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Hentati A, Ayed AB, Jdidi J, Chaari Z, Halima GB, Frikha I. Enhanced recovery after thoracic surgery in low- and middle-income countries: Feasibility and outcomes. Asian Cardiovasc Thorac Ann 2024; 32:27-35. [PMID: 37993978 DOI: 10.1177/02184923231216131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) applies multimodal, perioperative, and evidence-based practices to decrease postoperative morbi-mortality, the length of hospital stay, and hospitalization costs. Implementing enhanced recovery after thoracic surgery (ERATS) in low- and middle-income countries (LMIC) is problematic. This randomized controlled trial evaluated the feasibility and effectiveness of an ERATS protocol adapted to LMIC conditions in Tunisia. MATERIALS AND METHODS We conducted this randomized controlled trial between December 2015 and August 2017 in the Thoracic and Cardiovascular Surgery Department at Habib Bourguiba University Hospital of Sfax, Tunisia. RESULTS One hundred patients undergoing thoracic surgery were randomly allocated to the ERATS group or Control group. During the postoperative phase, 13 patients (13%) were excluded secondary. These complication rates were lower in the ERATS group: lack of reexpansion (14.63% vs 16.10%: p = 0.72), pleural effusion (0% vs 10.86%, p = 0.05), and prolonged air leak (17.07% vs 30.43%, p = 0.14). The pain level decreased significantly in the ERATS group from postoperative H3 (p = 0.006). This difference was significant at H6 (p = 0.001), H24 (p = 0.05), H48 (p = 0.01), discharge (p = 0.002), and after 15 days (p = 0.01), with a decreased analgesic consumption. The length of hospital stay was shorter in the ERAS group (median six days vs seven days, p = 0.17). CONCLUSION This study provides an adapted ERATS protocol, applicable regardless of the surgical approach or the type of resection and suitable for LMIC hospital's conditions. This protocol can improve the postoperative outcomes of thoracic surgery.
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Affiliation(s)
- Abdessalem Hentati
- University of Sfax Faculty of Medicine of Sfax, Sfax, Tunisia
- Department of Cardiovascular and Thoracic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Ahmed Ben Ayed
- University of Sfax Faculty of Medicine of Sfax, Sfax, Tunisia
- Surgery Department, Gabes University Hospital, Gabes, Tunisia
| | - Jihen Jdidi
- University of Sfax Faculty of Medicine of Sfax, Sfax, Tunisia
- Community Medicine Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Zied Chaari
- University of Sfax Faculty of Medicine of Sfax, Sfax, Tunisia
- Department of Cardiovascular and Thoracic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Ghassen Ben Halima
- University of Sfax Faculty of Medicine of Sfax, Sfax, Tunisia
- Department of Cardiovascular and Thoracic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Imed Frikha
- University of Sfax Faculty of Medicine of Sfax, Sfax, Tunisia
- Department of Cardiovascular and Thoracic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia
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de Boer HD, Scott MJ, Fawcett WJ. Anaesthesia role in enhanced recovery after surgery: a revolution in care outcomes. Curr Opin Anaesthesiol 2023; 36:202-207. [PMID: 36745085 DOI: 10.1097/aco.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Enhanced recovery after surgery (ERAS) has revolutionized care outcomes. The purpose of this review is to provide an overview of how ERAS changed healthcare outcomes. RECENT FINDINGS Development of multidisciplinary evidence-based ERAS guidelines for specific surgical specialties and systematic implementation of these guidelines resulted in improved healthcare outcomes, reduction in length of stay, reduction in complications and improved survival. The value of audit of the outcomes is essential for implementation and to improve healthcare. Healthcare economics analysis related to the implementation of ERAS showed significant cost savings up to a return to investment ratio of more than seven. SUMMARY ERAS has revolutionized healthcare by developing evidence-based ERAS guidelines and systematic implementation of these guidelines. Audit of outcomes is essential, not only to improve healthcare but also to significantly save healthcare expenditures.
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Affiliation(s)
- Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
| | - Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital, Guildford, UK
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Thomas M, Agarwal V, DeSouza A, Joshi R, Mali M, Panhale K, Salvi OK, Ambulkar R, Shrikhande S, Saklani A. Enhanced recovery pathway in open and minimally invasive colorectal cancer surgery: a prospective study on feasibility, compliance, and outcomes in a high-volume resource limited tertiary cancer center. Langenbecks Arch Surg 2023; 408:99. [PMID: 36811742 DOI: 10.1007/s00423-023-02832-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Enhanced recovery program (ERP) has demonstrated improved postoperative outcomes with increased compliance to pathway. However, there is scarce data on feasibility and safety in resource limited setting. The objective was to assess compliance with ERP and its impact on postoperative outcomes and return to intended oncological treatment (RIOT). METHODS A single center prospective observational audit was conducted from 2014 to 2019, in elective colorectal cancer surgery. Before implementation, multi-disciplinary team was educated regarding ERP. Compliance to ERP protocol and its elements was recorded. Impact of quantum of compliance (≥80% vs. <80%) to ERP on postoperative morbidity, mortality, readmission, stay, re-exploration, functional GI recovery, surgical-specific complications, and RIOT was evaluated for open and minimal invasive surgery (MIS). RESULTS During study, 937 patients underwent elective colorectal cancer surgery. Overall compliance with ERP was 73.3%. More than 80% compliance was observed in 332 (35.4%) patients in the entire cohort. Patients with <80% compliance had significantly higher overall, minor and surgery-specific complications, longer postoperative stay, delayed functional GI recovery for both open and MIS procedures. RIOT was observed in 96.5% patients. Duration to RIOT was significantly shorter following open surgery with ≥80% compliance. Compliance <80% to ERP was identified as one of the independent predictors for developing postoperative complications. CONCLUSION The study demonstrates beneficial impact of increased compliance to ERP on postoperative outcomes following open and minimally invasive surgery for colorectal cancer. Within a resource limited setting, ERP was found to feasible, safe, and effective in both open and minimally invasive colorectal cancer surgery.
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Affiliation(s)
- Martin Thomas
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
- Department of Intensive Care Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Vandana Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
| | - Ashwin DeSouza
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Riddhi Joshi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Minal Mali
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
- King Edward Memorial Hospital, Mumbai, Maharashtra, 400012, India
| | - Karuna Panhale
- Research Nurse, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Omkar K Salvi
- Research Statistician, Clinical Research Secretariat, Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, 400012, India
| | - Reshma Ambulkar
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Shailesh Shrikhande
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
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Pilkington M, Nelson G, Cauley C, Holder K, Ljungqvist O, Molina G, Oodit R, Brindle ME. Development of an Enhanced Recovery After Surgery Surgical Safety Checklist Through a Modified Delphi Process. JAMA Netw Open 2023; 6:e2248460. [PMID: 36753283 DOI: 10.1001/jamanetworkopen.2022.48460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
IMPORTANCE Enhanced Recovery After Surgery (ERAS) guidelines and the World Health Organization Surgical Safety Checklist (SSC) are 2 well-established tools for optimizing patient outcomes perioperatively. OBJECTIVE To integrate the 2 tools to facilitate key perioperative decision-making. EVIDENCE REVIEW Snowball sampling recruited international ERAS users from multiple clinical specialties. A 3-round modified Delphi consensus model was used to evaluate 27 colorectal or gynecologic oncology ERAS recommendations for appropriateness to include in an ERAS SSC. Items attaining potential consensus (65%-69% agreement) or consensus (≥70% agreement) were used to develop ERAS-specific SSC prompts. These proposed prompts were evaluated in a second round by the panelists with regard to inclusion, modification, or exclusion. A final round of interactive discussion using quantitative consensus and qualitative comments was used to produce an ERAS-specific SSC. The panel of ERAS experts included surgeons, anesthesiologists, and nurses within diverse practice settings from 19 countries. Final analysis was conducted in May 2022. FINDINGS Round 1 was completed by 105 experts from 18 countries. Eleven ERAS components met criteria for development into an SSC prompt. Round 2 was completed by 88 experts. There was universal consensus (≥70% agreement) to include all 37 proposed prompts within the 3-part ERAS-specific SSC (used prior to induction of anesthesia, skin incision, and leaving the operating theater). A third round of qualitative comment review and expert discussion was used to produce a final ERAS-specific SSC that expands on the current WHO SSC to include discussion of analgesia strategies, nausea prevention, appropriate fasting, fluid management, anesthetic protocols, appropriate skin preparation, deep vein thrombosis prophylaxis, hypothermia prevention, use of foley catheters, and surgical access. The final products of this work included an ERAS-specific SSC ready for implementation and a set of recommendations to integrate ERAS elements into existing SSCs. CONCLUSIONS AND RELEVANCE The SSC could be modified to align with ERAS recommendations for patients undergoing major surgery within an ERAS protocol. The stakeholder- and expert-generated ERAS SSC could be adopted directly, or the recommendations for modification could be applied to an existing institutional SSC to facilitate implementation.
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Affiliation(s)
- Mercedes Pilkington
- Formerly at Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Surgery, Division of Pediatric Surgery, University of Toronto, Toronto, Canada
- Ariadne Labs, Harvard School of Public Health, Harvard University, Boston, MA
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Canada
| | - Christy Cauley
- Ariadne Labs, Harvard School of Public Health, Harvard University, Boston, MA
| | | | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - George Molina
- Ariadne Labs, Harvard School of Public Health, Harvard University, Boston, MA
| | - Ravi Oodit
- Global Surgery, University of Cape Town, Cape Town, South Africa
| | - Mary E Brindle
- Ariadne Labs, Harvard School of Public Health, Harvard University, Boston, MA
- Division of Pediatric Surgery, University of Calgary, Calgary, Canada
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Varallo JE, Ruto D, Patted A. Surgical Burden of Disease in Women. Obstet Gynecol Clin North Am 2022; 49:795-808. [DOI: 10.1016/j.ogc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Oodit R, Biccard BM, Panieri E, Alvarez AO, Sioson MRS, Maswime S, Thomas V, Kluyts HL, Peden CJ, de Boer HD, Brindle M, Francis NK, Nelson G, Gustafsson UO, Ljungqvist O. Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation. World J Surg 2022; 46:1826-1843. [PMID: 35641574 PMCID: PMC9154207 DOI: 10.1007/s00268-022-06587-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2022] [Indexed: 12/24/2022]
Abstract
Background This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle-income countries (LMIC’s) for elective abdominal and gynecologic care. Methods The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC’s. The group consisted of seven members from the ERAS® Society and eight members from LMIC’s. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC’s and LMIC’s were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC’s. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC’s and determined through discussions and consensus. Results In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline. Conclusions These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC’s.
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Affiliation(s)
- Ravi Oodit
- Division of Global Surgery, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Eugenio Panieri
- Division of General Surgery, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Adrian O Alvarez
- Anesthesia Department, Hospital Italiano de Buenos Aires, Teniente General Juan Domingo Peron, 4190, C1199ABB, Beunos Aires, Argentina
| | - Marianna R S Sioson
- Head Section of Medical Nutrition, Department of Medicine and ERAS Team, The Medical City, Ortigas Avenue, Manila, Metro Manila, Philippines
| | - Salome Maswime
- Division of Global Surgery, University of Cape Town, Anzio Road, Observatory, Cape Town, Western Cape, South Africa
| | - Viju Thomas
- Department of Obstetrics and Gynaecology, Tygerberg Hospital and University of Stellenbosch, Francie Van Zyl Drive, Parow, Cape Town, Western Cape, South Africa
| | - Hyla-Louise Kluyts
- Department of Anaesthesiology, Sefako Makgatho Health Sciences University, Medunsa, Molotlegi Street, P.O. Box 60, Ga-Rankuwa, Pretoria, 0204, Gauteng, South Africa
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Van Swietenplein 1, 9728 NT, Groningen, The Netherlands
| | - Mary Brindle
- Cumming School of Medicine, University of Calgary, London, Canada.,Alberta Children's Hospital, Calgary, Canada.,Safe Systems, Ariadne Labs, Stockholm, USA.,EQuIS Research Platform, Orebro, Canada
| | - Nader K Francis
- Division of Surgery and Interventional Science- UCL, Gower Street, London, WC1E 6BT, UK
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, 1331 29 St NW, Calgary, AB, T2N 4N2, Canada
| | - Ulf O Gustafsson
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Entrevägen 2, 19257, Stockholm, Danderyd, Sweden
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, 701 85, Örebro, Sweden.
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Priorities for content for a short-course on postoperative care relevant for low- and middle-income countries: an e-Delphi process with training facilitators. Anaesthesia 2022; 77:570-579. [PMID: 35319098 PMCID: PMC9315034 DOI: 10.1111/anae.15675] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/30/2022]
Abstract
Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low- and middle-income countries. Various short courses have been developed to improve patient outcomes in low- and middle-income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short-course addressing this topic using a Delphi process with low- and middle-income country anaesthesia providers trained as short-course facilitators. An initial questionnaire was co-developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south-east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high-income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short-course design rather than a one-size-fits-all model.
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Moyano JR, Santoyo MF. Letter to the Editor: ERAS Society Recommendations for Improving Perioperative Care in Low- and Middle-Income Countries Through Implementation of Existing Tools and Programs: An Urgent Need for the Surgical Safety Checklist and Enhanced Recovery After Surgery. World J Surg 2022; 46:1245-1246. [DOI: 10.1007/s00268-021-06428-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2021] [Indexed: 10/18/2022]
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Oodit R, Biccard B, Brindle M, Ljungqvist O, Nelson G. ERAS Society Recommendations for Improving Perioperative Care in Low- and Middle-Income Countries through Implementation of Existing Tools and Programs: An Urgent Need for the Surgical Safety Checklist and Enhanced Recovery After Surgery. World J Surg 2022. [PMID: 35182174 DOI: 10.1007/s00268-022-06450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
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Bajwa SJS, Mehdiratta L. Adopting newer strategies of perioperative quality improvement: The bandwagon moves on…. Indian J Anaesth 2021; 65:639-643. [PMID: 34764497 PMCID: PMC8577711 DOI: 10.4103/ija.ija_866_21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
| | - Lalit Mehdiratta
- Department of Anaesthesiology, Critical Care and Emergency Medicine, Narmada Trauma Centre, Bhopal, Madhya Pradesh, India
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