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Liebing N, Ziehr B, Röber S, Nibbe L, Oppert M, Warnke U. [Ward-based clinical pharmacists in intensive care medicine: an economic evaluation]. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-023-01102-y. [PMID: 38263495 DOI: 10.1007/s00063-023-01102-y] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/06/2023] [Accepted: 12/07/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND The positive impact of pharmaceutical care in improving medication safety is considered proven. Little is known about the economic benefit of clinical pharmaceutical services in Germany. OBJECTIVE In 2020, a pilot project was started at the Ernst von Bergmann Hospital to introduce ward-based clinical pharmacists in intensive care medicine, also in order to determine the economic benefit of the medication management offered. METHODS By a team of experienced intensive care physicians and clinical pharmacists on the basis of a consensus principle, each pharmaceutical intervention (PI) was assigned a probability score (Nesbit probability score) with which an adverse drug event (ADE) would have occurred. Assuming that each ADE results in an increased length of stay, the costs of intensive care treatment/day were used as potential savings. The model thereby combines the findings of two international publications to enable an economic analysis of pharmaceutical services. RESULTS During the study period, 177 pharmaceutical interventions were evaluated and corresponding probability scores for the occurrence of ADE were determined. From this, annual savings of € 80,000 through avoided costs were calculated. CONCLUSION In this project, the economic benefit of pharmaceutical services in intensive care medicine was proven. Ward-based clinical pharmacists are now an integral part of the intensive care treatment team at the Ernst von Bergmann Hospital.
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Affiliation(s)
- Nadja Liebing
- Apotheke, Klinikum Ernst von Bergmann gGmbH, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Benjamin Ziehr
- Apotheke, Klinikum Ernst von Bergmann gGmbH, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Susanne Röber
- Zentrum für Notfall- und Internistische Intensivmedizin, Klinikum Ernst von Bergmann gGmbH, Potsdam, Deutschland
| | - Lutz Nibbe
- Zentrum für Notfall- und Internistische Intensivmedizin, Klinikum Ernst von Bergmann gGmbH, Potsdam, Deutschland
| | - Michael Oppert
- Zentrum für Notfall- und Internistische Intensivmedizin, Klinikum Ernst von Bergmann gGmbH, Potsdam, Deutschland
| | - Ulrich Warnke
- Apotheke, Klinikum Ernst von Bergmann gGmbH, Charlottenstr. 72, 14467, Potsdam, Deutschland.
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Nibbe L. Ein risikoarmes Verfahren der Tracheostomie bei COVID-19-Patienten. Pneumo News 2020; 12:51-57. [PMID: 33354243 PMCID: PMC7746989 DOI: 10.1007/s15033-020-1950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Lutz Nibbe
- Zentrum für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann Potsdam, Charlottenstr. 72, 14467 Potsdam, Deutschland
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Nibbe L, Jungehülsing M, Röber S, Ripberger G, Oppert M. ["Hybrid tracheostomy": a low risk procedure for tracheostomy in COVID-19 patients]. Med Klin Intensivmed Notfmed 2020; 115:585-590. [PMID: 32757019 PMCID: PMC7403784 DOI: 10.1007/s00063-020-00710-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 07/04/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Tracheostomy in ventilated patients suffering from Coronavirus disease 2019 (COVID-19) carries an increased risk of exposure to virus-containing aerosol for the staff. OBJECTIVE Evaluation of a risk-reduced procedure for tracheostomy. METHOD Presentation of "hybrid tracheostomy": a method combining the advantages of conventional surgical and percutaneous dilative tracheostomy. RESULTS Tracheostomy of six patients using the hybrid method without any complications. CONCLUSION "Hybrid tracheostomy" offers a minimally invasive and safe procedure with low risk of exposure to virus-containing aerosol.
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Affiliation(s)
- L Nibbe
- Zentrum für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann Potsdam, Charlottenstr. 72, 14467, Potsdam, Deutschland.
| | - M Jungehülsing
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Klinikum Ernst von Bergmann Potsdam, Potsdam, Deutschland
| | - S Röber
- Zentrum für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann Potsdam, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - G Ripberger
- Zentrum für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann Potsdam, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - M Oppert
- Zentrum für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann Potsdam, Charlottenstr. 72, 14467, Potsdam, Deutschland
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Nee J, Koerner R, Zickler D, Schroeder T, Enghard P, Nibbe L, Hasper D, Buder R, Leithner C, Ploner CJ, Eckardt KU, Storm C, Kruse JM. Establishment of an extracorporeal cardio-pulmonary resuscitation program in Berlin - outcomes of 254 patients with refractory circulatory arrest. Scand J Trauma Resusc Emerg Med 2020; 28:96. [PMID: 32972428 PMCID: PMC7513459 DOI: 10.1186/s13049-020-00787-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/10/2020] [Indexed: 11/10/2022] Open
Abstract
Objective Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined. Design Prospective cohort study. Setting Tertiary referral university hospital center. Patients Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017. Intervention eCPR program for OHCA. Mesurements and main results A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR. State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol. Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p < 0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p < 0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality. Conclusion An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival.
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Affiliation(s)
- Jens Nee
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Roland Koerner
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lutz Nibbe
- Department of Emergency and Intensive Care Medicine, Ernst von Bergmann Klinikum, Charlottenstraße 72, 14467, Potsdam, Germany
| | - Dietrich Hasper
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Robert Buder
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jan M Kruse
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Huber K, Ducrocq G, Hamm CW, van 't Hof A, Lapostolle F, Coste P, Gordini G, Steinmetz J, Verheugt FWA, Adgey J, Nibbe L, Kaniĉ V, Clemmensen P, Zeymer U, Bernstein D, Prats J, Deliargyris EN, Gabriel Steg P. Early clinical outcomes as a function of use of newer oral P2Y 12 inhibitors versus clopidogrel in the EUROMAX trial. Open Heart 2017; 4:e000677. [PMID: 29225903 PMCID: PMC5708315 DOI: 10.1136/openhrt-2017-000677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/16/2017] [Accepted: 09/12/2017] [Indexed: 12/26/2022] Open
Abstract
Objective To ascertain whether different oral P2Y12 inhibitors might affect rates of acute stent thrombosis and 30-day outcomes after primary percutaneous coronary intervention (pPCI). Methods The European Ambulance Acute Coronary Syndrome Angiography (EUROMAX) randomised trial compared prehospital bivalirudin with heparin with optional glycoprotein IIb/IIIa inhibitor treatment in patients with ST-segment elevation myocardial infarction triaged to pPCI. Choice of P2Y12 inhibitor was at the investigator’s discretion. In a prespecified analysis, we compared event rates with clopidogrel and newer oral P2Y12 inhibitors (prasugrel, ticagrelor). Rates of the primary outcome (acute stent thrombosis) were examined as a function of the P2Y12 inhibitor used for loading and 30-day outcomes (including major adverse cardiac events) as a function of the P2Y12 inhibitor used for maintenance therapy. Logistic regression was used to adjust for differences in baseline characteristics. Results Prasugrel or ticagrelor was given as the loading P2Y12 inhibitor in 49% of 2198 patients and as a maintenance therapy in 59%. No differences were observed in rates of acute stent thrombosis for clopidogrel versus newer P2Y12 inhibitors (adjusted OR 0.50, 95% CI 0.13 to 1.85). After adjustment, no difference was observed in 30-day outcomes according to maintenance therapy except for protocol major (p=0.029) or minor (p=0.025) bleeding and Thrombolysis In Myocardial Infarction minor bleeding (p=0.002), which were less frequent in patients on clopidogrel. Consistent results were observed in the bivalirudin and heparin arms. Conclusions The choice of prasugrel or ticagrelor over clopidogrel was not associated with differences in acute stent thrombosis or 30-day ischaemic outcomes after pPCI. Trial registration number NCT01087723.
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Affiliation(s)
- Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Gregory Ducrocq
- FACT (French Alliance for Cardiovascular Trials) an F-CRIN network, DHU FIRE, Hôpital Bichat, Paris, France.,Université Paris-Diderot, Paris, France.,INSERM U‑1148, LVTS, Paris, France
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany
| | | | - Frédéric Lapostolle
- Cardiology Department, Hôpitaux Universitaires, Paris-Seine Saint-Denis, Saint Denis, France
| | - Pierre Coste
- Hôpital Cardiologique-Centre Hospitalier Universitaire Bordeaux, Université de Bordeaux, Pessac, France
| | | | - Jacob Steinmetz
- Emergency Medical Service of the Capital Region and Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Lutz Nibbe
- Department of Nephrology and Medical Intensive Care, Charité, Campus Virchow-Klinikum, Universitätsmedizin Berlin, Berlin, Germany
| | - Vojko Kaniĉ
- University Medical Centre Maribor, Maribor, Slovenia
| | - Peter Clemmensen
- Rigshospitalet, Department of Cardiology, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of General and Interventional Cardiology, University Heart Center-Hamburg-Eppendorf, Hamberg, Germany.,Department of Medicine, Nykoebing F Hospital, University of Southern Denmark, Odense, Denmark
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | | | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey, USA
| | | | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials) an F-CRIN network, DHU FIRE, Hôpital Bichat, Paris, France.,Université Paris-Diderot, Paris, France.,INSERM U‑1148, LVTS, Paris, France.,National Heart and Lung Institute, Imperial College, ICMS, Royal Brompton Hospital, London, UK
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Beygui F, Castren M, Brunetti ND, Rosell-Ortiz F, Christ M, Zeymer U, Huber K, Folke F, Svensson L, Bueno H, Van't Hof A, Nikolaou N, Nibbe L, Charpentier S, Swahn E, Tubaro M, Goldstein P. [Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin.]. Recenti Prog Med 2017; 108:27-51. [PMID: 28151526 DOI: 10.1701/2624.26982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts' opinions, for all emergency medical services' health providers involved in the pre-hospital management of acute cardiovascular care.
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Affiliation(s)
- Farzin Beygui
- Department of Cardiology, Interventional Cardiology and Cardiology Research Units, Caen University Hospital, France
| | - Maaret Castren
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Finland; Karolinska Institutet, Department of Clinical Science and Education, Stockholm, Sweden
| | | | | | | | - Uwe Zeymer
- Wir leben Medizin, Klinikum der Stadt Ludwigshafen am Rhein gGmbH, Germany
| | - Kurt Huber
- Third Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Austria
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark
| | - Leif Svensson
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Solna, Sweden
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares and Department of Cardiology, Hospital 12 de Octubre, Madrid, Spain
| | - Arnoud Van't Hof
- ISALA Academy, Interventional Cardiology, Zwolle, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Lutz Nibbe
- Universitätsmedizin Berlin, Charité, Campus Virchow-Klinikum, Medizinische Klinik m.S. Intensivmedizin und Nephrologie, Berlin, Germany
| | | | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Marco Tubaro
- ICCU, Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
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Zeymer U, van 't Hof A, Adgey J, Nibbe L, Clemmensen P, Cavallini C, ten Berg J, Coste P, Huber K, Deliargyris EN, Day J, Bernstein D, Goldstein P, Hamm C, Steg PG. Bivalirudin is superior to heparins alone with bailout GP IIb/IIIa inhibitors in patients with ST-segment elevation myocardial infarction transported emergently for primary percutaneous coronary intervention: a pre-specified analysis from the EUROMAX trial. Eur Heart J 2014; 35:2460-7. [PMID: 24849104 PMCID: PMC4169872 DOI: 10.1093/eurheartj/ehu214] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims In the HORIZONS trial, in-hospital treatment with bivalirudin reduced bleeding and mortality in primary percutaneous coronary intervention (PCI) compared with heparin and routine glycoprotein IIb/IIIa inhibitors (GPI). It is unknown whether this advantage of bivalirudin is observed in comparison with heparins only with GPI used as bailout. Methods and results In the EUROMAX study, 2198 patients with ST-segment elevation myocardial infarction (STEMI) were randomized during transport for primary PCI to bivalirudin or to heparins with optional GPI. Primary and principal outcome was the composites of death or non-CABG-related major bleeding at 30 days. This pre-specified analysis compared patients receiving bivalirudin (n = 1089) with those receiving heparins with routine upstream GPI (n = 649) and those receiving heparins only with GPI use restricted to bailout (n = 460). The primary outcome death and major bleeding occurred in 5.1% with bivalirudin, 7.6% with heparin plus routine GPI (HR 0.67 and 95% CI 0.46–0.97, P = 0.034), and 9.8% with heparins plus bailout GPI (HR 0.52 and 95% CI 0.35–0.75, P = 0.006). Following adjustment by logistic regression, bivalirudin was still associated with significantly lower rates of the primary outcome (odds ratio 0.53, 95% CI 0.33–0.87) and major bleeding (odds ratio 0.44, 95% CI 0.24–0.82) compared with heparins alone with bailout GPI. Rates of stent thrombosis were higher with bivalirudin (1.6 vs. 0.6 vs. 0.4%, P = 0.09 and 0.09). Conclusion Bivalirudin, started during transport for primary PCI, reduces major bleeding compared with both patients treated with heparin only plus bailout GPI and patients treated with heparin and routine GPI, but increased stent thrombosis.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen, Bremser Str. 79, Ludwigshafen 67063, Germany
| | | | | | - Lutz Nibbe
- Department of Nephrology and Medical Intensive Care, Charité, Campus Virchow-Klinikum, Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Clemmensen
- Department of Cardiology, Institute for Clinical Medicine, University of Copenhagen, Rigshospitalet, Copenhagen
| | | | | | - Pierre Coste
- Hôpital Cardiologique-Centre Hospitalier Universitaire Bordeaux, Université de Bordeaux, Pessac, France
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology, Wilhelminenhospital, Vienna
| | | | | | | | | | - Christian Hamm
- Department of Cardiology, Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany
| | - Philippe Gabriel Steg
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France Département Hospitalo-Universitaire FIRE, Université Paris-Diderot, INSERM U-1148, Paris, France NHLI, Imperial College, Royal Brompton Hospital, London, UK
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Huber K, Hamm CW, Hof AV, Lapostolle F, Coste P, Thicoipe M, Gordini G, Steinmetz J, Verheugt F, Adgey J, Nibbe L, Kanic V, Clemmensen P, Bernstein D, Prats J, Deliargyris EN. IMPACT OF P2Y12 INHIBITOR CHOICE ON 30-DAY OUTCOMES AFTER PRIMARY PCI: AN ANALYSIS FROM THE EUROMAX TRIAL. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60100-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Steg PG, van 't Hof A, Hamm CW, Clemmensen P, Lapostolle F, Coste P, Ten Berg J, Van Grunsven P, Eggink GJ, Nibbe L, Zeymer U, Campo dell' Orto M, Nef H, Steinmetz J, Soulat L, Huber K, Deliargyris EN, Bernstein D, Schuette D, Prats J, Clayton T, Pocock S, Hamon M, Goldstein P. Bivalirudin started during emergency transport for primary PCI. N Engl J Med 2013; 369:2207-17. [PMID: 24171490 DOI: 10.1056/nejmoa1311096] [Citation(s) in RCA: 386] [Impact Index Per Article: 35.1] [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: 12/14/2022]
Abstract
BACKGROUND Bivalirudin, as compared with heparin and glycoprotein IIb/IIIa inhibitors, has been shown to reduce rates of bleeding and death in patients undergoing primary percutaneous coronary intervention (PCI). Whether these benefits persist in contemporary practice characterized by prehospital initiation of treatment, optional use of glycoprotein IIb/IIIa inhibitors and novel P2Y12 inhibitors, and radial-artery PCI access use is unknown. METHODS We randomly assigned 2218 patients with ST-segment elevation myocardial infarction (STEMI) who were being transported for primary PCI to receive either bivalirudin or unfractionated or low-molecular-weight heparin with optional glycoprotein IIb/IIIa inhibitors (control group). The primary outcome at 30 days was a composite of death or major bleeding not associated with coronary-artery bypass grafting (CABG), and the principal secondary outcome was a composite of death, reinfarction, or non-CABG major bleeding. RESULTS Bivalirudin, as compared with the control intervention, reduced the risk of the primary outcome (5.1% vs. 8.5%; relative risk, 0.60; 95% confidence interval [CI], 0.43 to 0.82; P=0.001) and the principal secondary outcome (6.6% vs. 9.2%; relative risk, 0.72; 95% CI, 0.54 to 0.96; P=0.02). Bivalirudin also reduced the risk of major bleeding (2.6% vs. 6.0%; relative risk, 0.43; 95% CI, 0.28 to 0.66; P<0.001). The risk of acute stent thrombosis was higher with bivalirudin (1.1% vs. 0.2%; relative risk, 6.11; 95% CI, 1.37 to 27.24; P=0.007). There was no significant difference in rates of death (2.9% vs. 3.1%) or reinfarction (1.7% vs. 0.9%). Results were consistent across subgroups of patients. CONCLUSIONS Bivalirudin, started during transport for primary PCI, improved 30-day clinical outcomes with a reduction in major bleeding but with an increase in acute stent thrombosis. (Funded by the Medicines Company; EUROMAX ClinicalTrials.gov number, NCT01087723.).
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Steg PG, van ‘t Hof A, Clemmensen P, Lapostolle F, Dudek D, Hamon M, Cavallini C, Gordini G, Huber K, Coste P, Thicoipe M, Nibbe L, Steinmetz J, Ten Berg J, Eggink GJ, Zeymer U, Campo dell' Orto M, Kanic V, Deliargyris EN, Day J, Schuette D, Hamm CW, Goldstein P. Design and methods of European Ambulance Acute Coronary Syndrome Angiography Trial (EUROMAX): an international randomized open-label ambulance trial of bivalirudin versus standard-of-care anticoagulation in patients with acute ST-segment-elevation myocardial infarction transferred for primary percutaneous coronary intervention. Am Heart J 2013; 166:960-967.e6. [PMID: 24268209 DOI: 10.1016/j.ahj.2013.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) triaged to primary percutaneous coronary intervention (PCI), anticoagulation often is initiated in the ambulance during transfer to a PCI site. In this prehospital setting, bivalirudin has not been compared with standard-of-care anticoagulation. In addition, it has not been tested in conjunction with the newer P2Y12 inhibitors prasugrel or ticagrelor. DESIGN EUROMAX is a randomized, international, prospective, open-label ambulance trial comparing bivalirudin with standard-of-care anticoagulation with or without glycoprotein IIb/IIIa inhibitors in 2200 patients with STEMI and intended for primary percutaneous coronary intervention (PCI), presenting either via ambulance or to centers where PCI is not performed. Patients will receive either bivalirudin given as a 0.75 mg/kg bolus followed immediately by a 1.75-mg/kg per hour infusion for ≥30 minutes prior to primary PCI and continued for ≥4 hours after the end of the procedure at the reduced dose of 0.25 mg/kg per hour, or heparins at guideline-recommended doses, with or without routine or bailout glycoprotein IIb/IIIa inhibitor treatment according to local practice. The primary end point is the composite incidence of death or non-coronary-artery-bypass-graft related protocol major bleeding at 30 days by intention to treat. CONCLUSION The EUROMAX trial will test whether bivalirudin started in the ambulance and continued for 4 hours after primary PCI improves clinical outcomes compared with guideline-recommended standard-of-care heparin-based regimens, and will also provide information on the combination of bivalirudin with prasugrel or ticagrelor.
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Tubaro M, Danchin N, Goldstein P, Filippatos G, Hasin Y, Heras M, Jansky P, Norekval TM, Swahn E, Thygesen K, Vrints C, Zahger D, Arntz HR, Bellou A, De La Coussaye JE, De Luca L, Huber K, Lambert Y, Lettino M, Lindahl B, Mclean S, Nibbe L, Peacock WF, Price S, Quinn T, Spaulding C, Tatu-Chitoiu G, Van De Werf F. Tratamiento prehospitalario de los pacientes con IAMCEST. Una declaración científica del Working Group Acute Cardiac Care de la European Society of Cardiology. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Tubaro M, Danchin N, Goldstein P, Filippatos G, Hasin Y, Heras M, Jansky P, Norekval TM, Swahn E, Thygesen K, Vrints C, Zahger D, Arntz HR, Bellou A, de La Coussaye JE, de Luca L, Huber K, Lambert Y, Lettino M, Lindahl B, McLean S, Nibbe L, Peacock WF, Price S, Quinn T, Spaulding C, Tatu-Chitoiu G, van de Werf F. Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology. ACTA ACUST UNITED AC 2011; 13:56-67. [DOI: 10.3109/17482941.2011.581292] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Tanriver Y, Betz MJ, Nibbe L, Pfluger T, Beuschlein F, Strowski MZ. Sepsis and cardiomyopathy as rare clinical manifestations of pheochromocytoma--two case report studies. Exp Clin Endocrinol Diabetes 2010; 118:747-53. [PMID: 20539976 DOI: 10.1055/s-0030-1253413] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The clinical manifestation of pheochromocytomas is highly variable and can closely resemble numerous clinical conditions. Here, we report on two cases of patients with pheochromocytoma, which manifested as sepsis or cardiomyopathy. The first patient initially presented with bacterial urosepsis due to klebsiella oxytoca. Despite effective antibiotic therapy, the patient developed recurring fever accompanied by hypertension. The inconsistency between therapy-refractory hypertension and fever indicated the possibility of excessive catecholamine production. In the second case, the patient presented with a suspected ST-segment elevation myocardial infarction accompanied by E. coli sepsis and a previously undiagnosed unilateral tumor mass of the adrenal gland. Severely impaired myocardial contraction of the apical anterior and inferior regions without significant coronary artery disease was consistent with the Takotsubo cardiomyopathy, a known transient functional myocardial complication associated with pheochromocytoma. Both patients were diagnosed with unilateral pheochromocytoma. Following pre-operative antihypertensive therapy, both patients were cured by surgery and still remain free of disease after two years of follow-up.
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Affiliation(s)
- Y Tanriver
- Department of Nephrology and Medical Intensive Care, Charité -Universitätsmedizin Berlin, Berlin, Germany
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Zeymer U, Arntz HR, Dirks B, Ellinger K, Genzwürker H, Nibbe L, Tebbe U, Senges J, Schneider S. Reperfusion rate and inhospital mortality of patients with ST segment elevation myocardial infarction diagnosed already in the prehospital phase: Results of the German Prehospital Myocardial Infarction Registry (PREMIR). Resuscitation 2009; 80:402-6. [DOI: 10.1016/j.resuscitation.2008.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Revised: 11/20/2008] [Accepted: 12/01/2008] [Indexed: 11/24/2022]
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Storm C, Gebker R, Kruger A, Nibbe L, Schefold JC, Martens F, Hasper D. A rare case of neuroleptic malignant syndrome presenting with serious hyperthermia treated with a non-invasive cooling device: a case report. J Med Case Rep 2009. [DOI: 10.1186/1752-1947-3-66] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hampel DJ, Stoll J, Nibbe L, Gollasch M. Hyperammonaemic encephalopathy and severe metabolic acidosis in a patient with chronic renal insufficiency years after ureterosigmoidostomy. Nephrol Dial Transplant 2007; 22:2713-9. [PMID: 17556426 DOI: 10.1093/ndt/gfm276] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dierk J Hampel
- Department of Medicine, Charité - Universitätsmedizin Berlin, Germany.
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Storm C, Schefold JC, Nibbe L, Martens F, Krueger A, Oppert M, Joerres A, Hasper D. Therapeutic hypothermia after cardiac arrest--the implementation of the ILCOR guidelines in clinical routine is possible! Crit Care 2007; 10:425. [PMID: 17096867 PMCID: PMC1794441 DOI: 10.1186/cc5061] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Christian Storm
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Joerg C Schefold
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Lutz Nibbe
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Frank Martens
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Anne Krueger
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Michael Oppert
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Achim Joerres
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Dietrich Hasper
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
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Möckel M, Bocksch W, Strohm S, Kühnle Y, Vollert J, Nibbe L, Dietz R. Facilitated percutaneous coronary intervention (PCI) in patients with acute ST-elevation myocardial infarction: Comparison of prehospital tirofiban versus fibrinolysis before direct PCI. Int J Cardiol 2005; 103:193-200. [PMID: 16080980 DOI: 10.1016/j.ijcard.2004.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [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] [Received: 05/18/2004] [Revised: 08/11/2004] [Accepted: 10/04/2004] [Indexed: 11/21/2022]
Abstract
AIMS Early start of treatment including coronary revascularization has been recognized as crucial variable in the outcome of acute ST-segment elevation myocardial infarction (STEMI). The lack of availability and the realisation that an optimum reperfusion strategy will need to incorporate mechanical reperfusion as part of that strategy has led to a great deal of interest in pharmacologic reperfusion combined with mechanical reperfusion or facilitated PCI. It is not clear whether GPIIb/IIIa-blockade or fibrinolysis better facilitates PCI. METHODS We identified 138 patients who have been primarily treated by our mobile emergency care mobile from July 2001 until February 2003 with tirofiban or fibrinolysis. Seventy-nine patients had ST-elevation myocardial infarction (STEMI) and available angiograms within 24 h. RESULTS Forty-four patients had tirofiban (TIRO; 60.6 S.D. 11.4 years, 64% male) and 35 patients underwent fibrinolysis (FIB; 31.4% tenecteplase, 54.3% reteplase, 11.4% alteplase, 2.9% streptokinase; 58.8 S.D. 12.2 years, 80% male). Data were analyzed with respect to TIMI-flow and corrected frame count (cTFC) before and after PCI, bleeding complications at 30 days and long-term follow up for major adverse events (median 288 days; MACE: Death, hospitalized re-infarction, intracranial hemorrhage). Catheter films were re-analyzed by an investigator blinded to the prehospital therapy. Time from onset of symptoms to first medical contact was 1.98 h in TIRO compared to 0.5 h in FIB (p<0.001) and time from first prehospital medical contact to catheter was 1.46 h in the TIRO compared to 2.85 h in the FIB group (p<0.001). TIMI 3-flow before PCI was observed in 20.5% of TIRO and 62.9% in FIB (p<0.001). After PCI TIMI 3-flow was achieved in 90.5% and 90.0%, respectively (p=n.s.). Final cTFC was 24 in TIRO and 29 in FIB (p=n.s.). Visible thrombi were detected in 30.2% in TIRO and 23.5% in FIB (p=n.s.). Major bleeding occurred in one TIRO patient (fatal lung bleeding after ultima ratio abciximab on top of tirofiban), 2 patients (4.5%) received transfusions. In FIB 2 intracerebral hemorrhages, 5 transfusions (14.3%) and 3 pulmonary bleedings during mandatory ventilation were observed. After 30 days 4.5% in TIRO and 22.9% in FIB had MACE (p=0.015). During long-term follow up the primary endpoint was observed in 4.5% of TIRO and 28.6% (p=0.003) of FIB. Two patients died in TIRO and 9 patients in FIB. CONCLUSIONS We conclude that (1) prehospital start of tirofiban for facilitated PCI is safe and effective if administered by experienced emergency physicians; (2) routine fibrinolysis should be limited to areas where catheter based therapy is not available within 90 min and (3) fibrinolysis should be given for facilitated PCI in randomized trials only at the moment.
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Affiliation(s)
- Martin Möckel
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
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Zeymer U, Arntz HR, Baubin M, Gulba D, Ellinger K, Nibbe L. Verbesserung der Zusammenarbeit zwischen Not�rzten und Kardiologen zur Optimierung der fr�hen Therapie bei akutem ST-Hebungs-Infarkt. Notf Rett Med 2004. [DOI: 10.1007/s10049-004-0692-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
We report a case of puncture of the thoracic duct during left subclavian vein catheterization on the intensive care unit. Computed tomography and measurement of the triglyceride levels in the aspirated fluid proved the inadvertent penetration of the guidewire into the thoracic duct. Early recognition of central line misplacement avoided serious complications. Inadvertent central venous catheter placement into the thoracic duct may have the potential complications of infusion mediastinum and chylothorax.
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Affiliation(s)
- Ulf K M Teichgraber
- Department of Radiology, Charité Campus Virchow-Klinikum Humboldt-Universität zu, Berlin, Augusten berger Platz 1, 13353 Berlin, Germany.
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Affiliation(s)
- J S Jürgensen
- Department of Nephrology and Medical Intensive Care, Charité, Campus Virchow Klinikum, Humboldt University, Berlin, Germany.
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Kuhlen R, Max M, Nibbe L, Hausmann S, Sprenger M, Falke K, Rossaint R. [Respiratory pattern and respiratory strain in automatic tube compensation and inspiratory pressure support]. Anaesthesist 1999; 48:871-5. [PMID: 10672350 DOI: 10.1007/s001010050800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [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: 11/30/2022]
Abstract
STUDY OBJECTIVE To investigate whether automatic tube compensation (ATC) or conventional pressure support (PS) is suitable to compensate for the work of breathing imposed by the breathing circuit without altering the breathing pattern. METHODS Breathing pattern and work of breathing were measured in healthy volunteers. After a 20 min period of quiet breathing through a mouth piece (control) the volunteers were breathing through a 8.0 mm ID endotracheal tube (ETT) with four different settings: CPAP at 0 mbar, ATC, PS 5 mbar, PS 10 mbar. Each mode was applied for a 20 min period. At the end of each period data from 10 consecutive breaths were analyzed and averaged. Tidal volume (VT), breathing frequency (f), and minute ventilation (Ve) were determined from the stored gas flow tracings. Work of breathing was assessed as the pressure time product (PTP) calculated from the transdiaphragmatic pressure (Pdi) using a combined esophageal and gastric balloon catheter. RESULTS During the control period the breathing pattern was as follows: VT = 882 +/- 277 ml, f = 13.7 +/- 5/min, Ve = 11.5 +/- 4.2 L/min. Maximal Pdi was 9.2 +/- 5.4 mbar and PTP was 11.3 +/- 7.1 mbar x s. Breathing CPAP through the ETT resulted in a slight increase in Pdi (10.8 +/- 5.4 mbar) and PTP (14.8 +/- 10.4 mbar x s) with an unchanged breathing pattern. However, for the same amount of unloading from respiratory workload ATC did not alter the breathing pattern, whereas PS 5 mbar and PS 10 mbar resulted in a clear increase in VT (1014 +/- 202 ml, 1336 +/- 305 ml, respectively). CONCLUSION From the presented data in healthy volunteers it might be concluded that ATC and PS 5 mbar and 10 mbar are suitable modes for unloading the respiratory system from work imposed by the breathing circuit. ATC does not alter the breathing pattern in contrast to PS which results in an increased tidal volume. Therefore, the exact compensation of the work imposed by the ETT during ATC seems to be advantageous over ATC to assess the actual breathing pattern.
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Affiliation(s)
- R Kuhlen
- Klinik für Anästhesiologie, RWTH Aachen.
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Abstract
Emphysematous pyelonephritis is a rare, often severe infection of one or both kidneys that is most often caused by bacterial infection. Surgical intervention is often necessary. We describe a case of a diabetic patient with bilateral emphysematous pyelonephritis caused by Candida infection that was treated conservatively. Renal function recovered almost completely in spite of giving a potential nephrotoxic drug for 6 weeks.
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Affiliation(s)
- T S Hildebrand
- Campus Virchow-Klinikum, Humboldt-University of Berlin, Berlin, Germany.
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Kuhlen R, Guttmann J, Nibbe L, Max M, Reyle-Hahn S, Rossaint R, Falke K. Proportional pressure support and automatic tube compensation: new options for assisted spontaneous breathing. Acta Anaesthesiol Scand Suppl 1998; 111:155-9. [PMID: 9420994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- R Kuhlen
- Department of Anesthesiology and Intensive Care Medicine, Virchow Clinic, Humboldt University Berlin, Germany.
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