PLR. CONCLUSIONS Changes in rPP might be used to detect changes in SV via FC in mechanically ventilated patients after cardiac surgery. In contrast, changes in rPP induced by PLR are unreliable predictors of fluid responsiveness.
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Affiliation(s)
- Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Ming Lin
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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Gavelli F, Shi R, Teboul JL, Azzolina D, Monnet X. The end-expiratory occlusion test for detecting preload responsiveness: a systematic review and meta-analysis. Ann Intensive Care 2020; 10:65. [PMID: 32449104 PMCID: PMC7246264 DOI: 10.1186/s13613-020-00682-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis of studies assessing the end-expiratory occlusion test (EEXPO test)-induced changes in cardiac output (CO) measured by any haemodynamic monitoring device, as indicators of preload responsiveness. METHODS MEDLINE, EMBASE and Cochrane Database were screened for original articles. Bivariate random-effects meta-analysis determined the Area under the Summary Receiver Operating Characteristic (AUSROC) curve of EEXPO test-induced changes in CO to detect preload responsiveness, as well as pooled sensitivity and specificity and the best diagnostic threshold. RESULTS Thirteen studies (530 patients) were included. Nine studies were performed in the intensive care unit and four in the operating room. The pooled sensitivity and the pooled specificity for the EEXPO test-induced changes in CO were 0.85 [0.77-0.91] and 0.88 [0.83-0.91], respectively. The AUSROC curve was 0.91 [0.86-0.94] with the best threshold of CO increase at 5.1 ± 0.2%. The accuracy of the test was not different when changes in CO were monitored through pulse contour analysis compared to other methods (AUSROC: 0.93 [0.91-0.95] vs. 0.87 [0.82-0.96], respectively, p = 0.62). Also, it was not different in studies in which the tidal volume was ≤ 7 mL/kg compared to the remaining ones (AUSROC: 0.96 [0.92-0.97] vs. 0.89 [0.82-0.95] respectively, p = 0.44). Subgroup analyses identified one possible source of heterogeneity. CONCLUSIONS EEXPO test-induced changes in CO reliably detect preload responsiveness. The diagnostic performance is not influenced by the method used to track the EEXPO test-induced changes in CO. Trial registration The study protocol was prospectively registered on PROSPERO: CRD42019138265.
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Affiliation(s)
- Francesco Gavelli
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France. .,Emergency Medicine Unit, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, 28100, Novara, Italy.
| | - Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France
| | - Danila Azzolina
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, 28100, Novara, Italy
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France
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Gavelli F, Teboul JL, Monnet X. The end-expiratory occlusion test: please, let me hold your breath! Crit Care 2019; 23:274. [PMID: 31391083 PMCID: PMC6686261 DOI: 10.1186/s13054-019-2554-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/24/2019] [Indexed: 01/10/2023] Open
Affiliation(s)
- Francesco Gavelli
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
- Faculté de médecine Paris-Sud, Université Paris-Sud, Inserm UMR S_999, F-94270 Le Kremlin-Bicêtre, France
- Department of Translational Medicine, Emergency Medicine Unit, Università degli Studi del Piemonte Orientale, 28100 Novara, Italy
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
- Faculté de médecine Paris-Sud, Université Paris-Sud, Inserm UMR S_999, F-94270 Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
- Faculté de médecine Paris-Sud, Université Paris-Sud, Inserm UMR S_999, F-94270 Le Kremlin-Bicêtre, France
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