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1.
Emerg Med Clin North Am ; 38(4): 819-839, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981620

RESUMO

Pediatric cardiac arrest is a relatively rare but devastating presentation in infants and children. In contrast to adult patients, in whom a primary cardiac dysrhythmia is the most likely cause of cardiac arrest, pediatric patients experience cardiovascular collapse most frequently after an initial respiratory arrest. Aggressive treatment in the precardiac arrest state should be initiated to prevent deterioration and should focus on support of oxygenation, ventilation, and hemodynamics, regardless of the presumed cause. Unfortunately, outcomes for pediatric cardiac arrest, whether in hospital or out of hospital, continue to be poor.


Assuntos
Parada Cardíaca/terapia , Ressuscitação/métodos , Manuseio das Vias Aéreas , Glicemia/análise , Criança , Maus-Tratos Infantis/terapia , Cardioversão Elétrica , Eletroencefalografia , Serviço Hospitalar de Emergência , Epinefrina/uso terapêutico , Oxigenação por Membrana Extracorpórea , Parada Cardíaca/etiologia , Cardiopatias Congênitas/terapia , Frequência Cardíaca , Humanos , Hipotermia/complicações , Hipotermia/terapia , Hipotermia Induzida , Pneumopatias/terapia , Pais , Exame Físico , Envenenamento/terapia , Avaliação de Processos em Cuidados de Saúde , Valores de Referência , Insuficiência Respiratória/terapia , Taxa Respiratória , Ordens quanto à Conduta (Ética Médica) , Sepse/terapia , Choque/etiologia , Choque/terapia , Vasoconstritores/uso terapêutico , Ferimentos e Lesões/terapia
4.
Scand J Trauma Resusc Emerg Med ; 28(1): 27, 2020 Apr 10.
Artigo em Inglês | MEDLINE | ID: mdl-32276599

RESUMO

BACKGROUND: Treatment of arrhythmias evoked by accidental or therapeutic hypothermia and rewarming remains challenging. We aim to find an ECG-biomarker that can predict ventricular arrhythmias at temperatures occurring in therapeutic and accidental hypothermia. MAIN BODY: Evaluation of ECG-data from accidental and therapeutic hypothermia patients and experimental data on ECG and ventricular fibrillation (VF) threshold in hypothermic New Zealand White Rabbits. VF threshold was measured in rabbit hearts cooled to moderate (31 °C) and severe (17 °C) hypothermia. QRS-interval divided by corrected QT-interval (QTc) was calculated at same temperatures. Clinical QRS/QTc data were obtained after a systematic literature review. Rabbit QRS/QTc values correlated with risk for VF (correlation coefficient: 0.97). Human QRS/QTc values from hypothermic patients, showed similar correlation with risk for ventricular fibrillation in the experimental data (correlation coefficient: 1.00). CONCLUSIONS: These calculations indicate that QRS/QTc has potential as novel biomarker for predicting risk of hypothermia-induced cardiac arrest. Our findings apply both to victims of accidental hypothermia and to patients undergoing therapeutic hypothermia during surgery or after e.g. cardiac arrest.


Assuntos
Parada Cardíaca/diagnóstico , Hipotermia Induzida/efeitos adversos , Hipotermia/complicações , Fibrilação Ventricular/diagnóstico , Animais , Biomarcadores , Modelos Animais de Doenças , Eletrocardiografia , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Hipotermia/terapia , Masculino , Coelhos , Reaquecimento/efeitos adversos , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/fisiopatologia
5.
Air Med J ; 39(2): 133-136, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32197691

RESUMO

Cardiac arrest secondary to accidental hypothermia is rare in the United Kingdom. However, some evidence suggests that it is under-reported; furthermore, recognizing hypothermia as the cause of death is difficult in the postmortem setting. Urban and rural residents are exposed to cold winter conditions both at home and while undertaking recreational activities. Understanding the physiology underpinning hypothermic cardiac arrest is crucial in order to make informed clinical decisions in regard to triage and management by air ambulance services and in prevention of this rare presentation. This article discusses the epidemiology and pathophysiology of accidental hypothermic to explain how personnel can survive after 8 hours 40 minutes of cardiac arrest.


Assuntos
Parada Cardíaca/fisiopatologia , Hipotermia/fisiopatologia , Parada Cardíaca/etiologia , Humanos , Hipotermia/complicações
6.
J Perinatol ; 40(3): 433-438, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31666645

RESUMO

OBJECTIVES: To determine the prevalence of hypothermia on admission and at 24 h of life in very low birth weight infants (VLBWI) and associated morbidity and mortality. STUDY DESIGN: Hospital records of VLBWI admitted to a neonatal unit were reviewed for information on patient's body temperature, clinical characteristics and mortality. Comparisons between normothermic and hypothermic VLBWI were performed. RESULTS: Mean gestational age and birth weight of enrolled infants were 29 ± 3 weeks and 1140 ± 253 g, respectively. Prevalence of admission hypothermia was 46.1%, with 38% developing hypothermia within 24-h following admission. VLBWI with hypothermia were more likely to have been born vaginally [aOR 2.85 (1.37-5.91)], have a birth weight < 1000 g [aOR 2.28 (1.25-4.16)], required resuscitation at birth [aOR 2.20 (1.23-3.94)], develop metabolic acidosis [aOR 3.04 (1.35-6.84)] and die within the first week of life [aOR 4.79 (1.43-16.02)]. CONCLUSIONS: Prevalence of hypothermia in VLBWI is high and is associated with poor outcomes.


Assuntos
Hipotermia/epidemiologia , Doenças do Prematuro/epidemiologia , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Temperatura Corporal , Idade Gestacional , Humanos , Hipotermia/complicações , Recém-Nascido , Doenças do Prematuro/mortalidade , Unidades de Terapia Intensiva Neonatal , Gravidade do Paciente , Prevalência , África do Sul , Centros de Atenção Terciária
7.
J Pediatr Surg ; 55(1): 80-85, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31708210

RESUMO

BACKGROUND: Perioperative hypothermia has been shown to increase surgical site infection (SSI) rates in adults. We sought to characterize whether intraoperative hypothermia or hyperthermia is associated with postoperative infections in infants. METHODS: We conducted a retrospective review of patients ≤6 months old who underwent surgical procedures from November 2013 to October 2015 at a Level I ACS Children's Surgical Center. The outcome was infections within 30 days after operation, with particular attention to SSI. Data obtained included weight and age at surgery, American Society of Anesthesiologists (ASA) physiologic status, wound class, case length, blood transfusion within 72 h of surgery, and administration of prophylactic antibiotics. Temperatures were classified as hypothermia (T < 36 °C), normothermia (T = 36.0 to 37.9 °C), and hyperthermia (T ≥ 38 °C). RESULTS: The 885 patients had 25 SSIs (2.8%) and 11 nonsurgical site infections (1.2%). On univariate analysis, weight at surgery, higher ASA, perioperative transfusions, and longer case length were associated with higher rate of SSI. Higher median Thigh, higher median T low, and any hyperthermia were associated with higher rate of SSI. On multivariable logistic regression adjusted analyses, hyperthermia at any time during the case was associated with SSI (OR 3.47, [95% CI 1.34, 9.04], p = 0.011). Transfusions were also associated with higher SSI rates (OR 3.60 [95% CI, 1.28, 10.3], p = 0.016). CONCLUSIONS: Intraoperative hyperthermia is associated with increased SSI rates in infants. LEVEL OF EVIDENCE: III.


Assuntos
Temperatura Corporal , Hipotermia/complicações , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Análise de Variância , Transfusão de Sangue , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Salas Cirúrgicas , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/fisiopatologia
8.
J Med Case Rep ; 13(1): 354, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31787101

RESUMO

BACKGROUND: We report a case of successful prolonged cardiopulmonary resuscitation (5 hours and 44 minutes) following severe accidental hypothermia with cardiac arrest treated without rewarming on extracorporeal life support. CASE PRESENTATION: A 52-year-old Italian mountaineer, was trapped in a crevasse and rescued approximately 7 hours later by a professional rescue team. After extrication, he suffered a witnessed cardiac arrest with ventricular fibrillation. Immediate defibrillation and cardiopulmonary resuscitation were started. His core temperature was 26.0 °C. Due to weather conditions, air transport to an extracorporeal life support center was not possible. Thus, he was rewarmed with conventional rewarming methods in a rural hospital. Auto-defibrillation occurred at a core temperature of 29.8 °C after 5 hours and 44 minutes of continued cardiopulmonary resuscitation. With a core temperature of 33.4 °C, he was finally admitted to a level 1 trauma center and extracorporeal life support was no longer required. Seven weeks following the accident, he was discharged home with complete neurological recovery. CONCLUSIONS: Successful rewarming from severe hypothermia without extracorporeal life support use as performed in this case suggests that patients with primary hypothermic cardiac arrest have a chance of a favorable neurological outcome even after several hours of cardiac arrest when cardiopulmonary resuscitation and conventional rewarming are performed continuously. This may be especially relevant in remote areas, where extracorporeal life support rewarming is not available.


Assuntos
Reanimação Cardiopulmonar , Hipotermia/complicações , Parada Cardíaca Extra-Hospitalar/terapia , Reanimação Cardiopulmonar/métodos , Humanos , Hipotermia/terapia , Masculino , Pessoa de Meia-Idade , Montanhismo/lesões , Parada Cardíaca Extra-Hospitalar/etiologia , Fatores de Tempo
9.
Scand J Trauma Resusc Emerg Med ; 27(1): 113, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842931

RESUMO

BACKGROUND: To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests. METHODS: Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL). RESULTS: Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were - 1.6 to + 1.7 mmol/L; - 1.18 to + 2.7 mmol/L and - 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium. CONCLUSIONS: We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03096561.


Assuntos
Testes Diagnósticos de Rotina/normas , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Hipotermia/complicações , Potássio/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Gasometria , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Deficiência de Potássio , Estudos Prospectivos
10.
Wilderness environ. med ; 30(4): [S70-S86], Dec. 01, 2019.
Artigo em Inglês | BIGG - guias GRADE | ID: biblio-1117202

RESUMO

Approximately 360,000 deaths globally are attributed to drowning every year. Drowning often affects young victims and can have dire personal, emotional, and financial consequences for patients, families, and society. The goal of these practice guidelines is to reduce the burden of drowning through improvements in treatment and prevention. We present accepted drowning terminology as part of a review and evaluation of literature regarding acute care for the drowning patient, in both out-of-hospital and emergency medical care settings, with particular focus on the wilderness context. The authors relied upon the experience and knowledge of a panel of wilderness and emergency medicine practitioners to make recommendations where little or unreliable evidence is available. This is the first update of the original publication from 2016.


Assuntos
Humanos , Criança , Afogamento/prevenção & controle , Afogamento/epidemiologia , Hipotermia/complicações , Hipotermia/diagnóstico , Hipotermia/prevenção & controle
11.
Ann Biol Clin (Paris) ; 77(6): 651-659, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31649011

RESUMO

Hypothermia is a potentially lethal pathology whose in vivo diagnosis is relatively easy, based on the observation of a body temperature below 35̊C. However, its post mortem diagnosis is much more complex because of a thermal decrease occurring systematically after the death, which renders most often uninterpretable the body temperature as a diagnostic argument for hypothermia. Moreover, none of the macroscopic or microscopic autopsy elements described as suspicious of hypothermia are pathognomonic of a hypothermic death. Currently, this diagnosis arises in the light of an association of concordant arguments including these autopsic and histological elements but also some biomarkers. The aim of this article is to illustrate by a practical case the diagnostic complexity of a death by hypothermia through the evocative elements currently described, by emphasizing the reflection on some biomarkers confirmed or under study.


Assuntos
Autopsia/métodos , Bioquímica/métodos , Técnicas de Laboratório Clínico/métodos , Idoso de 80 Anos ou mais , Biomarcadores/análise , Temperatura Corporal/fisiologia , Causas de Morte , Diagnóstico Diferencial , Medicina Legal/métodos , Humanos , Hipotermia/complicações , Hipotermia/diagnóstico , Hipotermia/metabolismo , Masculino
14.
BMJ Case Rep ; 12(7)2019 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-31352387

RESUMO

Takotsubo cardiomyopathy (TTC) is most commonly characterised by transient apical ballooning in response to physical or emotional stress without significant coronary artery disease (CAD). Various physical and emotional factors can trigger TTC. We report a case of hypothermia-induced biventricular TTC in an 84-year-old man admitted with a core body temperature of 29.8°C, followed by quick recovery of systolic function and resolution of wall motion abnormality after discharge. TTC should be suspected in hypothermic patients presenting with evidence of new onset heart failure and be added to the expanding list of factors triggering TTC. Similar to TTC induced by various other factors, hypothermia-induced TTC also carries a favourable prognosis with relatively quick recovery of wall motion abnormalities.


Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Temperatura Baixa/efeitos adversos , Hipotermia/complicações , Cardiomiopatia de Takotsubo/etiologia , Idoso de 80 Anos ou mais , Hidratação , Humanos , Hipotermia/fisiopatologia , Hipotermia/terapia , Masculino , Fatores Desencadeantes , Reaquecimento , Cardiomiopatia de Takotsubo/fisiopatologia , Cardiomiopatia de Takotsubo/terapia , Resultado do Tratamento
15.
Enferm. glob ; 18(55): 270-284, jul. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-186242

RESUMO

Introducción: la hipotermia es un evento común en el período intraoperatorio, acarrea consecuencias en la recuperación del paciente, con complicaciones en diversos sistemas del organismo, como el cardíaco, respiratorio, tegumentario, digestivo, inmunológico y también el sistema de coagulación. Objetivo: analizar las complicaciones presentadas por el paciente en el período postoperatorio relacionadas con la hipotermia intraoperatoria. Métodos: estudio de cohorte retrospectivo, muestra compuesta por 54 registros clínicos de pacientes, participantes de un estudio anterior, de diseño experimental, en que fueron sometidos o no a infusión de solución intravenosa caliente, en el período intraoperatorio y de recuperación anestésica. Las variables fueron analizadas en 4 tiempos diferentes, a la llegada a la Unidad de Internación, después de 17, 32 y 108 horas de período postoperatorio. El modelo utilizado fue el logístico marginal. Resultados: la mayoría de los pacientes 40 (74,07%) eran del sexo femenino, edad media de 47,06 años, y 42 (77,78%) salieron normotérmicos de la Sala de Recuperación Post-Anestésica, con temperatura media de 36,2ºC. En cuanto a la comparación de las variables entre los grupos de pacientes normotérmicos e hipotérmicos, a lo largo del tiempo, las variables que presentaron significancia estadística fueron el tiempo de internación, dolor, náusea y herida operatoria con presencia de secreción, con p-valor menor que 0.05. Conclusión: ante las complicaciones encontradas en este estudio, se hace necesario el desarrollo de acciones de prevención y control de la hipotermia intraoperatoria buscando una mejor recuperación del paciente en el período de postoperatorio


Introdução: a hipotermia é um evento comum no período intraoperatório, acarreta consequências na recuperação do paciente, com complicações em diversos sistemas do organismo, como o cardíaco, respiratório, tegumentar, digestório, imunológico e também o sistema de coagulação. Objetivo: analisar as complicações apresentadas pelo paciente no período de pós-operatório relacionadas com a hipotermia intraoperatória. Métodos: estudo de coorte retrospectivo, amostra composta por 54 prontuários de pacientes, participantes de um estudo anterior, de delineamento experimental, em que foram submetidos ou não à infusão venosa aquecida no período intraoperatório e de recuperação anestésica. As variáveis foram analisadas em 4 tempos diferentes, na chegada a Unidade de Internação, após 17, 32 e 108 horas de período pós-operatório. O modelo utilizado foi o logístico marginal. Resultados: a maioria dos pacientes 40 (74,07%) eram do sexo feminino, com média de idade de 47,06 anos, e 42 (77,78%) saíram normotérmicos da Sala de Recuperação Pós-Anestésica, com temperatura média de 36,2ºC. Em relação à comparação entre as variáveis e os grupos de pacientes normotérmicos e hipotérmicos, ao longo do tempo, as variáveis que apresentaram significância estatística foram o tempo de internação, dor, náusea, evacuação e aspecto da ferida operatória com presença de secreção, com p-valor menor que 0,05. Conclusão: diante das complicações encontradas neste estudo, faz-se necessário o desenvolvimento de ações de prevenção e controle da hipotermia intraoperatória visando uma melhor recuperação do paciente no período de pós-operatório


Introduction: hypothermia is a common event in the intraoperative period, it triggers consequences in the recovery of the patient, with complications in several systems of the organism, such as cardiac, respiratory, integumentary, digestive, immunological and also the coagulation system. Objective: to analyze the complications presented by the patient in the postoperative period related to intraoperative hypothermia. Methods: a retrospective cohort study was carried out in a sample composed of 54 patients' files, from a previous experimental study, in which they were submitted or not to warmed intraoperative intravenous infusion and anesthetic recovery. The variables were analyzed at 4 different times, upon arrival at the hospitalization unit, after 17, 32 and 108 hours postoperative. The model used was the marginal logistics. Results: the majority of patients 40 (74.07%) were female, mean age of 47.06 years, 42 (77.78%) were normothermic patients from the Post Anesthesia Recovery Room, with a mean temperature of 36.2ºC. Regarding the comparison between variables and groups of normothermic and hypothermic patients, over time, the variables that presented statistical significance were the time of hospitalization, pain, nausea, evacuation and surgical wound with presence of secretion, with a p-value less than 0.05. Conclusion: in view of the complications found in this study, it is necessary to develop preventive and control actions for intraoperative hypothermia aiming at a better recovery of the patient in the postoperative period


Assuntos
Humanos , Hipotermia/complicações , Período de Recuperação da Anestesia , Dor Pós-Operatória/epidemiologia , Período Intraoperatório , Complicações Pós-Operatórias/epidemiologia , Enfermagem em Pós-Anestésico/métodos , Tempo de Internação/estatística & dados numéricos , Estudos Retrospectivos
16.
Turk Kardiyol Dern Ars ; 47(4): 315-318, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31219440

RESUMO

An Osborn wave may be observed on an electrocardiogram (ECG) as a late delta wave at the end of the QRS complex in cases of hypothermia. An 18-year-old male known to be a synthetic cannabinoid user was found unconscious and hypothermic. The patient's body temperature was 33ºC, and an Osborn wave and atrial fibrillation were detected in ECG readings. Following the application of heating and supportive therapy, consciousness returned and the ECG findings improved. Rewarming and supportive treatment can be life-saving in a hypothermic patient when initiated as soon as possible.


Assuntos
Fibrilação Atrial/etiologia , Hipotermia/complicações , Hipotermia/etiologia , Abuso de Maconha/complicações , Adolescente , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Gasometria , Temperatura Corporal , Eletrocardiografia , Emergências , Hidratação , Escala de Coma de Glasgow , Humanos , Masculino
17.
Artigo em Alemão | MEDLINE | ID: mdl-31212332

RESUMO

Persistent, uncontrolled bleeding after trauma is one of the leading causes of fatalities in patients with severe injuries. 40% of trauma deaths are associated with massive haemorrhage. Hypoperfusion due to major loss of blood volume leads to tissue damage. In combination with acidosis and hypothermia, a generalized immune response with activation of coagulation is triggered. This leads to trauma-induced coagulopathy. A suitable, early treatment might lead to a significant reduction in morbidity and mortality.


Assuntos
Acidose , Transtornos da Coagulação Sanguínea , Hemorragia , Hipotermia , Ferimentos e Lesões , Acidose/complicações , Coagulação Sanguínea , Transtornos da Coagulação Sanguínea/etiologia , Hemorragia/etiologia , Humanos , Hipotermia/complicações , Ferimentos e Lesões/complicações
18.
Intern Med ; 58(18): 2743-2748, 2019 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-31178478

RESUMO

Accidental hypothermia is defined as a core body temperature <35°C. Even with the use of multiple active rewarming methods, it has a high mortality rate. No standard treatment strategy for moderate or severe hypothermia in the absence of cardiac arrest has yet been established. We herein report three patients with severe or moderate accidental hypothermia who were treated by hemodialysis in the acute phase. This case report with a literature review describes the usefulness of hemodialysis for the treatment of moderate and severe accidental hypothermia without cardiac arrest.


Assuntos
Hipotermia/terapia , Diálise Renal/métodos , Reaquecimento/métodos , Idoso , Arritmias Cardíacas/etiologia , Eletrocardiografia , Humanos , Hipotermia/complicações , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença
20.
AORN J ; 109(6): 741-747, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31135987

RESUMO

Inadvertent perioperative hypothermia is a widely known patient condition that is associated with postoperative complications. This retrospective comparative study of 298 surgical patients was conducted at a single hospital site in the midwestern United States. Our aims were to describe risk factors and outcomes associated with perioperative hypothermia. We compared the type and frequency of patient factors, clinical factors, and postoperative complications during the inpatient stay of the sample patients to determine whether there were factors or complications associated with perioperative hypothermia. Significant factors associated with the occurrence of perioperative hypothermia included older age and type of surgery. Hypothermia in patients was associated with a higher rate of postoperative complications when compared with normothermic patients. Nurses and perioperative leaders should understand the risk factors and complications associated with perioperative hypothermia to collaboratively develop and test evidence-based initiatives, improve care, and promote optimal patient outcomes.


Assuntos
Hipotermia/prevenção & controle , Período Perioperatório/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Temperatura Corporal/fisiologia , Feminino , Humanos , Hipotermia/complicações , Hipotermia/epidemiologia , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Meio-Oeste dos Estados Unidos/epidemiologia , Período Perioperatório/normas , Estudos Retrospectivos
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