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Montgomery LD, Montgomery RW, Bodo M, Mahon RT, Pearce FJ. Thoracic, Peripheral, and Cerebral Volume, Circulatory and Pressure Responses To PEEP During Simulated Hemorrhage in a Pig Model: a Case Study. JOURNAL OF ELECTRICAL BIOIMPEDANCE 2021; 12:103-116. [PMID: 35069946 PMCID: PMC8713386 DOI: 10.2478/joeb-2021-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 06/14/2023]
Abstract
Positive end-expiratory pressure (PEEP) is a respiratory/ventilation procedure that is used to maintain or improve breathing in clinical and experimental cases that exhibit impaired lung function. Body fluid shift movement is not monitored during PEEP application in intensive care units (ICU), which would be interesting specifically in hypotensive patients. Brain injured and hypotensive patients are known to have compromised cerebral blood flow (CBF) autoregulation (AR) but currently, there is no non-invasive way to assess the risk of implementing a hypotensive resuscitation strategy and PEEP use in these patients. The advantage of electrical bioimpedance measurement is that it is noninvasive, continuous, and convenient. Since it has good time resolution, it is ideal for monitoring in intensive care units (ICU). The basis of its future use is to establish physiological correlates. In this study, we demonstrate the use of electrical bioimpedance measurement during bleeding and the use of PEEP in pig measurement. In an anesthetized pig, we performed multimodal recording on the torso and head involving electrical bioimpedance spectroscopy (EIS), fixed frequency impedance plethysmography (IPG), and bipolar (rheoencephalography - REG) measurements and processed data offline. Challenges (n=16) were PEEP, bleeding, change of SAP, and CO2 inhalation. The total measurement time was 4.12 hours. Systemic circulatory results: Bleeding caused a continuous decrease of SAP, cardiac output (CO), and increase of heart rate, temperature, shock index (SI), vegetative - Kerdo index (KI). Pulse pressure (PP) decreased only after second bleeding which coincided with loss of CBF AR. Pulmonary arterial pressure (PAP) increased during PEEP challenges as a function of time and bleeding. EIS/IPG results: Body fluid shift change was characterized by EIS-related variables. Electrical Impedance Spectroscopy was used to quantify the intravascular, interstitial, and intracellular volume changes during the application of PEEP and simulated hemorrhage. The intravascular fluid compartment was the primary source of blood during hemorrhage. PEEP produced a large fluid shift out of the intravascular compartment during the first bleeding period and continued to lose more blood following the second and third bleeding. Fixed frequency IPG was used to quantify the circulatory responses of the calf during PEEP and simulated hemorrhage. PEEP reduced the arterial blood flow into the calf and venous outflow from the calf. Head results: CBF AR was evaluated as a function of SAP change. Before bleeding, and after moderate bleeding, intracranial pressure (ICP), REG, and carotid flow pulse amplitudes (CFa) increased. This change reflected vasodilatation and active CBF AR. After additional hemorrhaging during PEEP, SAP, ICP, REG, CFa signal amplitudes decreased, indicating passive CBF AR. 1) The indicators of active AR status by modalities was the following: REG (n=9, 56 %), CFa (n=7, 44 %), and ICP (n=6, 38 %); 2) CBF reactivity was better for REG than ICP; 3) REG and ICP correlation coefficient were high (R2 = 0.81) during CBF AR active status; 4) PRx and REGx reflected active CBF AR status. CBF AR monitoring with REG offers safety for patients by preventing decreased CBF and secondary brain injury. We used different types of bioimpedance instrumentation to identify physiologic responses in the different parts of the body (that have not been discussed before) and how the peripheral responses ultimately lead to decreased cardiac output and changes in the head. These bioimpedance methods can improve ICU monitoring, increase the adequacy of therapy, and decrease mortality and morbidity.
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Affiliation(s)
| | | | - Michael Bodo
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Current position: Ochsner Medical Center, New Orleans, LA, USA
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Párraga Ros E, Correa-Martín L, Sánchez-Margallo FM, Candanosa-Aranda IE, Malbrain MLNG, Wise R, Latorre R, López Albors O, Castellanos G. Intestinal histopathological changes in a porcine model of pneumoperitoneum-induced intra-abdominal hypertension. Surg Endosc 2018; 32:3989-4002. [PMID: 29777353 DOI: 10.1007/s00464-018-6142-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/06/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Low splanchnic perfusion is an immediate effect of pneumoperitoneum-induced intra-abdominal hypertension (IAH). Anatomical structure results in the intestinal mucosa being the area most sensitive to hypoperfusion. The relationship between intestinal injury and clinical parameters of tissue perfusion [abdominal perfusion pressure (APP), gastric intramucosal pH (pHi) and lactic acid (Lc)] has not been previously studied. This study aimed to monitorize intestinal pathogenesis through sequential ileal biopsies and to measure APP, pHi, and Lc levels at different pneumoperitoneum-induced intra-abdominal pressures (20, 30, and 40 mmHg) to evaluate the potential relationships between them. MATERIALS AND METHODS Fifty pigs were divided into four groups; a control group (C) and three experimental groups with different pneumoperitoneum-induced levels [20 mmHg (G20), 30 mmHg (G30), and 40 mmHg (G40)], that were maintained for 3 and 5 h. APP, pHi, and Lc were measured and ileal biopsies taken laparoscopically every 30 min. The mucosal damage was graded using the standardized Park's Score and animals were classified as injured (I+) or uninjured (I-). RESULTS Different histopathological lesions were observed in groups G20, G30, and G40 but no damage observed in group C. A 33.3% of animals in G20 and G30 were I+ after 3 h, while 93.3% were injured in G40. After 5 h, histopathological lesions were no longer seen in some animals in G20 and only 10% were I+. Conversely, in G30 I+ pigs increased to 80% while those in G40 remained at 93.3% I+. The I+ animals had significantly lower APP and pHi than those I-. Lc was the clinical parameter that showed the earliest differences, with significantly higher figures in I+ animals. CONCLUSIONS The evolution of intestinal injuries from pneumoperitoneum-induced IAH depends on the degree of IAP. These damages may be associated with decreases in APP and pHi, and increases in Lc.
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Affiliation(s)
- Ester Párraga Ros
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100, Murcia, Spain.
| | - Laura Correa-Martín
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre (JUMISC), Cáceres, Spain
| | | | - Irma Eugenia Candanosa-Aranda
- Highlands Teaching and Research Farm (CEIEPAA), Faculty of Veterinary Medicine, National Autonomous University of México, Querétaro, Mexico
| | - Manu L N G Malbrain
- Medical and Surgical ICU and High Care Burn Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg/St-Erasmus, Lange Beeldekensstraat 267, 2060, Antwerp, Belgium
| | - Robert Wise
- Pietermaritzburg Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg, South Africa.,Clinical Unit, Critical Care, Edendale Hospital, Pietermaritzburg, South Africa.,Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Rafael Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100, Murcia, Spain
| | - Octavio López Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100, Murcia, Spain
| | - Gregorio Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
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Time-course evaluation of intestinal structural disorders in a porcine model of intra-abdominal hypertension by mechanical intestinal obstruction. PLoS One 2018; 13:e0191420. [PMID: 29357386 PMCID: PMC5777654 DOI: 10.1371/journal.pone.0191420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/04/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND A mechanical intestinal obstruction (MIO) can generate intraabdominal hypertension (IAH) that is life threatening. The intestines are very sensitive to IAH since the low splanchnic perfusion causes intestinal hypoxia, local acidosis and bacterial translocations. This may lead to acute intestinal distress syndrome (AIDS). The identification of intestinal injuries during IAH and its correlation with clinical parameters as the abdominal perfusion pressure (APP), the gastric intramucosal pH (pHi) and lactic acid (Lc) are still unknown. This study aimed to evaluate the sequence of intestinal histopathological findings in an MIO model and to analyze potential relationships with parameters currently used in clinical practice (APP, pHi and Lc). MATERIAL AND METHODS Twenty pigs were divided into three groups: a control group (n = 5) and two experimental groups with 20 mmHg (G1, n = 10) and 30 mmHg (G2, n = 5) of IAH by MIO. The pressures were maintained for 3 hours, except in 5 animals in G1 where it was maintained for 5 hours. The APP, pHi and LA were recorded and biopsies of the terminal ileum were taken every 30 minutes in all groups. The intestinal damage was graded according to the Park Score. RESULTS Intestinal injuries were found in 42.9% of pigs in the experimental groups. The lesions were independent of the level and duration of IAH. Although APP and pHi were slightly lower in injured animals (I +) of G1 and G2, there were no significant differences among those uninjured (I-). Lc was significantly increased in all I+ pigs from the onset of IAH. CONCLUSION The IAH by MIO causes intestinal lesions from the first 30 minutes with concurrent decreases in APP and pHi and increases in Lc. Lc could be the best clinical parameter related to intestinal damages with a clear difference between I + and I- animals.
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Ermolov AS, Koroshvili VT, Blagovestnov DA, Yartsev PA, Shlyakhovsky IA. [Postoperative abdominal hernia: a modern view on incidence and etiopathogenesis]. Khirurgiia (Mosk) 2017:76-82. [PMID: 28514387 DOI: 10.17116/hirurgia2017576-82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- A S Ermolov
- Chair of Emergency and General Surgery of the Russian Medical Academy of Postgraduate Education, Moscow; Sklifosovsky Research Institute for Emergency Care, Moscow
| | - V T Koroshvili
- Chair of Emergency and General Surgery of the Russian Medical Academy of Postgraduate Education, Moscow; Sklifosovsky Research Institute for Emergency Care, Moscow
| | - D A Blagovestnov
- Chair of Emergency and General Surgery of the Russian Medical Academy of Postgraduate Education, Moscow; Sklifosovsky Research Institute for Emergency Care, Moscow
| | - P A Yartsev
- Chair of Emergency and General Surgery of the Russian Medical Academy of Postgraduate Education, Moscow; Sklifosovsky Research Institute for Emergency Care, Moscow
| | - I A Shlyakhovsky
- Chair of Emergency and General Surgery of the Russian Medical Academy of Postgraduate Education, Moscow; Sklifosovsky Research Institute for Emergency Care, Moscow
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Milanesi R, Caregnato RCA. Intra-abdominal pressure: an integrative review. ACTA ACUST UNITED AC 2016; 14:423-430. [PMID: 26958978 PMCID: PMC5234758 DOI: 10.1590/s1679-45082016rw3088] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 06/30/2015] [Indexed: 12/14/2022]
Abstract
There is a growing request for measuring intra-abdominal pressure in critically ill patients with acute abdominal pain to be clarified. Summarizing the research results on measurement of vesical intra-abdominal pressure and analyzing the level of evidence were the purposes of this integrative literature review, carried out based on the databases LILACS, MEDLINE and PubMed, from 2005 to July 2012. Twenty articles were identified, in that, 12 literature reviews, 4 descriptive and exploratory studies, 2 expert opinions, one prospective cohort study and one was an experience report. The vesical intra-abdominal pressure measurement was considered gold standard. There are variations in the technique however, but some common points were identified: complete supine position, in absence of abdominal contracture, in the end of expiration and expressed in mmHg. Most research results indicate keeping the transducer zeroed at the level of the mid-axillary line at the iliac crest level, and instill 25mL of sterile saline. Strong evidence must be developed.
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Tiwari AR, Pandya JS. Study of the occurrence of intra-abdominal hypertension and abdominal compartment syndrome in patients of blunt abdominal trauma and its correlation with the clinical outcome in the above patients. World J Emerg Surg 2016; 11:9. [PMID: 26870155 PMCID: PMC4750285 DOI: 10.1186/s13017-016-0066-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/08/2016] [Indexed: 01/06/2023] Open
Abstract
Background Intra-abdominal pressure (IAP) measurements have been identified as essential for diagnosis and management of both intra-abdominal hypertension (IAH) and Abdominal compartment syndrome (ACS). It has gained prominent status in ICUs worldwide. We aimed to evaluate the utility of measurement of rise in bladder pressure to assess IAP levels in blunt abdominal trauma (BAT) patients. Patients and methods Thirty patients of BAT with solid organ injuries were included in this study. Intra-abdominal pressure was measured through a Foleys bladder catheter throughout their stay. Bladder pressure was compared with clinical parameters like mean arterial pressures(MAP), respiratory rate(RR), serum creatinine(SC) and abdominal girth(AG) and also with outcome in terms of intervention whether operative(OI) or non-operative(NOI). Results Bladder pressure showed significant correlation with MAP (R = −0.418; P = 0.022), AG (R = 0.755; P = 0.000), SC (R = 0.689; P = 0.000) and RR (R = 0.537; P = 0.002). Bladder pressure (R = 0.851; P = 0.000), SC (R = 0.625; P = 0.000), MAP (R = −0.350; P = 0.058) and maximum AG difference (R = 0.634; P = 0.000) showed significant correlation with intervention. In total, 17 patients (56 %) required intervention, 9 patients (30 %) underwent NOI (pigtailing or aspiration) while 8 (27 %) needed OI. More than 3 derailed parameters were associated with 100 % intervention (Mean 3.47, SD-1.23). High APACHE III score on admission (>40) was associated with increased intervention (p = 0.001). Intervention correlates well with Grade of injury (p = 0.000) and not with number of organs injured (p = 0.061). Blood transfusion of 2 or more units of blood was associated with increased intervention (p = 0.000). Conclusion Increased bladder pressure and other clinical parameters (MAP, SC, RR and change in AG) correlates well with intervention. Elevated bladder pressure correlates well with other clinical parameters in patients with BAT. Bladder pressure, SC, MAP, RR and AG difference can be used to determine the group of patients that can be managed conservatively and those that would benefit with minimal intervention or exploration. During Non-operative management (NOM) of patients with BAT and multiple solid organ injuries, IAP monitoring may be a simple and objective guideline to suggest further intervention whether NOI or OI. Although routine bladder pressure measurements will result in unnecessary monitoring of large number of patients it is hoped that patients with IAH can be detected early and subsequent ACS with morbid abdominal exploration can be prevented. However the criterion for non-operative failure and the point of decompression needs further refinement to prevent an increase of nontherapeutic operations.
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Affiliation(s)
- Ajeet Ramamani Tiwari
- Department of General Surgery, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai Central, 400008 India
| | - Jayashri Sanjay Pandya
- Department of General Surgery, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai Central, 400008 India
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Correa-Martín L, Párraga E, Sánchez-Margallo FM, Latorre R, López-Albors O, Wise R, Malbrain MLNG, Castellanos G. Mechanical Intestinal Obstruction in a Porcine Model: Effects of Intra-Abdominal Hypertension. A Preliminary Study. PLoS One 2016; 11:e0148058. [PMID: 26849559 PMCID: PMC4744005 DOI: 10.1371/journal.pone.0148058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 12/03/2015] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Mechanical intestinal obstruction is a disorder associated with intra-abdominal hypertension and abdominal compartment syndrome. As the large intestine intraluminal and intra-abdominal pressures are increased, so the patient's risk for intestinal ischaemia. Previous studies have focused on hypoperfusion and bacterial translocation without considering the concomitant effect of intra-abdominal hypertension. The objective of this study was to design and evaluate a mechanical intestinal obstruction model in pigs similar to the human pathophysiology. MATERIALS AND METHODS Fifteen pigs were divided into three groups: a control group (n = 5) and two groups of 5 pigs with intra-abdominal hypertension induced by mechanical intestinal obstruction. The intra-abdominal pressures of 20 mmHg were maintained for 2 and 5 hours respectively. Hemodynamic, respiratory and gastric intramucosal pH values, as well as blood tests were recorded every 30 min. RESULTS Significant differences between the control and mechanical intestinal obstruction groups were noted. The mean arterial pressure, cardiac index, dynamic pulmonary compliance and abdominal perfusion pressure decreased. The systemic vascular resistance index, central venous pressure, pulse pressure variation, airway resistance and lactate increased within 2 hours from starting intra-abdominal hypertension (p<0.05). In addition, we observed increased values for the peak and plateau airway pressures, and low values of gastric intramucosal pH in the mechanical intestinal obstruction groups that were significant after 3 hours. CONCLUSION The mechanical intestinal obstruction model appears to adequately simulate the pathophysiology of intestinal obstruction that occurs in humans. Monitoring abdominal perfusion pressure, dynamic pulmonary compliance, gastric intramucosal pH and lactate values may provide insight in predicting the effects on endorgan function in patients with mechanical intestinal obstruction.
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Affiliation(s)
- L. Correa-Martín
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre (JUMISC), Cáceres, Spain
| | - E. Párraga
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - F. M. Sánchez-Margallo
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre (JUMISC), Cáceres, Spain
| | - R. Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - O. López-Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - R. Wise
- Critical Care Unit, Edendale Hospital, Pietermaritzburg, South Africa, and Department of Anaesthetics and Critical Care, Perioperative Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - M. L. N. G. Malbrain
- Medical and surgical ICU and high care Burn Unit, Ziekenhuis Netwerk Antwerpen, Antwerpen, Belgium
| | - G. Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
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Al-Khyatt W, Thomas JD, Humes DJ, Lobo DN. Intestinal ischemia following laparoscopic surgery: a case series. J Med Case Rep 2013; 7:25. [PMID: 23336390 PMCID: PMC3552963 DOI: 10.1186/1752-1947-7-25] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 12/19/2012] [Indexed: 11/29/2022] Open
Abstract
Introduction Intestinal ischemia is a rare complication of laparoscopic surgery. Its prognosis depends on a high index of suspicion and effective early treatment. Case presentation In the present report, we describe three cases where intestinal ischemia developed following laparoscopic surgery. Case 1 concerns a 52-year-old Caucasian man who developed large bowel ischemia following laparoscopic adjustable gastric band surgery. Case 2 concerns an 82-year-old Caucasian woman who developed fatal intestinal ischemia following laparoscopic cholecystectomy. Case 3 concerns a 58-year old Caucasian woman who developed right-sided lower intestinal ischemia following open cholecystectomy. Conclusions Intestinal ischemia is a rare complication of laparoscopic surgery. The identification of high-risk patients is an essential primary preventive measure. A high index of suspicion is required to make an early diagnosis, which may help improve outcomes.
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Affiliation(s)
- Waleed Al-Khyatt
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Uttoxetter Road, Derby DE22 3DT, UK.
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Tavernier B, Robin E. Assessment of fluid responsiveness during increased intra-abdominal pressure: keep the indices, but change the thresholds. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:134. [PMID: 21457517 PMCID: PMC3219334 DOI: 10.1186/cc10074] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dynamic variables of fluid responsiveness are useful guides for fluid management in patients under controlled positive pressure ventilation. In the previous issue of Critical Care, Jacques and colleagues show that these variables remain reliable predictors of fluid responsiveness in a porcine model of intra-abdominal hypertension, but threshold values are higher than during normal intra-abdominal pressure. Their threshold values, however, cannot be applied to clinical practice. This study suggests that intra-abdominal pressure must be measured in critically ill patients, and 'supranormal' values of dynamic variables should be analyzed with caution. The 'fluid responsive part' of an increased dynamic variable in such patients may be estimated by measuring its change during a fluid challenge.
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Affiliation(s)
- Benoit Tavernier
- Pôle d'Anesthésie Réanimation, CHU de Lille, and EA 1046, Université Lille II, IMPRT-IFR 114, Lille, France.
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