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Kapoor PM, Oza P, Goyal V, Mehta Y, Kanchi M. Extracorporeal Membrane Oxygenation Carbon Dioxide Removal. JOURNAL OF CARDIAC CRITICAL CARE TSS 2023. [DOI: 10.25259/mm_jccc_304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Protective lung ventilation is the mainstay ventilation strategy for patients on extracorporeal membrane oxygenation (ECMO), as prolonged mechanical ventilation increases morbidity and mortality; the technicalities of ventilation with ECMO have evolved in the last decade. ECMO on the other end of the spectrum is a complete or total extracorporeal support, which supplies complete physiological blood gas exchanges, normally performed by the native lungs and thus is capable of delivering oxygen (O2) and removing CO equal to the metabolic needs of the patient, it requires higher flows, is more complex, and uses bigger cannulas, higher dose of heparin and higher blood volume for priming. This review describes in detail carbon dioxide removal on ECMO.
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Affiliation(s)
| | - Pranay Oza
- Department of ECMO, RVCC, Mumbai, Maharashtra, India,
| | - Venkat Goyal
- Department of ECMO, RVCC, Mumbai, Maharashtra, India,
| | - Yatin Mehta
- Department of ECMO, RVCC, Mumbai, Maharashtra, India,
| | - Muralidhar Kanchi
- Department of Anesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, Narayana Health City, Bommasandra, Karnataka, India,
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Past and present role of extracorporeal membrane oxygenation in combat casualty care: How far will we go? J Trauma Acute Care Surg 2019; 84:S63-S68. [PMID: 29443864 DOI: 10.1097/ta.0000000000001846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advanced extracorporeal therapies have been successfully applied in the austere environment of combat casualty care over the previous decade. In this review, we describe the historic underpinnings of extracorporeal membrane oxygenation, review the recent experience with both partial and full lung support during combat operations, and critically assess both the current status of the Department of Defense extracorporeal membrane oxygenation program and the way forward to establish long-range lung rescue therapy as a routine capability for combat casualty care.
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Partridge EA, Davey MG, Hornick M, Dysart KC, Olive A, Caskey R, Connelly JT, Hedrick HL, Peranteau WH, Flake AW. Pumpless arteriovenous extracorporeal membrane oxygenation: A novel mode of respiratory support in a lamb model of congenital diaphragmatic hernia. J Pediatr Surg 2018; 53:1453-1460. [PMID: 29605270 DOI: 10.1016/j.jpedsurg.2018.02.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is commonly required in neonates with congenital diaphragmatic hernia (CDH) complicated by pulmonary hypertension (PH). ECMO carries significant risk, and is contraindicated in the setting of extreme prematurity or intracranial hemorrhage. Pumpless arteriovenous ECMO (P-ECMO) may represent an alternative for respiratory support. The present study summarizes our initial experience with P-ECMO in a lamb model of CDH. STUDY DESIGN Surgical creation of CDH was performed at 65-75days' gestation. At term (135-145days), lambs were delivered into the P-ECMO circuit. Three animals were maintained on a low-heparin infusion protocol (target ACT 160-180) and three animals were maintained with no systemic heparinization. RESULTS Animals were supported by the circuit for 380.7 +/- 145.6h (range, 102-504h). Circuit flow rates ranged from 97 to 208ml/kg/min, with adequacy of organ perfusion demonstrated by stable serum lactate levels (3.0 +/- 1.7) and pH (7.4 +/- 0.3). Necropsy demonstrated no evidence of thrombogenic complications. CONCLUSION Pumpless extracorporeal membrane oxygenation achieved support of CDH model lambs for up to three weeks. This therapy has the potential to bridge neonates with decompensated respiratory failure to CDH repair with no requirement for systemic anticoagulation, and may be applicable to patients currently precluded from conventional ECMO support.
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Affiliation(s)
- Emily A Partridge
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Matthew Hornick
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Kevin C Dysart
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Aliza Olive
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Robert Caskey
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - James T Connelly
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Holly L Hedrick
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - William H Peranteau
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104.
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Slack A, Hogan BJ, Wendon J. Acute Hepatic Failure. LIVER ANESTHESIOLOGY AND CRITICAL CARE MEDICINE 2018. [PMCID: PMC7121978 DOI: 10.1007/978-3-319-64298-7_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW Increased understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in the development of core physiological targets and therapies to preserve cerebral oxygenation, and in doing so prevent secondary insult. This review addresses the many systemic complications of TBI that make achieving these targets challenging and can influence outcome. RECENT FINDINGS There are a wide range of systemic complications following TBI. Complications involve the cardiovascular, respiratory, immunological, haematological and endocrinological systems amongst others, and can influence early management and long-term outcomes. SUMMARY Effective management of TBI should go beyond formulaic-based pursuit of physiological targets and requires a detailed understanding of the multisystem response of the body.
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Extracorporeal support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S111-7. [PMID: 26035361 DOI: 10.1097/pcc.0000000000000439] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Extracorporeal life support has undergone a revolution in the past several years with the advent of new, miniaturized equipment and success in supporting patients with a variety of illnesses. Most experience has come with the use of extracorporeal membrane oxygenation, a modified form of cardiopulmonary bypass that can support the heart, lungs, and circulation for days to months at a time. To describe the recommendations for the use of extracorporeal membrane oxygenation in children with pediatric acute respiratory distress syndrome based on a review of the literature and expert opinion. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The extracorporeal support subgroup comprised two international experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 11 of which related to extracorporeal support. All recommendations had agreement, with 10 recommendations (91%) achieving strong agreement. These recommendations included the utilization of extracorporeal support for reversible causes of pediatric acute respiratory distress syndrome, consideration of quality of life when making the decision to use extracorporeal support, and the use of the Extracorporeal Life Support Organization registry to report all extracorporeal support activity, among others. CONCLUSIONS Pediatric extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome could benefit from more specific data collection and collaboration of focused investigators to establish validated criteria for optimal application of extracorporeal membrane oxygenation and patient management protocols. Until that time, consensus opinion offers some insight into guidelines.
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Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia. Curr Opin Crit Care 2014; 19:594-8. [PMID: 24240825 DOI: 10.1097/mcc.0000000000000034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Survival from traumatic cardiac arrest is associated with a very high mortality despite aggressive resuscitation including an Emergency Department thoracotomy (EDT). Novel salvage techniques are needed to improve these outcomes. RECENT FINDINGS More aggressive out-of-hospital interventions, such as chest decompression or thoracotomy by emergency physicians or anesthesiologists, seem feasible and show some promise for improving outcomes. For trauma patients who suffer severe respiratory failure or refractory cardiac arrest, there seems to be an increasing role for the use of extracorporeal life support (ECLS), utilizing heparin-bonded systems to avoid systemic anticoagulation. The development of exposure hypothermia is associated with poor outcomes in trauma patients, but preclinical studies have consistently demonstrated that mild, therapeutic hypothermia (34 °C) improves survival from severe hemorrhagic shock. Sufficient data exist to justify a clinical trial. For patients who suffer a cardiac arrest refractory to EDT, induction of emergency preservation and resuscitation by rapid cooling to a tympanic membrane temperature of 10 °C may preserve vital organs long enough to allow surgical hemostasis, followed by resuscitation with cardiopulmonary bypass. SUMMARY Salvage techniques, such as earlier thoracotomy, ECLS, and hypothermia, may allow survival from otherwise lethal injuries.
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Techniques d’assistance respiratoire veinoveineuses et alternatives au cours du syndrome de détresse respiratoire aiguë. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-014-0873-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hayes D, Tobias JD, Kukreja J, Preston TJ, Yates AR, Kirkby S, Whitson BA. Extracorporeal life support for acute respiratory distress syndromes. Ann Thorac Med 2013; 8:133-41. [PMID: 23922607 PMCID: PMC3731854 DOI: 10.4103/1817-1737.114290] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 01/21/2023] Open
Abstract
The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure.
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Affiliation(s)
- Don Hayes
- Section of Pulmonary Medicine, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph D. Tobias
- Section of Anesthesiology, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco Medical Center, San Francisco, CA, USA
| | - Thomas J. Preston
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
| | - Andrew R. Yates
- Section of Cardiology, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stephen Kirkby
- Section of Pulmonary Medicine, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A. Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Slinger P. Are lung-protective ventilation strategies worth the effort? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2013. [DOI: 10.1080/22201173.2013.10872890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Slinger P, Kilpatrick B. Perioperative lung protection strategies in cardiothoracic anesthesia: are they useful? Anesthesiol Clin 2012; 30:607-28. [PMID: 23089498 DOI: 10.1016/j.anclin.2012.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients are at risk for several types of lung injury in the perioperative period. These injuries include atelectasis, pneumonia, pneumothorax, bronchopleural fistula, acute lung injury, and acute respiratory distress syndrome. Anesthetic management can cause, exacerbate, or ameliorate most of these injuries. Lung-protective ventilation strategies using more physiologic tidal volumes and appropriate levels of positive end-expiratory pressure can decrease the extent of this injury. This review discusses the effects of mechanical ventilation and its role in ventilator-induced lung injury with specific reference to cardiothoracic anesthesia.
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Affiliation(s)
- Peter Slinger
- Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Baker A, Richardson D, Craig G. Extracorporeal Carbon Dioxide Removal (ECCO2R) in Respiratory Failure: An Overview, and where Next? J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is used to facilitate protective ventilation strategies and to treat severe hypercapnic acidosis that is refractory to mechanical ventilation. There is an increasing amount of interest in the use of ECCO2R but there are no recommendations for its use that take the most recent evidence into account. In 2008, the National Institute of Health and Clinical Excellence (NICE) published guidelines on ‘Arteriovenous Extracorporeal Membrane Carbon Dioxide Removal.’1 However, since that time there have been a number of studies in the area and some significant technological advances including the introduction of commercially available VV-ECCO2R systems. The aim of this article is to provide an overview of ECCO2R, review the literature relating to its use and discuss its future role in the intensive care setting.
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Affiliation(s)
- Andrew Baker
- Specialist Trainee year 7, Anaesthetics and Intensive Care Medicine, Southampton General Hospital
| | - Dominic Richardson
- Consultant in Anaesthetics and Intensive Care Medicine, Southampton General Hospital
| | - Gordon Craig
- Consultant in Anaesthetics and Intensive Care medicine, Queen Alexandra Hospital, Portsmouth
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Frade Mera MJ, Vergara Díez L, Fernández Gaute N, Montes Gil D. [Decubitus prone position in patient with extracorporeal CO2 removal device Novalung(®)]. ENFERMERIA INTENSIVA 2012; 23:132-41. [PMID: 22726348 DOI: 10.1016/j.enfi.2012.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 04/17/2012] [Accepted: 04/19/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the course of a patient with the extracorporeal CO2 removal device and discover the effect of Novalung on ventilation, considering the patient's prone position and its influence on the device's blood flow. To develop a protocol of managing and specific care of a patient with Novalung. MATERIAL AND METHODS A case report of a patient with Novalung in a tertiary hospital ICU unit is reported. Parameters considered are hemodynamic, respiratory, pharmacological, analytical, neuromonitoring, managing of the Novalung and length of decubitus prone cycles. Anova Test, Student's T test, Wilcoxon-Mann Whitney and Spearman correlation. Significance p <0.05. RESULTS A 46-year old women with nosocomial pneumonia and acute respiratory failure with indication of Novalung to decrease hypercapnia and optimize ventilatory management of refractory hypoxemia. ICU Stay 26 days, MBP 82 ± 9 mmHg, HR 110 ± 6l pm during the admission, monitoring PICCO 5 days CI 3.2 ± 0.8 l/min/m2, ELWI 33 ± 4 ml, continuous hemofiltration 13.2 days with a median removal 50 cc/h. Norepinephrine dose 0.68 ± 0.79 μ/kg/min for 15 days. Respiratory parameters during the admission: PO2 59 ± 13 mmHg, PCO2 68 ± 35 mmHg, SatO2 85 ± 12%, PO2/FIO2 69 ± 35, tidal volume 389 ± 141 cc. Novalung® 13 days, heparin dose 181.42 ± 145 mIU/Kg/min, Cephalin time 57.56 ± 16.41 sec, O2 flow 7 ± 3 l/min, median blood flow 1030 cc/h, interquartile range 1447-612 cc/h. Prone cycles 4, duration 53 ± 27 hours. With Novalung® PCO2 decreased regardless of position 66 ± 21:56 ± 9, p=0.005. Tidal volume 512 ± 67:267 ± 72, p=0.0001. Blood flow on supine-prone position 1053 ± 82:113 ± 112, p=0.001. There was no link between blood flow and PCO2 (p=0.2) and between O2 and PO2 flow (p=0.05). Specific care: pedal and tibial pulse monitoring, keep circuit safe to prevent and detect signs of bleeding, femoral arterial and venous catheter care, coagulation monitoring. COMMENTS During the use of Novalung protective, ventilation, low tidal volumes, decreased pressure plateau, PEEP and hypercapnia were achieved. Blood flow decreased in prone position, but the PCO2 did not increase. The device did not coagulate.
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Affiliation(s)
- M J Frade Mera
- Servicio de Medicina Intensiva, Polivalente del Hospital Universitario 12 de Octubre, Madrid, España.
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Abstract
Acute respiratory distress syndrome remains one of the most clinically vexing problems in critical care. As technology continues to evolve, it is likely that extracorporeal CO(2) removal devices will become smaller, more efficient, and safer. As the risk of extracorporeal support decreases, devices' role in acute respiratory distress syndrome patients remains to be defined. This article discusses the functional properties and management techniques of CO(2) removal and intracorporeal membrane oxygenation and provides a glimpse into the future of long-term gas-exchange devices.
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McNicholas JJK, Henning JD. Major military trauma: decision making in the ICU. J ROY ARMY MED CORPS 2011; 157:S284-8. [PMID: 22049809 DOI: 10.1136/jramc-157-03s-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The management of trauma in the field intensive care unit has evolved in recent years. Key issues in current practice and organisation are discussed, with particular attention to areas where civilian and military practice differs. Possible future improvements are explored.
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Abstract
Patients are at risk for several types of lung injury in the perioperative period including atelectasis, pneumonia, pneumothorax, acute lung injury, and acute respiratory distress syndrome. Anaesthetic management can cause, exacerbate, or ameliorate these injuries. This review examines the effects of perioperative mechanical ventilation and its role in ventilator-induced lung injury. Lung protective ventilatory strategies to specific clinical situations such as cardiopulmonary bypass and one-lung ventilation along with newer novel lung protective strategies are discussed.
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Affiliation(s)
- B Kilpatrick
- Department of Anaesthesia, 3 EN, The Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4.
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