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Song S, Song SW, Kim TH, Lee KH, Yoo KJ. Effects of preemptive cerebrospinal fluid drainage on spinal cord protection during thoracic endovascular aortic repair. J Thorac Dis 2017; 9:2404-2412. [PMID: 28932545 PMCID: PMC5594124 DOI: 10.21037/jtd.2017.07.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/21/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is reported to occur in 3-12% of thoracic endovascular aortic repair (TEVAR) cases, but is a potentially preventable complication of TEVAR for thoracoabdominal pathologies. Although many strategies have been devised to reduce the incidence of SCI, the effectiveness of prophylactic cerebrospinal fluid drainage (CSFD) and left subclavian artery (LSA) revascularization remains controversial. METHODS From 2012 to 2014, 162 patients underwent TEVAR at a single institution. We prospectively collected and retrospectively reviewed the data of 81 patients who underwent preoperative CSFD among the 162 patients. LSA revascularization was routinely used when LSA need to be covered. Preoperative characteristics, intraoperative variables, and outcomes were analyzed. RESULTS The mean (SD) age of the patients was 60.6 (12.5) years, and 57 patients (70%) were male. Twenty-five patients (31%) presented with degenerative aneurysm; 48 (59%), type B dissection; 5, (6%) penetrating aortic ulcer; and 3 (4%), intramural hematoma. Thirty-six patients (44%) underwent LSA revascularization before TEVAR. Two (2.5%) of the patients who underwent preoperative CSFD had SCI, of whom one recovered ambulatory status at discharge after hypertensive therapy and another had a permanent disability. Prior abdominal aortic aneurysm (AAA) repair tended to relate to SCI (P=0.065), and preoperative aortic rupture was a significant independent risk factor of SCI (P=0.002). CONCLUSIONS Preemptive CSFD as an adjunctive procedure to TEVAR proved to be more effective than selective use of CSFD in other prior reports of SCI cases. Preoperative CSFD is recommended as a prophylactic procedure in patients at high risk of SCI during TEVAR.
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Affiliation(s)
- Seungjun Song
- Department of Thoracic and Cardiovascular Surgery, International St. Mary’s Hospital, Catholic Kwandong University, Incheon, South Korea
| | - Suk-Won Song
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kwang-Hun Lee
- Department of Interventional Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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A novel microwave sensor to detect specific biomarkers in human cerebrospinal fluid and their relationship to cellular ischemia during thoracoabdominal aortic aneurysm repair. J Med Syst 2015; 39:208. [PMID: 25686914 DOI: 10.1007/s10916-015-0208-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
Thoraco-abdominal aneurysms (TAAA) represents a particularly lethal vascular disease that without surgical repair carries a dismal prognosis. However, there is an inherent risk from surgical repair of spinal cord ischaemia that can result in paraplegia. One method of reducing this risk is cerebrospinal fluid (CSF) drainage. We believe that the CSF contains clinically significant biomarkers that can indicate impending spinal cord ischaemia. This work therefore presents a novel measurement method for proteins, namely albumin, as a precursor to further work in this area. The work uses an interdigitated electrode (IDE) sensor and shows that it is capable of detecting various concentrations of albumin (from 0 to 100 g/L) with a high degree of repeatability at 200 MHz (R(2) = 0.991) and 4 GHz (R(2) = 0.975).
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Mancio J, Pires-Morais G, Bettencourt N, Oliveira M, Santos L, Melica B, Rodrigues A, Braga JP, Ribeiro VG. Meningeal haemorrhage secondary to cerebrospinal fluid drainage during thoracic endovascular aortic repair. Oxf Med Case Reports 2014; 2014:56-9. [PMID: 25988028 PMCID: PMC4370003 DOI: 10.1093/omcr/omu019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 05/07/2014] [Accepted: 05/13/2014] [Indexed: 11/13/2022] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) has shown lower mortality compared with open surgical repair (OSR). However, the risk of spinal cord ischaemia (SCI) remains similar than OSR. As a prophylactic measure to reduce the risk of SCI, cerebrospinal fluid (CSF) drainage has been widely used in OSR. In TEVAR, the utility of this adjunct is still controversial. We report a case of a 56-year-old man referred for TEVAR for a descending thoracic aneurysm that previously underwent an abdominal aneurysmectomy with aortobifemoral bypass graft. On the day before, a lumbar cerebrospinal drain was placed prophylactically. Forty-eight hours after the procedure, meningeal symptoms without neurological deficits developed. Clinical investigation revealed meningeal haemorrhage. Therapy with nimodipine was initiated with symptomatic relief. Evidence from randomized controlled trials supporting the role of CSF drainage in TEVAR is still lacking. We discuss the current recommendations, potential benefits and risks and cautions associated with CSF drainage in TEVAR.
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Affiliation(s)
- Jennifer Mancio
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - Gustavo Pires-Morais
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - Nuno Bettencourt
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Research and Developement Unit, Faculty of Medicine , University of Porto , Porto , Portugal
| | - Marco Oliveira
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - Lino Santos
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - Bruno Melica
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - Alberto Rodrigues
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - José Pedro Braga
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
| | - Vasco Gama Ribeiro
- Department of Cardiology , Centro Hospitalar de Vila Nova de Gaia e Espinho , Rua Conceição Fernandes, Vilar de Andorinho, 4434-502 Vila Nova de Gaia, Porto , Portugal
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Mortazavi MM, Verma K, Tubbs RS, Theodore N. Non-pharmacological experimental treatments for spinal cord injury: a review. Childs Nerv Syst 2012; 28:2041-5. [PMID: 22890472 DOI: 10.1007/s00381-012-1889-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 08/03/2012] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Spinal cord injury is a complex result of primary mechanical damage and the secondary vascular compromise and inflammatory reactions. Depending on timing, different treatment modalities may have various effects. CONCLUSIONS We review the latest advances in terms of non-pharmacological experimental treatments.
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Affiliation(s)
- Martin M Mortazavi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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Abstract
BACKGROUND During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury. OBJECTIVES To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 31 2012) and CENTRAL (2012, Issue 5) for publications describing randomised controlled trials of cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Reference lists of relevant articles were checked. SELECTION CRITERIA Randomised trials involving CSFD during thoracic and TAAA surgery. DATA COLLECTION AND ANALYSIS Both authors assessed the quality of trials independently. SNK extracted data and GS verified the data. MAIN RESULTS Three trials with a total of 287 participants operated on for Type I or II TAAA were included.In the first trial of 98 participants, neurological deficits in the lower extremities occurred in 14 (30%) of CSFD group and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from three to 22 days in 10 (32%) participants. CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord.The second trial of 33 participants used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (P = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial.In the third trial TAAA repair was performed on 145 participants. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 participants (12.2%) in the control group versus 2 of 82 participants (2.7%) receiving CSFD (P = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (95 % confidence interval (CI) 0.25 to 0.92). For CSFD-only trials, OR was 0.57 (95% CI 0.28 to 1.17) and for intention-to-treat analysis in CSFD-only studies, the OR remained unchanged. AUTHORS' CONCLUSIONS There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.
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Bilal H, O'Neill B, Mahmood S, Waterworth P. Is cerebrospinal fluid drainage of benefit to neuroprotection in patients undergoing surgery on the descending thoracic aorta or thoracoabdominal aorta? Interact Cardiovasc Thorac Surg 2012; 15:702-8. [PMID: 22761120 DOI: 10.1093/icvts/ivs284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is cerebrospinal fluid (CSF) drainage of benefit in patients undergoing surgery on the descending thoracic aorta or thoracoabdominal aorta?' Altogether 1177 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Ten of 13 studies demonstrate significant neurological protection from CSF drainage (± additional adjuncts), with two further papers showing no significant difference between patients who had or had not had CSF drainage and one study unable to provide any conclusions. For patients having surgery on the thoracic aorta or thoracoabdominal aorta CSF drainage, maintaining pressures <10 mmHg (P < 0.03), in conjunction with other neuroprotective strategies, minimizes the risk of neurological sequelae when compared with patients treated with similar adjuncts but without CSF drainage. The majority of studies used additional neuroprotective strategies, including cooling and reattachment of the intercostal arteries as adjuncts to CSF drainage. Logistic regression curves demonstrated that the longer the ischaemia time, the greater the benefit from CSF drainage (P < 0.04). Four papers observed complications of CSF drainage, of which the main complications were: catheter occlusion or dislodgement, headache, meningitis and subdural haematoma. Overall, CSF drainage does offer a neuroprotective benefit; preventing paraplegia if CSF pressures are maintained <10 mmHg.
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Affiliation(s)
- Haris Bilal
- Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK
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Hsu CCT, Kwan GNC, van Driel ML, Rophael JA. Distal aortic perfusion during thoracoabdominal aneurysm repair for prevention of paraplegia. Cochrane Database Syst Rev 2012:CD008197. [PMID: 22419329 DOI: 10.1002/14651858.cd008197.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND During thoracoabdominal aortic aneurysm (TAAA) surgery, decreased spinal cord perfusion can result in neurological deficits such as paraplegia and paraparesis. Distal aortic perfusion, alone or in combination with other adjuncts, may counter the decrease in spinal cord perfusion and hence reduce the risk of spinal cord injury. OBJECTIVES To determine the effectiveness of distal aortic perfusion with or without other adjuncts against other adjuncts without use of distal perfusion during TAAA surgery in reducing the risk of developing paraplegia and paraparesis. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Specialised Register (last searched 5 January 2012) and CENTRAL (Issue 4, 2011) were searched for publications describing randomised controlled trials of distal aortic perfusion during thoracoabdominal aortic aneurysm surgery. Reference lists of relevant studies were checked. SELECTION CRITERIA Randomised or quasi-randomised controlled clinical trials of distal aortic perfusion during TAAA repair. DATA COLLECTION AND ANALYSIS Studies identified for potential inclusion were independently assessed for inclusion by at least two authors, with excluded trials arbitrated by the third author. MAIN RESULTS There were no randomised controlled trials identified. AUTHORS' CONCLUSIONS Currently, there are no randomised controlled trials to support the role of distal aortic perfusion in TAAA surgery for prevention of neurological injury. However, randomised controlled trials are not always feasible based on ethical grounds. Observational studies suggest that distal aortic perfusion alone or in combination with other adjuncts, that is cerebrospinal fluid (CSF) drainage, reduces the rate of neurologic deficit across all types of TAAA; in particular making a striking difference in the rate of neurologic deficit following type II TAAA repair. In the absence of randomised controlled trials, we recommend a standardised approach to reporting through registry studies to strengthen the evidence base for distal aortic perfusion.
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Hecker JG, McGarvey M. Heat shock proteins as biomarkers for the rapid detection of brain and spinal cord ischemia: a review and comparison to other methods of detection in thoracic aneurysm repair. Cell Stress Chaperones 2011; 16:119-31. [PMID: 20803353 PMCID: PMC3059797 DOI: 10.1007/s12192-010-0224-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 08/16/2010] [Accepted: 08/17/2010] [Indexed: 12/14/2022] Open
Abstract
The heat shock proteins (HSPs) are members of highly conserved families of molecular chaperones that have multiple roles in vivo. We discuss the HSPs in general, and Hsp70 and Hsp27 in particular, and their rapid induction by severe stress in the context of tissue and organ expression in physiology and disease. We describe the current state of knowledge of the relationship and interactions between extra- and intracellular HSPs and describe mechanisms and significance of extracellular expression of HSPs. We focus on the role of the heat shock proteins as biomarkers of central nervous system (CNS) ischemia and other severe stressors and discuss recent and novel technologies for rapid measurement of proteins in vivo and ex vivo. The HSPs are compared to other proposed small molecule biomarkers for detection of CNS injury and to other methods of detecting brain and spinal cord ischemia in real time. While other biomarkers may be of use in prognosis and in design of appropriate therapies, none appears to be as rapid as the HSPs; therefore, no other measurement appears to be of use in the immediate detection of ongoing severe ischemia with the intention to immediately intervene to reduce the severity or risk of permanent damage.
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Affiliation(s)
- James G Hecker
- Department of Anesthesiology and Critical Care, University of Pennsylvania, 3620 Hamilton Walk, Philadelphia, PA 19104-6112, USA.
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Marinis A, Argyra E, Lykoudis P, Brestas P, Theodoraki K, Polymeneas G, Boviatsis E, Voros D. Ischemia as a possible effect of increased intra-abdominal pressure on central nervous system cytokines, lactate and perfusion pressures. Crit Care 2010; 14:R31. [PMID: 20230612 PMCID: PMC2887137 DOI: 10.1186/cc8908] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Revised: 12/09/2009] [Accepted: 03/15/2010] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION The aims of our study were to evaluate the impact of increased intra-abdominal pressure (IAP) on central nervous system (CNS) cytokines (Interleukin 6 and tumor necrosis factor), lactate and perfusion pressures, testing the hypothesis that intra-abdominal hypertension (IAH) may possibly lead to CNS ischemia. METHODS Fifteen pigs were studied. Helium pneumoperitoneum was established and IAP was increased initially at 20 mmHg and subsequently at 45 mmHg, which was finally followed by abdominal desufflation. Interleukin 6 (IL-6), tumor necrosis factor alpha (TNFa) and lactate were measured in the cerebrospinal fluid (CSF) and intracranial (ICP), intraspinal (ISP), cerebral perfusion (CPP) and spinal perfusion (SPP) pressures recorded. RESULTS Increased IAP (20 mmHg) was followed by a statistically significant increase in IL-6 (p = 0.028), lactate (p = 0.017), ICP (p < 0.001) and ISP (p = 0.001) and a significant decrease in CPP (p = 0.013) and SPP (p = 0.002). However, further increase of IAP (45 mmHg) was accompanied by an increase in mean arterial pressure due to compensatory tachycardia, followed by an increase in CPP and SPP and a decrease of cytokines and lactate. CONCLUSIONS IAH resulted in a decrease of CPP and SPP lower than 60 mmHg and an increase of all ischemic mediators, indicating CNS ischemia; on the other hand, restoration of perfusion pressures above this threshold decreased all ischemic indicators, irrespective of the level of IAH.
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Affiliation(s)
- Athanasios Marinis
- Second Department of Surgery, Aretaieion University Hospital, 76 Vassilisis Sofia's Av, GR-11528, Athens, Greece
| | - Eriphili Argyra
- First Department of Anesthesiology, Aretaieion University Hospital, 76 Vassilisis Sofia's Av., GR-11528, Athens, Greece
| | - Pavlos Lykoudis
- Second Department of Surgery, Aretaieion University Hospital, 76 Vassilisis Sofia's Av, GR-11528, Athens, Greece
| | - Paraskevas Brestas
- Second Department of Surgery, Aretaieion University Hospital, 76 Vassilisis Sofia's Av, GR-11528, Athens, Greece
| | - Kassiani Theodoraki
- First Department of Anesthesiology, Aretaieion University Hospital, 76 Vassilisis Sofia's Av., GR-11528, Athens, Greece
| | - Georgios Polymeneas
- Second Department of Surgery, Aretaieion University Hospital, 76 Vassilisis Sofia's Av, GR-11528, Athens, Greece
| | - Efstathios Boviatsis
- Department of Neurosurgery, "Evangelismos" Athens General Hospital, 45-47 Ipsilantou STR, GR-10676, Athens, Greece
| | - Dionysios Voros
- Second Department of Surgery, Aretaieion University Hospital, 76 Vassilisis Sofia's Av, GR-11528, Athens, Greece
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Knapp J, Bernhard M, Rauch H, Hyhlik-Dürr A, Böckler D, Walther A. [Anesthesiologic procedure for elective aortic surgery]. Anaesthesist 2009; 58:1161-82. [PMID: 19907924 DOI: 10.1007/s00101-009-1630-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aortic aneurysms are frequent in the elderly who often suffer from relevant co-morbidities. In Germany it is estimated that approximately 250,000 patients suffer from an aortic aneurysm. Due to the high risk of cardiac or pulmonary complications operative management poses a challenge to the anesthesiologist. Especially hemodynamic management during aortic cross-clamping requires anesthesiologic know-how and an anticipatory use of vasodilators and catecholamines. Furthermore, the anesthesiologist has to protect renal function. In order to avoid paraplegia due to spinal ischemia cerebrospinal fluid drainage may be necessary in patients with aneurysms of the thoracic aorta. In recent years endovascular repair of aortic aneurysms has been established in addition to conventional open surgery. As a consequence in some patients aortic surgery can be performed under regional or local anesthesia. In special cases thoracic endovascular repair requires a medicinal induction of heart arrest or the reduction of aortic blood flow by overpacing.
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Affiliation(s)
- J Knapp
- Klinik für Anaesthesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Scherr K, Urquhart G, Eichorst C, Bulbuc C. Paraplegia After Coronary Artery Bypass Graft Surgery. Crit Care Nurse 2006. [DOI: 10.4037/ccn2006.26.5.34] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Kimberly Scherr
- Kimberly Scherr is the nurse practitioner in internal medicine at Misericordia Community Hospital and Health Centre, Edmonton, Alberta. At the time this article was written, she was the nurse practitioner for the cardiovascular intensive care unit at University of Alberta Hospital in Edmonton
| | - Gayle Urquhart
- Gayle Urquhart is the professional practice leader in nursing at University of Alberta Hospital and Stollery Children’s Hospital in Edmonton. At the time this article was written, she was the clinical nurse specialist for cardiac sciences, University of Alberta Hospital
| | - Christina Eichorst
- Christina Eichorst is the educator for the cardiovascular surgical intensive care unit at University of Alberta Hospital
| | - Catherine Bulbuc
- Catherine Bulbuc is the patient care manager for the cardiovascular surgical intensive care unit at University of Alberta Hospital
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