FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2113134101> ?p ?o ?g. }

• W2113134101 endingPage "855" @default.
• W2113134101 startingPage "851" @default.
• W2113134101 abstract "Remifentanil undergoes extensive placental transfer and has been used to provide fetal immobilization and anaesthesia for in utero fetal endoscopic interventions. We report three cases of the ex utero intrapartum treatment performed under neuraxial anaesthesia where the maternal administration of remifentanil was used to provide fetal immobilization and analgesia. Fetal pathology included goiter and arthrogryposis, with one case requiring a tracheostomy. The longest time on placental circulation was 21 min. No clinically significant maternal sedation or respiratory depression was observed. In all cases, remifentanil provided adequate fetal immobilization and obviated the need to administer other analgesics or neuromuscular blocking agents. Remifentanil is a useful adjunct for ex utero fetal procedures. Remifentanil undergoes extensive placental transfer and has been used to provide fetal immobilization and anaesthesia for in utero fetal endoscopic interventions. We report three cases of the ex utero intrapartum treatment performed under neuraxial anaesthesia where the maternal administration of remifentanil was used to provide fetal immobilization and analgesia. Fetal pathology included goiter and arthrogryposis, with one case requiring a tracheostomy. The longest time on placental circulation was 21 min. No clinically significant maternal sedation or respiratory depression was observed. In all cases, remifentanil provided adequate fetal immobilization and obviated the need to administer other analgesics or neuromuscular blocking agents. Remifentanil is a useful adjunct for ex utero fetal procedures. Editor's key pointsMaternal remifentanil infusion provided adequate fetal immobilization during EXIT procedure.Remifentanil infusion provided mild maternal sedation with no clinically significant respiratory depression.Remifentanil infusion may be used to supplement neuraxial blockade for EXIT surgery. Maternal remifentanil infusion provided adequate fetal immobilization during EXIT procedure.Remifentanil infusion provided mild maternal sedation with no clinically significant respiratory depression.Remifentanil infusion may be used to supplement neuraxial blockade for EXIT surgery. The ex utero intrapartum treatment (EXIT) procedure allows for the maintenance of uteroplacental blood flow and oxygenation to the fetus during airway and surgical interventions after partial delivery. Traditionally, general anaesthesia with high concentrations of volatile agents has been used.1Liechty KW Ex-utero intrapartum therapy.Semin Fetal Neonatal Med. 2010; 15: 34-39Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 2Mychaliska GB Bealer JF Graf JL Rosen MA Adzick NS Harrison MR Operating on placental support: the ex utero intrapartum treatment procedure.J Pediatr Surg. 1997; 32: 227-231Abstract Full Text PDF PubMed Scopus (304) Google Scholar, 3Rosen MA Anesthesia for fetal procedures and surgery.Yonsei Med J. 2001; 42: 669-680Crossref PubMed Scopus (28) Google Scholar This produces profound uterine relaxation, maintains uteroplacental perfusion, and provides fetal anaesthesia.3Rosen MA Anesthesia for fetal procedures and surgery.Yonsei Med J. 2001; 42: 669-680Crossref PubMed Scopus (28) Google Scholar, 4Gaiser R Cheek T Kurth C Anesthetic management of cesarean delivery complicated by ex utero intrapartum treatment of the fetus.Anesth Analg. 1997; 84: 1150-1153Crossref PubMed Scopus (58) Google Scholar, 5Kuczkowski KM Advances in obstetric anesthesia: anesthesia for fetal intrapartum operations on placental support.J Anesth. 2007; 21: 243-251Crossref PubMed Scopus (26) Google Scholar Neuraxial anaesthesia has also been used successfully for the EXIT procedure.6Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita, using continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation.Int J Obstet Anesth. 2008; 17: 53-56Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar 7George RB Melnick AH Rose EC Habib AS Case series: combined spinal epidural anesthesia for Cesarean delivery and ex utero intrapartum treatment procedure.Can J Anaesth. 2007; 54: 218-222Crossref PubMed Scopus (50) Google Scholar However, it does not provide fetal anaesthesia or analgesia, and additional agents may be needed for this purpose. The use of remifentanil to achieve these goals for ex utero fetal surgery has not been previously described. We report three cases of the EXIT procedure performed under neuraxial anaesthesia where the maternal administration of remifentanil was used successfully to provide fetal immobilization and analgesia for airway manipulation and surgery. A summary of relevant neonatal and maternal data is presented in Table 1.Table 1A summary of the neonatal and maternal findings for all three cases. Data are n, range, or median (IQR). RASS, Richmond agitation sedation scale19Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).J Am Med Assoc. 2003; 289: 2983-2991Crossref PubMed Scopus (1129) Google ScholarCase 1Case 2Case 3Neonatal DiagnosisFetal goitreFetal arthrogryposisFetal arthrogryposis Airway procedureIntubationIntubationTracheostomy Uterine incision to cord clamp time (min)9321 Apgars at 1 min385 Apgars at 5 min897 Naloxone administered (Y/N)NNNUmbilical cord gases (arterial) pH7.227.17— Po2 (kPa)3.201.89— Pco2 (kPa)8.279.73— Bicarbonate (mmol litre−1)2425— Base excess (mmol litre−1)−5−5—Umbilical cord gases (venous) pH—7.25— Po2 (kPa)—3.33— Pco2 (kPa)—8.00— Bicarbonate (mmol litre−1)—26— Base excess (mmol litre−1)———Maternal RASS sedation score0 to −20 to −10 to −1 Predelivery systolic pressure (mm Hg)123 (116, 135)98 (90, 103)122 (113, 129) Predelivery diastolic pressure (mm Hg)65 (61, 73)45 (39, 52)64 (53, 70) Predelivery heart rate (beats min−1)68 (65, 71)62 (58, 68)82 (68, 95) Intraoperative Spo2 (%)99 (98, 100)99 (97, 100)99 (98, 100) Intraoperative ventilatory frequency (bpm)12 (9,17)14 (12, 18)15 (13, 21) Estimated blood loss (ml)8007501200 Open table in a new tab A 37-yr-old, Gravida 2 Parity 1 woman at 34 weeks gestation was found on ultrasound to have a fetus with a large goitre. A fetal MRI confirmed upper airway obstruction. The patient had a BMI of 47 kg m−2 and a history of Grave's disease treated with propylthiouracil throughout pregnancy. After a multidisciplinary team meeting with the paediatric otolaryngologists, neonatalogists, maternal and fetal medicine specialists, and the obstetric anaesthesia team, an EXIT procedure was planned. At 36 weeks gestation, she was taken to the operating theatre for a scheduled EXIT procedure under combined spinal–epidural (CSE) anaesthesia performed in the sitting position at L3–L4. She received hyperbaric bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg intrathecally. She was then placed in the supine position with left uterine displacement. A phenylephrine infusion was initiated at 50 µg min−1 to prevent maternal hypotension and 2 litre min−1 of oxygen was administered by the nasal cannula with monitoring of end-tidal carbon dioxide, ventilatory frequency, and level of sedation. A remifentanil infusion was initiated at 0.15 µg kg−1 min−1 15 min before skin incision. One minute before uterine incision, an i.v. bolus of 50 µg nitroglycerine followed by an infusion at 50 µg min−1 was administered for uterine relaxation. After delivery of the fetal head, direct laryngoscopy was performed and the infant's trachea was intubated on the second attempt by the Paediatric Otolaryngologist without the need for neuromuscular blocking agents. At the time of laryngoscopy and intubation, remifentanil had been infusing for a total of 41 min. After clamping of the umbilical cord and delivery of the remainder of the fetus, the nitroglycerin and remifentanil infusions were stopped. Oxytocin 5 units was given as an i.v. bolus followed by an infusion of 10 units h−1. Carboprost 250 µg i.m. was then administered for uterine hypotonus. The time interval from uterine incision to cord clamping was 9 min. Apgar scores and umbilical cord gases are summarized in Table 1. Maternal haemodynamic parameters and oxygen saturation remained stable during the predelivery period. There was some mild sedation and respiratory depression while on remifentanil (Table 1). A 20-yr-old, Gravida 2 Parity 1 woman with a BMI of 24 kg m−2 was found to have a fetus with severe arthrogryposis. An EXIT procedure was scheduled to allow intubation of the fetal airway. At 37 weeks gestation, we performed a CSE at L3–4 with bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg intrathecally. A phenylephrine infusion was initiated at 50 µg min−1 and oxygen 4 litre min−1 was given by the nasal cannula. A remifentanil infusion was initiated at 0.1 µg kg−1 min−1 and titrated up to 0.15 µg kg−1 min−1 16 min before skin incision. A nitroglycerin bolus of 100 µg i.v. followed by an infusion of 50–100 µg min−1 was administered 3 min before uterine incision. After delivery of the fetal head, direct laryngoscopy was performed followed by intubation with a 3.5 uncuffed tracheal tube on the first attempt. No muscle relaxation or anaesthesia was required for the fetus. The remainder of the fetus was then delivered and transferred to the paediatric team for further evaluation. The remifentanil and nitroglycerin infusions were immediately discontinued. The patient received a bolus of oxytocin 5 units and a 10 units h−1 infusion after delivery. She also required carboprost 250 µg and methylergonovine 0.2 mg i.m. for uterine hypotonus. The time from uterine incision to cord clamping was 3 min. Predelivery maternal haemodynamics remained stable and there was no evidence of clinically significant respiratory depression or sedation while on a remifentanil infusion (Table 1). Apgar scores and umbilical cord gases are listed in Table 1. A 22-yr-old, Gravida 3 Parity 1 woman with a BMI of 29 kg m−2 was found to have a fetus with arthrogryposis with temporomandibular joint involvement and a hyper-extended neck. Given the potential for significant airway compromise, an EXIT procedure with a tracheostomy was planned. At 38 weeks, we performed a CSE at L3–4 with bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg intrathecally in the sitting position. The patient was then placed in the supine position with left uterine displacement and given 4 litre min−1 of oxygen by the nasal cannula. A phenylephrine infusion was initiated at 50 µg min−1 immediately after CSE placement. A remifentanil infusion was also started at that time at 0.10 µg kg−1 min−1 and titrated up to 0.2 µg kg−1 min−1 before skin incision due to significant maternal anxiety. Three minutes before uterine incision, a nitroglycerin infusion was initiated at 100 µg min−1. After confirming adequate uterine relaxation, the fetal head, neck, and upper trunk were delivered and warmed lactated Ringer's was then infused into the uterine cavity. Lidocaine with epinephrine was injected around the tracheostomy operative site with no noticeable fetal response. During the performance of the tracheostomy, the fetus remained immobile apart from occasional shallow respiratory efforts. The fetus remained on placental circulation for 21 min during which time the tracheostomy was successfully completed. No neuromuscular blocking agents or analgesic adjuncts were needed. After delivery, the nitroglycerin infusion was immediately discontinued and a 5 unit oxytocin bolus was administered followed by an infusion at 10 units h−1. Methylergonovine 0.2 mg and carboprost 250 µg were administered i.m. for uterine hypotonus. Apgar scores at 1 and 5 min were 5 and 7, respectively. The baby was admitted to the neonatal intensive care unit for further management. The remifentanil infusion was continued after delivery of the fetus because of maternal intraoperative discomfort. Predelivery maternal haemodynamics remained stable after CSE placement (Table 1). Remifentanil administration provided mild maternal sedation and respiratory depression during the procedure (Table 1). Providing fetal analgesia and immobilization is an important aspect of an EXIT procedure performed under neuraxial anaesthesia. It facilitates inhibition of fetal movements and attenuates the hormonal stress response which may be associated with adverse surgical neonatal outcomes.8Lee SJ Ralston HJP Drey EA Partridge JC Rosen MA Fetal pain: a systematic multidisciplinary review of the evidence.J Am Med Assoc. 2005; 294: 947-954Crossref PubMed Scopus (296) Google Scholar It also prevents possible adverse effects on the long-term neuro-developmental and behavioural responses to pain.8Lee SJ Ralston HJP Drey EA Partridge JC Rosen MA Fetal pain: a systematic multidisciplinary review of the evidence.J Am Med Assoc. 2005; 294: 947-954Crossref PubMed Scopus (296) Google Scholar There are several ways of achieving fetal analgesia and immobilization. These include direct administration of analgesics to the fetus by the i.v. or i.m. route, intra-amniotic delivery, or delivery via maternal infusion.8Lee SJ Ralston HJP Drey EA Partridge JC Rosen MA Fetal pain: a systematic multidisciplinary review of the evidence.J Am Med Assoc. 2005; 294: 947-954Crossref PubMed Scopus (296) Google Scholar In this case series, we relied on the latter technique. We chose to use remifentanil based on its favourable pharmacokinetic profile in pregnancy. When given to pregnant term patients, remifentanil undergoes extensive placental transfer as evidenced by its umbilical vein/maternal arterial ratio (UV:MA) of 0.88.9Kan RE Hughes SC Rosen MA Kessin C Preston PG Lobo EP Intravenous remifentanil: placental transfer, maternal and neonatal effects.Anesthesiology. 1998; 88: 1467-1474Crossref PubMed Scopus (289) Google Scholar In addition, a remifentanil infusion appears to achieve steady state within 15 min without the need for a bolus. Remifentanil also undergoes extensive redistribution in the fetus as evidenced by its low umbilical artery:umbilical vein ratio of 0.29, making any long-lasting fetal adverse effects unlikely.9Kan RE Hughes SC Rosen MA Kessin C Preston PG Lobo EP Intravenous remifentanil: placental transfer, maternal and neonatal effects.Anesthesiology. 1998; 88: 1467-1474Crossref PubMed Scopus (289) Google Scholar Remifentanil infusions have been used for fetal immobilization and anaesthesia during fetal in utero interventions.10Van de Velde M Van Schoubroeck D Lewi LE et al.Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam.Anesth Analg. 2005; 101: 251-258Crossref PubMed Scopus (59) Google Scholar A double-blind randomized controlled trial found that, compared with diazepam, remifentanil provided better surgical conditions due to more rapid and marked fetal immobilization for fetoscopic procedures. The mean (sd) infusion rate used in this study was 0.115 (0.020) µg kg−1 min−1 which guided our dosing regime.10Van de Velde M Van Schoubroeck D Lewi LE et al.Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam.Anesth Analg. 2005; 101: 251-258Crossref PubMed Scopus (59) Google Scholar This immobilization may be due to the opioids’ ability to induce fetal sleep and not anesthesia.10Van de Velde M Van Schoubroeck D Lewi LE et al.Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam.Anesth Analg. 2005; 101: 251-258Crossref PubMed Scopus (59) Google Scholar It is important to note that immobilization does not equate to a reduction in pain perception, and determining whether remifentanil provided any appreciable analgesia is debatable. However, fetal mu-opioid receptors are known to be abundant in the brainstem and spinal cord by 20 weeks of gestation.11Fisk NM Gitau R Teixeira JM Giannakoulopoulos X Cameron AD Glover VA Effect of direct fetal opioid analgesia on fetal hormonal and hemodynamic stress response to intrauterine needling.Anesthesiology. 2001; 95: 828-835Crossref PubMed Scopus (148) Google Scholar In addition, the direct administration of mu-opioid agonists such as fentanyl have been shown to blunt the fetal stress response to intrauterine needling as evidenced by a reduction in the β-endorphin and cortisol stress response along with attenuation of the middle cerebral artery pulsatility index.11Fisk NM Gitau R Teixeira JM Giannakoulopoulos X Cameron AD Glover VA Effect of direct fetal opioid analgesia on fetal hormonal and hemodynamic stress response to intrauterine needling.Anesthesiology. 2001; 95: 828-835Crossref PubMed Scopus (148) Google Scholar There is no established dose–response relationship between opioids and the attenuation of the fetal stress response, and since fetal pharmacokinetics are so poorly understood, we have no clear evidence that the doses of remifentanil that we were using were appropriate. Achieving sufficient fetal doses to completely attenuate the stress response would mean administering larger maternal doses, which in turn could jeopardize maternal safety by increasing the risks of significant maternal sedation, respiratory depression, and aspiration. On the other hand, an advantage of using remifentanil is the ability to administer a continuous infusion of a single agent, which potentially provides a continuous source of fetal sedation and analgesia instead of utilizing bolus administration of opioids, anaesthetics, and neuromuscular blocking agents by the i.m. or i.v. routes as has been reported.3Rosen MA Anesthesia for fetal procedures and surgery.Yonsei Med J. 2001; 42: 669-680Crossref PubMed Scopus (28) Google Scholar 12Dahlgren G Tornberg DC Pregner K Irestedt L Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications.Int J Obstet Anesth. 2004; 13: 178-182Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar In case number 3, which to our knowledge is the longest placental bypass time reported to date when the EXIT procedure has been performed under regional anaesthesia, the remifentanil infusion provided near ideal operating conditions. Umbilical cord gases for EXIT procedures performed under neuraxial anaesthesia have been rarely reported in the literature. The umbilical cord gases reported in our small case series are at least comparable with those previously reported, despite differences in uteroplacental bypass times and anaesthetic technique. In one EXIT to airway procedure performed under epidural anaesthesia for a fetal neck teratoma, umbilical cord arterial blood gases were pH 7.31, Pco2 5.6 kPa, and Po2 3.6 kPa.13Gagnon AL Bebbington MW Kamani A Solimano A Prenatally diagnosed fetal neck teratoma. Case report and novel management options.Fetal Diagn Ther. 1998; 13: 266-270Crossref PubMed Scopus (29) Google Scholar The fetus was 34 weeks gestation and the reported placental bypass time was 4.5 min. In a review of five cases, with an average uteroplacental bypass of 28 min performed under general anaesthesia, the mean (sd) umbilical arterial cord gases were: pH of 7.22 (0.05), Pco2 of 8.13 (1.47) kPa, and Po2 of 5.6 (1.07) kPa.14Bouchard S Johnson MP Flake AW et al.The EXIT procedure: experience and outcome in 31 cases.J Pediatr Surg. 2002; 37: 418-426Abstract Full Text PDF PubMed Scopus (290) Google Scholar We strongly advocate the use of a prophylactic phenylephrine infusion to avoid maternal hypotension associated with the co-administration of remifentanil and nitroglycerin in the setting of neuraxial anaesthesia with the aim of maintaining uteroplacental perfusion, especially during placental bypass. Excessive sedation, respiratory depression, and hypotension are all potential risks associated with remifentanil use in the parturient.9Kan RE Hughes SC Rosen MA Kessin C Preston PG Lobo EP Intravenous remifentanil: placental transfer, maternal and neonatal effects.Anesthesiology. 1998; 88: 1467-1474Crossref PubMed Scopus (289) Google Scholar 10Van de Velde M Van Schoubroeck D Lewi LE et al.Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam.Anesth Analg. 2005; 101: 251-258Crossref PubMed Scopus (59) Google Scholar Much of the data regarding maternal safety and efficacy comes from studies that have been performed in the setting of labour analgesia. In a dose-escalation study assessing the efficacy of remifentanil for patient-controlled i.v. analgesia (PCIA) during labour, parturients receiving boluses of up to 0.5 µg kg−1 reported only mild to moderate sedation and respiratory depression.15Blair JM Hill DA Fee JP Patient-controlled analgesia for labour using remifentanil: a feasibility study.Br J Anaesth. 2001; 87: 415-420Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar An increase in bolus doses up to 1 µg kg−1 along with the addition of a background infusion ranging from 0.025 to 0.05 µg kg−1 min−1 was associated with an increase in maternal sedation scores and also the incidence and frequency of oxygen desaturation (Spo2<90%), with no further improvement in analgesic efficacy. These adverse events were transient, responded quickly to a reduction in the dose of remifentanil, and did not require naloxone administration.15Blair JM Hill DA Fee JP Patient-controlled analgesia for labour using remifentanil: a feasibility study.Br J Anaesth. 2001; 87: 415-420Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar Other studies have reported similar findings.16Volmanen P Akural EI Raudaskoski T Alahuhta S Remifentanil in obstetric analgesia: a dose-finding study.Anesth Analg. 2002; 94: 913-917Crossref PubMed Scopus (118) Google Scholar,17Volmanen P Sarvela J Akural EI Raudaskoski T Korttila K Alahuhta S Intravenous remifentanil vs. epidural levobupivacaine with fentanyl for pain relief in early labour: a randomised, controlled, double-blinded study.Acta Anaesthesiol Scand. 2008; 52: 249-255Crossref PubMed Scopus (88) Google Scholar In comparison with PCIA administration, continuous i.v. administration may offer a safer alternative. In an observational study of 205 patients, remifentanil was administered as a continuous infusion for labour analgesia. Infusions were initiated at 0.025 µg kg−1 min−1 and titrated by 0.025 µg kg−1 min−1 increments to a maximum infusion rate of 0.15 µg kg−1 min−1.18D'Onofrio P Novelli AMM Mecacci F Scarselli G The efficacy and safety of continuous intravenous administration of remifentanil for birth pain relief: an open study of 205 parturients.Anesth Analg. 2009; 109: 1922-1924Crossref PubMed Scopus (36) Google Scholar In this cohort, ∼50% of patients required a maximum infusion rate of ≥0.1 µg kg−1 min−1. The authors reported a low incidence of maternal sedation. All patients had Spo2>95% and none required oxygen supplementation.18D'Onofrio P Novelli AMM Mecacci F Scarselli G The efficacy and safety of continuous intravenous administration of remifentanil for birth pain relief: an open study of 205 parturients.Anesth Analg. 2009; 109: 1922-1924Crossref PubMed Scopus (36) Google Scholar These findings and our own experience suggest that with adequate monitoring, a carefully titrated remifentanil infusion can be safely administered as an adjunct to neuraxial anaesthesia for EXIT procedures. We observed only mild sedation (lowest observed RASS19Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).J Am Med Assoc. 2003; 289: 2983-2991Crossref PubMed Scopus (1129) Google Scholar score −1: drowsy but responding to voice with sustained eye opening) which was beneficial in relieving the maternal stress and anxiety that may be experienced by patients having this procedure performed under neuraxial anaesthesia. We also observed only mild respiratory depression (ventilatory frequency at a nadir of 12 bpm) and no episodes of oxygen desaturation (Spo2<94%) requiring clinical interventions. Remifentanil was also useful for alleviating the visceral discomfort associated with surgical manipulation associated with the procedure. In summary, the maternal administration of remifentanil as a continuous i.v. infusion provided adequate fetal immobilization and possibly analgesia for three EXIT procedures involving airway surgery or manipulation. This case series highlights the usefulness of remifentanil for providing fetal immobilization, therefore avoiding the need for the administration of additional adjuncts when the EXIT procedure is performed under neuraxial anaesthesia. None declared. This study was supported solely by funding from the Duke University Medical Center's Department of Anaesthesiology, Division of Women's Anaesthesia." @default.
• W2113134101 created "2016-06-24" @default.
• W2113134101 creator A5038047624 @default.
• W2113134101 creator A5060878734 @default.
• W2113134101 creator A5077043469 @default.
• W2113134101 date "2011-06-01" @default.
• W2113134101 modified "2023-10-14" @default.
• W2113134101 title "Remifentanil for fetal immobilization and analgesia during the ex utero intrapartum treatment procedure under combined spinal–epidural anaesthesia" @default.
• W2113134101 cites W1969854979 @default.
• W2113134101 cites W1971542665 @default.
• W2113134101 cites W1977328410 @default.
• W2113134101 cites W1978911577 @default.
• W2113134101 cites W1986801308 @default.
• W2113134101 cites W1988522868 @default.
• W2113134101 cites W1997751589 @default.
• W2113134101 cites W2010260511 @default.
• W2113134101 cites W2011103187 @default.
• W2113134101 cites W2020369080 @default.
• W2113134101 cites W2028548218 @default.
• W2113134101 cites W2073623233 @default.
• W2113134101 cites W2073842000 @default.
• W2113134101 cites W2077762094 @default.
• W2113134101 cites W2099066338 @default.
• W2113134101 cites W2103270251 @default.
• W2113134101 cites W2122614564 @default.
• W2113134101 cites W2196477493 @default.
• W2113134101 cites W4232712975 @default.
• W2113134101 doi "https://doi.org/10.1093/bja/aer097" @default.
• W2113134101 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/21531744" @default.
• W2113134101 hasPublicationYear "2011" @default.
• W2113134101 type Work @default.
• W2113134101 sameAs 2113134101 @default.
• W2113134101 citedByCount "36" @default.
• W2113134101 countsByYear W21131341012012 @default.
• W2113134101 countsByYear W21131341012013 @default.
• W2113134101 countsByYear W21131341012014 @default.
• W2113134101 countsByYear W21131341012016 @default.
• W2113134101 countsByYear W21131341012017 @default.
• W2113134101 countsByYear W21131341012018 @default.
• W2113134101 countsByYear W21131341012019 @default.
• W2113134101 countsByYear W21131341012020 @default.
• W2113134101 countsByYear W21131341012021 @default.
• W2113134101 countsByYear W21131341012022 @default.
• W2113134101 crossrefType "journal-article" @default.
• W2113134101 hasAuthorship W2113134101A5038047624 @default.
• W2113134101 hasAuthorship W2113134101A5060878734 @default.
• W2113134101 hasAuthorship W2113134101A5077043469 @default.
• W2113134101 hasBestOaLocation W21131341011 @default.
• W2113134101 hasConcept C172680121 @default.
• W2113134101 hasConcept C201614185 @default.
• W2113134101 hasConcept C2776277131 @default.
• W2113134101 hasConcept C2778891214 @default.
• W2113134101 hasConcept C2779234561 @default.
• W2113134101 hasConcept C2992886682 @default.
• W2113134101 hasConcept C42219234 @default.
• W2113134101 hasConcept C54355233 @default.
• W2113134101 hasConcept C71924100 @default.
• W2113134101 hasConcept C86803240 @default.
• W2113134101 hasConceptScore W2113134101C172680121 @default.
• W2113134101 hasConceptScore W2113134101C201614185 @default.
• W2113134101 hasConceptScore W2113134101C2776277131 @default.
• W2113134101 hasConceptScore W2113134101C2778891214 @default.
• W2113134101 hasConceptScore W2113134101C2779234561 @default.
• W2113134101 hasConceptScore W2113134101C2992886682 @default.
• W2113134101 hasConceptScore W2113134101C42219234 @default.
• W2113134101 hasConceptScore W2113134101C54355233 @default.
• W2113134101 hasConceptScore W2113134101C71924100 @default.
• W2113134101 hasConceptScore W2113134101C86803240 @default.
• W2113134101 hasIssue "6" @default.
• W2113134101 hasLocation W21131341011 @default.
• W2113134101 hasLocation W21131341012 @default.
• W2113134101 hasOpenAccess W2113134101 @default.
• W2113134101 hasPrimaryLocation W21131341011 @default.
• W2113134101 hasRelatedWork W1997187961 @default.
• W2113134101 hasRelatedWork W2034242176 @default.
• W2113134101 hasRelatedWork W205352654 @default.
• W2113134101 hasRelatedWork W2079384918 @default.
• W2113134101 hasRelatedWork W2348337844 @default.
• W2113134101 hasRelatedWork W2372876988 @default.
• W2113134101 hasRelatedWork W2381287366 @default.
• W2113134101 hasRelatedWork W2591029733 @default.
• W2113134101 hasRelatedWork W3028716847 @default.
• W2113134101 hasRelatedWork W2119387934 @default.
• W2113134101 hasVolume "106" @default.
• W2113134101 isParatext "false" @default.
• W2113134101 isRetracted "false" @default.
• W2113134101 magId "2113134101" @default.
• W2113134101 workType "article" @default.