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Raasveld SJ, Karami M, Schenk J, Dos Reis Miranda D, Mandigers L, Dauwe DF, De Troy E, Pappalardo F, Fominskiy E, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, de Haan M, Donker DW, Meuwese CL, Taccone FS, Peluso L, Lorusso R, Delnoij TSR, Scholten E, Overmars M, Ivančan V, Bojčić R, de Metz J, van den Bogaard B, de Bakker M, Reddi B, Hermans G, Broman LM, Henriques JPS, Vlaar APJ. Transfusion of red blood cells in venoarterial extracorporeal membrane oxygenation: A multicenter retrospective observational cohort study. Transfusion 2023; 63:1809-1820. [PMID: 37668074 DOI: 10.1111/trf.17505] [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: 03/15/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Evidence-based recommendations for transfusion in patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) are scarce. The current literature is limited to single-center studies with small sample sizes, therefore complicating generalizability. This study aims to create an overview of red blood cell (RBC) transfusion in VA ECMO patients. METHODS This international mixed-method study combined a survey with a retrospective observational study in 16 centers. The survey inventoried local transfusion guidelines. Additionally, retrospective data of all adult patients with a VA ECMO run >24 h (January 2018 until July 2019) was collected of patient, ECMO, outcome, and daily transfusion parameters. All patients that received VA ECMO for primary cardiac support were included, including surgical (i.e., post-cardiotomy) and non-surgical (i.e., myocardial infarction) indications. The primary outcome was the number of RBC transfusions per day and in total. Univariable logistic regressions and a generalized linear mixed model (GLMM) were performed to assess factors associated with RBC transfusion. RESULTS Out of 419 patients, 374 (89%) received one or more RBC transfusions. During a median ECMO run of 5 days (1st-3rd quartile 3-8), patients received a median total of eight RBC units (1st-3rd quartile 3-17). A lower hemoglobin (Hb) prior to ECMO, longer ECMO-run duration, and hemorrhage were associated with RBC transfusion. After correcting for duration and hemorrhage using a GLMM, a different transfusion trend was found among the regimens. No unadjusted differences were found in overall survival between either transfusion status or the different regimens, which remained after adjustment for potential confounders. CONCLUSION RBC transfusion in patients on VA ECMO is very common. The sum of RBC transfusions increases rapidly after ECMO initiation, and is dependent on the Hb threshold applied. This study supports the rationale for prospective studies focusing on indications and thresholds for RBC transfusion.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
| | - Mina Karami
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Location AMC, Amsterdam Public Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Loes Mandigers
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dieter F Dauwe
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Erwin De Troy
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Allesandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Maarten de Haan
- Department of Extracorporeal Circulation, Catharina hospital Eindhoven, Eindhoven, the Netherlands
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Roberto Lorusso
- Cardiothoracic surgery, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn Overmars
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Višnja Ivančan
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | | | - Martin de Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska, University Hospital, Stockholm, Sweden
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, the Netherlands
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Raasveld SJ, van den Oord C, Schenk J, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, Lorusso R, Delnoij TSR, Dos Reis Miranda D, Scholten E, Taccone FS, Dauwe DF, De Troy E, Hermans G, Pappalardo F, Fominskiy E, Ivancan V, Bojčić R, de Metz J, van den Bogaard B, Donker DW, Meuwese CL, De Bakker M, Reddi B, Henriques JPS, Broman LM, Dongelmans DA, Vlaar APJ. The interaction of thrombocytopenia, hemorrhage, and platelet transfusion in venoarterial extracorporeal membrane oxygenation: a multicenter observational study. Crit Care 2023; 27:321. [PMID: 37605277 PMCID: PMC10441744 DOI: 10.1186/s13054-023-04612-5] [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: 06/08/2023] [Accepted: 08/14/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Thrombocytopenia, hemorrhage and platelet transfusion are common in patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). However, current literature is limited to small single-center experiences with high degrees of heterogeneity. Therefore, we aimed to ascertain in a multicenter study the course and occurrence rate of thrombocytopenia, and to assess the association between thrombocytopenia, hemorrhage and platelet transfusion during VA ECMO. METHODS This was a sub-study of a multicenter (N = 16) study on transfusion practices in patients on VA ECMO, in which a retrospective cohort (Jan-2018-Jul-2019) focusing on platelets was selected. The primary outcome was thrombocytopenia during VA ECMO, defined as mild (100-150·109/L), moderate (50-100·109/L) and severe (< 50·109/L). Secondary outcomes included the occurrence rate of platelet transfusion, and the association between thrombocytopenia, hemorrhage and platelet transfusion, assessed through mixed-effect models. RESULTS Of the 419 patients included, median platelet count at admission was 179·109/L. During VA ECMO, almost all (N = 398, 95%) patients developed a thrombocytopenia, of which a significant part severe (N = 179, 45%). One or more platelet transfusions were administered in 226 patients (54%), whereas 207 patients (49%) suffered a hemorrhagic event during VA ECMO. In non-bleeding patients, still one in three patients received a platelet transfusion. The strongest association to receive a platelet transfusion was found in the presence of severe thrombocytopenia (adjusted OR 31.8, 95% CI 17.9-56.5). After including an interaction term of hemorrhage and thrombocytopenia, this even increased up to an OR of 110 (95% CI 34-360). CONCLUSIONS Thrombocytopenia has a higher occurrence than is currently recognized. Severe thrombocytopenia is strongly associated with platelet transfusion. Future studies should focus on the etiology of severe thrombocytopenia during ECMO, as well as identifying indications and platelet thresholds for transfusion in the absence of bleeding. TRIAL REGISTRATION This study was registered at the Netherlands Trial Registry at February 26th, 2020 with number NL8413 and can currently be found at https://trialsearch.who.int/Trial2.aspx?TrialID=NL8413.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Claudia van den Oord
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Amsterdam Public Health, University of Amsterdam, Location AMC, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, The Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Dieter F Dauwe
- Surgical Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Erwin De Troy
- Surgical Intensive Care Unit, Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Federico Pappalardo
- Department of CardioThoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Višnja Ivancan
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive Care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | | | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, The Netherlands
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Martin De Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, Location Academic Medical Centers, Amsterdam, The Netherlands
| | - Lars Mikael Broman
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Dave A Dongelmans
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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van Haeren MMT, Raasveld SJ, Karami M, Miranda DDR, Mandigers L, Dauwe DF, De Troy E, Pappalardo F, Fominskiy E, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, de Haan M, Donker DW, Meuwese CL, Taccone FS, Peluso L, Lorusso R, Delnoij TSR, Scholten E, Overmars M, Ivancan V, Bojčić R, de Metz J, van den Bogaard B, de Bakker M, Reddi B, Hermans G, Broman LM, Henriques JPS, Schenk J, Vlaar APJ, Müller MCA. Plasma Transfusion and Procoagulant Product Administration in Extracorporeal Membrane Oxygenation: A Secondary Analysis of an International Observational Study on Current Practices. Crit Care Explor 2023; 5:e0949. [PMID: 37614800 PMCID: PMC10443757 DOI: 10.1097/cce.0000000000000949] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES To achieve optimal hemostatic balance in patients on extracorporeal membrane oxygenation (ECMO), a liberal transfusion practice is currently applied despite clear evidence. We aimed to give an overview of the current use of plasma, fibrinogen concentrate, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) in patients on ECMO. DESIGN A prespecified subanalysis of a multicenter retrospective study. Venovenous (VV)-ECMO and venoarterial (VA)-ECMO are analyzed as separate populations, comparing patients with and without bleeding and with and without thrombotic complications. SETTING Sixteen international ICUs. PATIENTS Adult patients on VA-ECMO or VV-ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 420 VA-ECMO patients, 59% (n = 247) received plasma, 20% (n = 82) received fibrinogen concentrate, 17% (n = 70) received TXA, and 7% of patients (n = 28) received PCC. Fifty percent of patients (n = 208) suffered bleeding complications and 27% (n = 112) suffered thrombotic complications. More patients with bleeding complications than patients without bleeding complications received plasma (77% vs. 41%, p < 0.001), fibrinogen concentrate (28% vs 11%, p < 0.001), and TXA (23% vs 10%, p < 0.001). More patients with than without thrombotic complications received TXA (24% vs 14%, p = 0.02, odds ratio 1.75) in VA-ECMO, where no difference was seen in VV-ECMO. Of 205 VV-ECMO patients, 40% (n = 81) received plasma, 6% (n = 12) fibrinogen concentrate, 7% (n = 14) TXA, and 5% (n = 10) PCC. Thirty-nine percent (n = 80) of VV-ECMO patients suffered bleeding complications and 23% (n = 48) of patients suffered thrombotic complications. More patients with than without bleeding complications received plasma (58% vs 28%, p < 0.001), fibrinogen concentrate (13% vs 2%, p < 0.01), and TXA (11% vs 2%, p < 0.01). CONCLUSIONS The majority of patients on ECMO receive transfusions of plasma, procoagulant products, or antifibrinolytics. In a significant part of the plasma transfused patients, this was in the absence of bleeding or prolonged international normalized ratio. This poses the question if these plasma transfusions were administered for another indication or could have been avoided.
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Affiliation(s)
- Maite M T van Haeren
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Mina Karami
- Department of Cardiology, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Loes Mandigers
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Dieter F Dauwe
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Erwin De Troy
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Allesandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Maarten de Haan
- Department of Extracorporeal Circulation, Catharina hospital Eindhoven, the Netherlands
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Roberto Lorusso
- Cardiothoracic Surgery, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Martijn Overmars
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Višnja Ivancan
- Department of Anesthesia and Intensive care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | | | - Martin de Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, location AMC, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
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4
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Bouwmeester S, van Nunen LX, van de Berg P. ‘Stadium wave-like’ ventricular contraction due to extreme conduction delay in tricyclic antidepressant intoxication. Eur Heart J 2020; 41:1777. [DOI: 10.1093/eurheartj/ehz920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sjoerd Bouwmeester
- Department of Cardiology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Lokien X van Nunen
- Department of Cardiology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Pablo van de Berg
- Department of Cardiology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
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