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Schoettler JJ, Kirschning T, Hagmann M, Hahn B, Fairley AM, Centner FS, Schneider-Lindner V, Herrle F, Tzatzarakis E, Thiel M, Krebs J. Maintaining oxygen delivery is crucial to prevent intestinal ischemia in critical ill patients. PLoS One 2021; 16:e0254352. [PMID: 34242347 PMCID: PMC8270469 DOI: 10.1371/journal.pone.0254352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/24/2021] [Indexed: 01/16/2023] Open
Abstract
Background Intestinal ischemia is a common complication with obscure pathophysiology in critically ill patients. Since insufficient delivery of oxygen is discussed, we investigated the influence of oxygen delivery, hemoglobin, arterial oxygen saturation, cardiac index and the systemic vascular resistance index on the development of intestinal ischemia. Furthermore, we evaluated the predictive power of elevated lactate levels for the diagnosis of intestinal ischemia. Methods In a retrospective case-control study data (mean oxygen delivery, minimum oxygen delivery, systemic vascular resistance index) of critical ill patients from 02/2009–07/2017 were analyzed using a proportional hazard model. General model fit and linearity were tested by likelihood ratio tests. The components of oxygen delivery (hemoglobin, arterial oxygen saturation and cardiac index) were individually tested in models. Results 59 out of 874 patients developed intestinal ischemia. A mean oxygen delivery less than 250ml/min/m2 (LRT vs. null model: p = 0.018; LRT for non-linearity: p = 0.012) as well as a minimum oxygen delivery less than 400ml/min/m2 (LRT vs null model: p = 0.016; LRT for linearity: p = 0.019) were associated with increased risk of the development of intestinal ischemia. We found no significant influence of hemoglobin, arterial oxygen saturation, cardiac index or systemic vascular resistance index. Receiver operating characteristics analysis for elevated lactate levels, pH, CO2 and central venous saturation was poor with an area under the receiver operating characteristic of 0.5324, 0.52, 0.6017 and 0.6786. Conclusion There was a significant correlation for mean and minimum oxygen delivery with the incidence of intestinal ischemia for values below 250ml/min/m2 respectively 400ml/min/m2. Neither hemoglobin, arterial oxygen saturation, cardiac index, systemic vascular resistance index nor elevated lactate levels could be identified as individual risk factors.
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Affiliation(s)
- Jochen J. Schoettler
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
- * E-mail:
| | - Thomas Kirschning
- Clinic for Thorax- and Cardiovascular Surgery HDZ NRW, University of Ruhr-University Bochum, Bochum, Germany
| | - Michael Hagmann
- Interdisciplinary Center for Scientific Computing, Heidelberg University, Heidelberg, Germany
| | - Bianka Hahn
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Anna-Meagan Fairley
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Franz-Simon Centner
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Verena Schneider-Lindner
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Florian Herrle
- Surgical Department, University Medical Center Mannheim, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Emmanouil Tzatzarakis
- Surgical Department, University Medical Center Mannheim, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Manfred Thiel
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Joerg Krebs
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
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Zerillo J, Kim S, Hill B, Shapiro D, Lin HM, Burnham A, Moon J, Iyer K, DeMaria S. Anesthetic management for intestinal transplantation: A decade of experience. Clin Transplant 2017; 31. [PMID: 28801969 DOI: 10.1111/ctr.13085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intestinal transplantation (ITx) is the definitive therapy for patients suffering from intestinal failure. Previously published reports suggest that these cases should be managed perioperatively with the same intensive monitors and techniques as in liver transplantation. METHODS We retrospectively reviewed the anesthetic management of 67 isolated intestinal, intestinal-pancreas, and intestinal-kidney transplants over the previous decade (2005-2015) in our tertiary care institution. RESULTS Patients were typically managed with a single arterial line, a single central venous catheter, and rarely intensive modalities such as a pulmonary artery catheter, a transesophageal echocardiography, a second arterial catheter or central venous catheter, a rapid infusion system, a cell salvage device, or viscoelastic testing. Significant hemodynamic derangements were rare, and the rate of postreperfusion syndrome was 8.96%. Our fluid administration type and volume and transfusion type and volume were similar to previous reports in which more intensive anesthetic management was employed. CONCLUSION We demonstrate that ITx can safely occur without utilizing the intensive resources requisite for a liver transplant.
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Affiliation(s)
- Jeron Zerillo
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sang Kim
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Shapiro
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alyssa Burnham
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jang Moon
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kishore Iyer
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
The diagnosis of irreversible intestinal failure confers significant morbidity, mortality, and decreased quality of life. Patients with irreversible intestinal failure may be treated with intestinal transplantation. Intestinal transplantation may include intestine only, liver-intestine, or other visceral elements. Intestinal transplantation candidates present with systemic manifestations of intestinal failure requiring multidisciplinary evaluation at an intestinal transplantation center. Central access may be difficult in intestinal transplantation candidates. Intestinal transplantation is a complex operation with potential for hemodynamic and metabolic instability. Patient and graft survival are improving, but graft failure remains the most common postoperative complication.
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Affiliation(s)
- Christine Nguyen-Buckley
- Department of Anesthesiology, David Geffen School of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Suite 3304, Los Angeles, CA 90095, USA.
| | - Melissa Wong
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
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Dalal A. Intestinal transplantation: The anesthesia perspective. Transplant Rev (Orlando) 2015; 30:100-8. [PMID: 26683875 DOI: 10.1016/j.trre.2015.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 06/30/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
Intestinal transplantation is a complex and challenging surgery. It is very effective for treating intestinal failure, especially for those patients who cannot tolerate parenteral nutrition nor have extensive abdominal disease. Chronic parental nutrition can induce intestinal failure associated liver disease (IFALD). According to United Network for Organ Sharing (UNOS) data, children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list when compared with all candidates for solid organ transplantation. Intestinal transplant grafts can be isolated or combined with the liver/duodenum/pancreas. Organ Procurement and Transplantation Network (OPTN) has defined intestinal donor criteria. Living donor intestinal transplant (LDIT) has the advantages of optimal timing, short ischemia time and good human leukocyte antigen matching contributing to lower postoperative complications in the recipient. Thoracic epidurals provide excellent analgesia for the donors, as well as recipients. Recipient management can be challenging. Thrombosis and obstruction of venous access maybe common due to prolonged parenteral nutrition and/or hypercoaguability. Thromboelastography (TEG) is helpful for managing intraoperative product therapy or thrombosis. Large fluid shifts and electrolyte disturbances may occur due to massive blood loss, dehydration, third spacing etc. Intestinal grafts are susceptible to warm and cold ischemia and ischemia-reperfusion injury (IRI). Post-reperfusion syndrome is common. Cardiac or pulmonary clots can be monitored with transesophageal echocardiography (TEE) and treated with recombinant tissue plasminogen activator. Vasopressors maybe used to ensure stable hemodynamics. Post-intestinal transplant patients may need anesthesia for procedures such as biopsies for surveillance of rejection, bronchoscopy, endoscopy, postoperative hemorrhage, anastomotic leaks, thrombosis of grafts etc. Asepsis, drug interactions between anesthetic and immunosuppressive agents and venous access are some of the anesthetic considerations for this group.
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Affiliation(s)
- Aparna Dalal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, United States.
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5
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Song X, Farmer D, Xia V. Intraoperative Management and Postoperative Outcome in Intestine-Inclusive Liver Transplantation Versus Liver Transplantation. Transplant Proc 2015; 47:2473-7. [DOI: 10.1016/j.transproceed.2015.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/03/2015] [Indexed: 10/22/2022]
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Llanos JC, Ruiz P, Takahashi H, Delacruz V, Bakonyi Neto A. Outcome of pigs with short gut syndrome submitted to orthotopic intestinal transplantation. Acta Cir Bras 2015; 30:143-50. [PMID: 25714694 DOI: 10.1590/s0102-86502015002000009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/20/2015] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To evaluate the current model of small bowel resection and intestinal transplantation in pigs. METHODS Forty two Large White pigs were distributed in five groups: G1(n=6), G2(n=6) and G3(n=6) were submitted to 80%,100% and 100% plus right colon resection respectively and G4(n=7) and G5(n=5) to 100% SBR plus IT without and with immunosuppression based on Tacrolimus and Mycophenolic acid. Evaluation included weight control, clinical status, biochemical analysis and endoscopies for graft biopsies. Follow-up in G1 and 2 was 84 days, while in G3, four and five was ± three weeks. RESULTS G1 increased weight suggesting adaptation while G2 and 3 loused weight and inadequate adaptation. G4 and 5 died of acute cellular rejection (ACR) and sepses respectively. Overall survival in G1, 2, 3, 4 and 5 at 30 days was 100, 100, 0 and 20 %, respectively. Medium survival in G4 and 5 was 14 and 16 days. CONCLUSIONS The resection of 80% of small intestine in pigs is not suitable for short bowel syndrome induction. Intestinal transplantation with the proposed immunosuppression protocol was effective in prevent the occurrence of severe acute rejection, but inappropriate to increase recipients survival.
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Affiliation(s)
- Juan Carlos Llanos
- Department of Surgery and Orthopedics, Botucatu Medical School, State University of Sao Paulo, Brasil
| | - Philip Ruiz
- Division of Transplantation, Department of Immunopathology, University of Miami School of Medicine, Miami, Florida, USA
| | - Hidenori Takahashi
- Division of Transplantation, Department of Immunopathology, University of Miami School of Medicine, Miami, Florida, USA
| | - Victor Delacruz
- Division of Transplantation, Department of Immunopathology, University of Miami School of Medicine, Miami, Florida, USA
| | - Alexandre Bakonyi Neto
- Department of Surgery and Orthopedics, Botucatu Medical School, State University of Sao Paulo, Brasil
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Park YS, Oh JY, Hwang BY, Moon Y, Lee HM, Hwang GS. Prolonged post-reperfusion syndrome during multivisceral organ transplantation in a pediatric patient: a case report. Korean J Anesthesiol 2014; 66:467-71. [PMID: 25006372 PMCID: PMC4085269 DOI: 10.4097/kjae.2014.66.6.467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 03/18/2013] [Accepted: 03/29/2013] [Indexed: 11/21/2022] Open
Abstract
Multivisceral organ transplantation involves the transplantation of three or more abdominal organs, including small bowel, duodenum, stomach, liver, pancreas, colon, and so on. The large amounts of cold and acidic loading into systemic circulation from the graft during multivisceral organ transplantation may result in severe post-reperfusion syndrome (PRS). We describe here a 6-year-old pediatric patient with chronic intestinal pseudo-obstruction who experienced prolonged PRS and severe metabolic acidosis during seven abdominal organ transplantation including the liver, spleen, stomach, duodenum, small bowel, colon and pancreas. The hypotensive period lasted approximately 10 minutes after graft reperfusion and was accompanied by severe metabolic acidosis and hypothermia. Since PRS can be easily associated with adverse outcomes, such as poor early graft function and primary non-function, not only meticulous surveillance for aggravating factors for PRS but also their immediate correction were necessary in managing a pediatric patient undergoing multivisceral organ transplantation.
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Affiliation(s)
- Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Young Oh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Young Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngjin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa-Mi Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Combined Liver-Intestine Grafts Compared With Isolated Intestinal Transplantation in Children. Transplantation 2012; 94:859-65. [DOI: 10.1097/tp.0b013e318265c508] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Siniscalchi A, Cucchetti A, Miklosova Z, Lauro A, Zanoni A, Spedicato S, Bernardi E, Aurini L, Pinna AD, Faenza S. Post-reperfusion syndrome during isolated intestinal transplantation: outcome and predictors. Clin Transplant 2011; 26:454-60. [PMID: 22004008 DOI: 10.1111/j.1399-0012.2011.01530.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Post-reperfusion syndrome (PRS) during isolated intestinal transplantation (ITx) is characterized by decreased systemic blood pressure, systemic vascular resistance, and cardiac output and by a moderate increased pulmonary arterial pressure. We hypothesize that the more severe PRS causes a poorer long-term outcome. The primary aim of this study was to determine the independent clinical predictors of intra-operative PRS, as well as to investigate the link between the severity of PRS and the intra-operative profiles and to examine the post-operative complications and their relationship with transplant outcome. METHODS This observational study was conducted on 27 patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure was 30% lower than the pre-unclamping value and lasted for at least one min within 10 min after unclamping. RESULTS AND CONCLUSIONS The main results of this study can be summarized in two findings: in patients undergoing ITx, the duration of cold ischemia and the pre-operative glomerular filtration rate were independent predictors of PRS and the occurrence of intra-operative PRS was associated with significantly more frequent post-operative renal failure and early post-operative death.
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Affiliation(s)
- Antonio Siniscalchi
- Department of Anesthesiology, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
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Evaluation of hemodynamic, metabolic, and electrolytic changes after graft reperfusion in a porcine model of intestinal transplantation. Transplant Proc 2010; 42:87-91. [PMID: 20172287 DOI: 10.1016/j.transproceed.2009.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to establish an anesthetic protocol to evaluate the hemodynamic, metabolic, and electrolytic changes after graft reperfusion in pigs undergoing orthotopic intestinal transplant (ITx). METHODS Fifteen pigs were distributed into two groups: GI (n = 6), without immunosuppression, and GII (n = 9), immunosuppressed before surgery with tacrolimus (0.3 mg/kg). The animals were premedicated at 1 hour before surgery with IM acepromazine (0.1 mg/kg), morphine (0.4 mg/kg), ketamine (10 mg/kg), and atropine (0.044 mg/kg IM). Anesthesia induction used equal proportions of diazepam and ketamine (0.1-0.15 mL/kg/IV) and for maintenance in IV infusion of xylazine (1 mg/mL), ketamine (2 mg/mL), and guaiacol glyceryl ether 5% (50 mg/mL), diluted in 250 mL of 5% glucose solution. In addition, recipient pigs were treated with isofluorane inhalation. Heart rate (HR), systolic (SAP), mean (MAP), and diastolic (DAP) arterial pressure, pulse oximetry, respiratory frequency (f), capnography, body temperature (T), blood gas analysis (pH, Paco(2), Pao(2), base excess, BE; Hco(3)(-), Sato(2)), serum potassium (K), calcium (Ca), sodium, hematocrit (Hct), and glucose (Glu) were measured at four times; M0: after incision (basal value); M1: 10 minutes before reperfusion; and M2 and M3: 10 and 20 minutes after graft reperfusion. RESULTS All groups behaved in a similar pattern. There was significant hypotension after graft reperfusion in GI and GII (M2 = 56.2 +/- 6.4 and M3 = 57.2 +/- 8.3 mm Hg and M2 = 65.7 +/- 10.2 and M3 = 67.8 +/- 16.8 mm Hg, respectively), accompanied by elevated HR. The ETco(2) was elevated at M2 (42 mm Hg) and M3 (40 mm Hg). Metabolic acidosis was observed after reperfusion, with significant increase in K levels. CONCLUSION The anesthetic protocol for donors and recipients was safe to perform the procedure, allowing control of hemodynamic and metabolic changes after reperfusion without differences regarding immunosuppression.
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Siniscalchi A, Piraccini E, Miklosova Z, Bagni A, D'Errico A, Cucchetti A, Lauro A, Pinna AD, Faenza S. Metabolic, Coagulative, and Hemodynamic Changes During Intestinal Transplant: Good Predictors of Postoperative Damage? Transplantation 2007; 84:346-50. [PMID: 17700159 DOI: 10.1097/01.tp.0000275376.63674.1c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Analysis of intraoperative changes of metabolic, hemodynamic, and coagulative parameters is useful to detect early ischemia-reperfusion damage after intestinal transplant. METHODS The objective of our study is to correlate the histological damage at the end of transplant in relation to the intraoperative changes after reperfusion. The histological aspect was graded according to Park's classification at the end of the surgical procedure with biopsies of the graft. Patients were divided into two groups according to the presence or absence of histological damage of the small bowel wall: group A (normal mucosa/minimal damage: Park's grades 0-1) and group B (mucosal damage: Park's grades 2-8). RESULTS Significant hemodynamic, metabolic, and coagulative disorders were observed in group B. Consequently, these disorders are thought to be early indicators of graft damage. CONCLUSIONS Actual monitoring procedures used for postoperative graft surveillance remain paramount in detecting postoperative intestinal dysfunction, but the indicators described in this paper could represent a further help in intraoperative and postoperative management.
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