Smooth Extubation and Smooth Emergence Techniques: A Narrative Review

Tiffany H Wong, Garret Weber, Apolonia E Abramowicz, Tiffany H Wong, Garret Weber, Apolonia E Abramowicz

Abstract

There is a paucity of literature on extubation technique and a lack of consensus regarding the definition of smooth extubation. This narrative review paper defines an ideal extubation, otherwise known as a "smooth extubation," reviews perioperative criteria for extubation and risks and adverse events related to extubation, and explores various perioperative techniques that can be used to achieve a smooth extubation while caring for an uncomplicated patient without significant risk factors for extubation failure. In light of the evolving practice during the SARS CoV2 (COVID-19) pandemic to minimize aerosol generation and infection transmission, smooth extubation is particularly important.

Conflict of interest statement

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Copyright © 2021 Tiffany H. Wong et al.

References

    1. Koga K., Asai T., Vaughan R. S., Latto I. P. Respiratory complications associated with tracheal extubation. Timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia. 1998;53(6):540–544. doi: 10.1046/j.1365-2044.1998.00397.x.
    1. Hartley M., Vaughan R. S. Problems associated with tracheal extubation. British Journal of Anaesthesia. 1993;71(4):561–568. doi: 10.1093/bja/71.4.561.
    1. Cook T. M., Woodall N., Frerk C. Major complications of airway management in the UK: results of the fourth national audit project of the royal college of anaesthetists and the difficult airway society. Part 1: anaesthesia †. British Journal of Anaesthesia. 2011;106(5):617–631. doi: 10.1093/bja/aer058.
    1. Domino K. B., Posner K. L., Caplan R. A., Cheney F. W. Airway injury during anesthesia: a closed claims analysis. Anesthesiology. 1999;91(6):1703–1711. doi: 10.1097/00000542-199912000-00023.
    1. Metzner J., Posner K. L., Lam M. S., Domino K. B. Closed claims’ analysis. Best Practice & Research Clinical Anaesthesiology. 2011;25(2):263–276. doi: 10.1016/j.bpa.2011.02.007.
    1. Peterson G. N., Domino K. B., Caplan R. A., Posner K. L., Lee L. A., Cheney F. W. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33–39. doi: 10.1097/00000542-200507000-00009.
    1. Popat M., Mitchell V., Dravid R., Patel A., Swampillai C., Higgs A. Difficult airway society guidelines for the management of tracheal extubation. Anaesthesia. 2012;67(3):318–340. doi: 10.1111/j.1365-2044.2012.07253.x.
    1. Matava C. T., Yu J., Denning S. Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19. Canadian Journal of Anesthesia/Journal Canadien D’anesthésie. 2020;67(7):902–904. doi: 10.1007/s12630-020-01649-w.
    1. Brown S., Patrao F., Verma S., Lean A., Flack S., Polaner D. Barrier system for airway management of COVID-19 patients. Anesthesia & Analgesia. 2020;131 doi: 10.1213/ane.0000000000004876.
    1. Au Yong P. S., Chen X. Reducing droplet spread during airway manipulation: lessons from the COVID-19 pandemic in Singapore. British Journal of Anaesthesia. 2020;125(1):e176–e178. doi: 10.1016/j.bja.2020.04.007.
    1. D’Silva D. F., McCulloch T. J., Lim J. S., Smith S. S., Carayannis D. Extubation of patients with COVID-19. British Journal of Anaesthesia. 2020;125(1):e192–e195. doi: 10.1016/j.bja.2020.03.016.
    1. Aminnejad R., Salimi A., Saeidi M. Lidocaine during intubation and extubation in patients with coronavirus disease (COVID-19) Canadian Journal of Anesthesia/Journal Canadien D’anesthésie. 2020;67(6):p. 759. doi: 10.1007/s12630-020-01627-2.
    1. Miller K. A., Harkin C. P., Bailey P. L. Postoperative tracheal extubation. Anesthesia & Analgesia. 1995;80(1):149–172. doi: 10.1213/00000539-199501000-00025.
    1. Lee B., Lee J.-R., Na S. Targeting smooth emergence: the effect site concentration of remifentanil for preventing cough during emergence during propofol-remifentanil anaesthesia for thyroid surgery. British Journal of Anaesthesia. 2009;102(6):775–778. doi: 10.1093/bja/aep090.
    1. Bindu B., Pasupuleti S., Gowd U. P., Gorre V., Murthy R. R., Laxmi M. B. A double blind, randomized, controlled trial to study the effect of dexmedetomidine on hemodynamic and recovery responses during tracheal extubation. Journal of Anaesthesiology, Clinical Pharmacology. 2013;29(2):162–167. doi: 10.4103/0970-9185.111665.
    1. Rani P., Hemanth Kumar V., Ravishankar M., Sivashanmugam T., Sripriya R., Trilogasundary M. Rapid and reliable smooth extubation - comparison of fentanyl with dexmedetomidine: a randomized, double-blind clinical trial. Anesthesia: Essays and Researches. 2016;10(3):597–601. doi: 10.4103/0259-1162.186605.
    1. Cranfield K. A., Bromley L. M. Minimum alveolar concentration of desflurane for tracheal extubation in deeply anaesthetized, unpremedicated children. British Journal of Anaesthesia. 1997;78(4):370–371. doi: 10.1093/bja/78.4.370.
    1. Foulds L., Dalton A. Extubation and emergence. Anaesthesia & Intensive Care Medicine. 2018;19(9):465–470. doi: 10.1016/j.mpaic.2018.06.001.
    1. Mathew J. P., Rosenbaum S. H., O’Connor T., Barash P. G. Emergency tracheal intubation in the postanesthesia care unit: physician error or patient disease? Anesthesia & Analgesia. 1990;71(6):691–697. doi: 10.1213/00000539-199012000-00020.
    1. Freundlich R. E., Maile M. D., Sferra J. J., Jewell E. S., Kheterpal S., Engoren M. Complications associated with mortality in the national surgical quality improvement program Database. Anesthesia & Analgesia. 2018;127(1):55–62. doi: 10.1213/ane.0000000000002799.
    1. Kheterpal S., Vaughn M. T., Dubovoy T. Z., et al. Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (stronger): a multicenter matched cohort analysis. Anesthesiology. 2020;132(6):1371–1381. doi: 10.1097/aln.0000000000003256.
    1. Burgess G. E., Cooper J. R., Jr., Marino R. J., Peuler M. J., Warriner R. A. Laryngeal competence after tracheal extubation. Anesthesiology. 1979;51(1):73–77. doi: 10.1097/00000542-197907000-00016.
    1. Kirmeier E. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respiratory Medicine. 2019;7(2):129–140. doi: 10.1016/s2213-2600(18)30294-7.
    1. Krause M., McWilliams S. K., Bullard K. J., et al. Neostigmine versus Sugammadex for reversal of neuromuscular blockade and effects on reintubation for respiratory failure or newly initiated noninvasive ventilation: an interrupted time series design. Anesthesia and Analgesia. 2020;131(1):141–151. doi: 10.1213/ane.0000000000004505.
    1. Sibert K. S., Long J. L., Haddy S. M. Extubation and the risks of coughing and laryngospasm in the era of coronavirus disease-19 (COVID-19) Cureus. 2020;12(5) doi: 10.7759/cureus.8196.e8196
    1. Bhattacharya M., Kallet R. H., Ware L. B., Matthay M. A. Negative-pressure pulmonary edema. Chest. 2016;150(4):927–933. doi: 10.1016/j.chest.2016.03.043.
    1. Warner M. E., Benenfeld S. M., Warner M. A., Schroeder D. R., Maxson P. M. Perianesthetic dental injuries. Anesthesiology. 1999;90(5):1302–1305. doi: 10.1097/00000542-199905000-00013.
    1. Yasny J. S. Perioperative dental considerations for the anesthesiologist. Anesthesia & Analgesia. 2009;108(5):1564–1573. doi: 10.1213/ane.0b013e31819d1db5.
    1. Brodsky M. B., Levy M. J., Jedlanek E., et al. Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care. Critical Care Medicine. 2018;46(12):2010–2017. doi: 10.1097/ccm.0000000000003368.
    1. Ha J. F., Vitale L. N., Pfarr M. A., Kawai Y., Zopf D. A. Massive macroglossia after posterior cranial fossa surgery: a case report. A & A Practice. 2018;10(8):204–208. doi: 10.1213/xaa.0000000000000663.
    1. Tasbihgou S. R., Vogels M. F., Absalom A. R. Accidental awareness during general anaesthesia-a narrative review. Anaesthesia. 2018;73(1):112–122. doi: 10.1111/anae.14124.
    1. Osterman J. E., van der Kolk B. A. Awareness during anesthesia and posttraumatic stress disorder. General Hospital Psychiatry. 1998;20(5):274–281. doi: 10.1016/s0163-8343(98)00035-8.
    1. Cook T. M., Andrade J., Bogod D. G., et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. Anaesthesia. 2014;69(10):1102–1116. doi: 10.1111/anae.12827.
    1. Bidwai A. V., Bidwai V. A., Rogers C. R., Stanley T. H. Blood-pressure and pulse-rate responses to endotracheal extubation with and without prior injection of lidocaine. Anesthesiology. 1979;51(2):171–173. doi: 10.1097/00000542-197908000-00020.
    1. Hu S., Li Y., Wang S., Xu S., Ju X., Ma L. Effects of intravenous infusion of lidocaine and dexmedetomidine on inhibiting cough during the tracheal extubation period after thyroid surgery. BMC Anesthesiology. 2019;19(1):p. 66. doi: 10.1186/s12871-019-0739-1.
    1. Nho J.-S., Lee S.-Y., Kang J.-M., et al. Effects of maintaining a remifentanil infusion on the recovery profiles during emergence from anaesthesia and tracheal extubation. British Journal of Anaesthesia. 2009;103(6):817–821. doi: 10.1093/bja/aep307.
    1. Rassam S., Sandbythomas M., Vaughan R. S., Hall J. E. Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland. Anaesthesia. 2005;60(10):995–1001. doi: 10.1111/j.1365-2044.2005.04235.x.
    1. Mostafa S. M., Vucevic M. Comparison of atropine and glycopyrronium in patients with pre-existing cardiac disease. Anaesthesia. 1984;39(12):1207–1213. doi: 10.1111/j.1365-2044.1984.tb06433.x.
    1. Daley M. D., Norman P. H., Coveler L. A. Tracheal extubation of adult surgical patients while deeply anesthetized: a survey of United States anesthesiologists. Journal of Clinical Anesthesia. 1999;11(6):445–452. doi: 10.1016/s0952-8180(99)00043-4.
    1. Baijal R. G., Bidani S. A., Minard C. G., Watcha M. F. Perioperative respiratory complications following awake and deep extubation in children undergoing adenotonsillectomy. Paediatric Anaesthesia. 2015;25(4):392–399. doi: 10.1111/pan.12561.
    1. von Ungern-Sternberg B. S., Davies K., Hegarty M., Erb T. O., Habre W. The effect of deep vs. awake extubation on respiratory complications in high-risk children undergoing adenotonsillectomy: a randomised controlled trial. European Journal of Anaesthesiology. 2013;30(9):529–536. doi: 10.1097/EJA.0b013e32835df608.
    1. Patel R. I., Hannallah R. S., Norden J., Casey W. F., Verghese S. T. Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients. Anesthesia and Analgesia. 1991;73(3):266–270.
    1. Koo C.-H., Lee S., Chung S., Ryu J.-H. Deep vs. Awake extubation and LMA removal in terms of airway complications in pediatric patients undergoing anesthesia: a systemic review and meta-analysis. Journal of Clinical Medicine. 2018;7(10):p. 353. doi: 10.3390/jcm7100353.
    1. Kim M. K., Baek C. W., Kang H., et al. Comparison of emergence after deep extubation using desflurane or desflurane with remifentanil in patients undergoing general anesthesia: a randomized trial. Journal of Clinical Anesthesia. 2016;28:19–25. doi: 10.1016/j.jclinane.2015.08.013.
    1. Fan Q., Hu C., Ye M., Shen X. Dexmedetomidine for tracheal extubation in deeply anesthetized adult patients after otologic surgery: a comparison with remifentanil. BMC Anesthesiology. 2015;15(1):p. 106. doi: 10.1186/s12871-015-0088-7.
    1. Patanwala A. E., Erstad B. L. Comparison of dexmedetomidine versus propofol on hospital costs and length of stay. Journal of Intensive Care Medicine. 2016;31(7):466–470. doi: 10.1177/0885066614544452.
    1. Guler G., Akin A., Tosun Z., Ors S., Esmaoglu A., Boyaci A. Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Paediatric Anaesthesia. 2005;15(9):762–766. doi: 10.1111/j.1460-9592.2004.01541.x.
    1. Artime C. A., Hagberg C. A. Tracheal extubation. Respiratory Care. 2014;59(6):991–1005. doi: 10.4187/respcare.02926.
    1. Suppiah R. K., Rajan S., Paul J., Kumar L. Respiratory and hemodynamic outcomes following exchange extubation with laryngeal mask airway as compared to traditional awake extubation. Anesthesia: Essays and Researches. 2016;10(2):212–217. doi: 10.4103/0259-1162.174469.
    1. Ma H. N., Li H. L., Che W. [Effect of exchange of tracheal tube for laryngeal mask airway (LMA) on intratracheal extubation stress response under deep anesthesia level after surgery in elderly patients with hypertension] Zhonghua Wai Ke Za Zhi. 2010;48(23):1811–1814.
    1. Tsui B. C., Wagner A., Cave D., Elliott C., El-Hakim H., Malherbe S. The incidence of laryngospasm with a “no touch” extubation technique after tonsillectomy and adenoidectomy. Anesthesia & Analgesia. 2004;98(2):327–329. doi: 10.1213/01.ane.0000097185.70171.89.
    1. Sheta S., Nada E., Abdelhalim A. Evaluation of “no touch” extubation technique on airway-related complications during emergence from general anesthesia. Saudi Journal of Anaesthesia. 2011;5(2):125–131. doi: 10.4103/1658-354x.82778.
    1. Peng F., Wang M., Yang H., Yang X., Long M. Efficacy of intracuff lidocaine in reducing coughing on tube: a systematic review and meta-analysis. Journal of International Medical Research. 2020;48(2):030006052090187–300060520901872. doi: 10.1177/0300060520901872.
    1. Lam F., Lin Y.-C., Tsai H.-C., Chen T.-L., Tam K.-W., Chen C.-Y. Effect of intracuff lidocaine on postoperative sore throat and the emergence phenomenon: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2015;10(8) doi: 10.1371/journal.pone.0136184.e0136184
    1. Zamora Lozano J., Cruz Villaseñor J. A., Rodríguez Reyes J., Sánchez Rodríguez J. P., Briones Corona G., Gallardo Alonso L. A. [Comparison of topical, intravenous, and intracuff lidocaine for reducing coughing after extubation during emergence from general anesthesia] Revista Española de Anestesiología y Reanimación. 2007;54(10):596–601.
    1. Yang S. S., Wang N.-N., Postonogova T., et al. Intravenous lidocaine to prevent postoperative airway complications in adults: a systematic review and meta-analysis. British Journal of Anaesthesia. 2020;124(3):314–323. doi: 10.1016/j.bja.2019.11.033.
    1. Swamy S. N., Madhusudhana R. Attenuation of hemodynamic responses to endotracheal extubation with different doses of diltiazem with lignocaine: a placebo-controlled study. Anesthesia, Essays and Researches. 2018;12(2):428–433. doi: 10.4103/aer.AER_28_18.
    1. Mikawa K., Nishina K., Maekawa N., Obara H. Attenuation of cardiovascular responses to tracheal extubation: verapamil versus diltiazem. Anesthesia and Analgesia. 1996;82(6):1205–1210. doi: 10.1097/00000539-199606000-00018.
    1. Hung N. K., Wu C. T., Chan S. M., et al. Effect on postoperative sore throat of spraying the endotracheal tube cuff with benzydamine hydrochloride, 10% lidocaine, and 2% lidocaine. Anesthesia and Analgesia. 2010;111(4):882–886. doi: 10.1213/ANE.0b013e3181d4854e.
    1. Huang Y.-S., Hung N.-K., Lee M.-S., et al. The effectiveness of benzydamine hydrochloride spraying on the endotracheal tube cuff or oral mucosa for postoperative sore throat. Anesthesia & Analgesia. 2010;111(4):1–91. doi: 10.1213/ANE.0b013e3181e6d82a.
    1. Lévy B., Mouillac F., Quilichini D., Schmitz J., Gaudart J., Gouin F. [Topical methylprednisolone vs lidocaïne for the prevention of postoperative sore throat] Annales Françaises d’Anesthésie et de Réanimation. 2003;22(7):595–599. doi: 10.1016/s0750-7658(03)00214-4.
    1. Watkins J., Lee D., White W. A., Jr., Mundy S. Effects of topical lidocaine on successful extubation time among patients undergoing elective carotid endarterectomies. AANA Journal. 2012;80(2):99–104.
    1. Turan G., Ozgultekin A., Turan C., Dincer E., Yuksel G. Advantageous effects of dexmedetomidine on haemodynamic and recovery responses during extubation for intracranial surgery. European Journal of Anaesthesiology. 2008;25(10):816–820. doi: 10.1017/s0265021508004201.
    1. Hadi S. M., Saleh A. J., Tang Y. Z., Daoud A., Mei X., Ouyang W. The effect of KETODEX on the incidence and severity of emergence agitation in children undergoing adenotonsillectomy using sevoflurane based-anesthesia. International Journal of Pediatric Otorhinolaryngology. 2015;79(5):671–676. doi: 10.1016/j.ijporl.2015.02.012.
    1. Dollo G., Estebe J.-P., Le Corre P., Chevanne F., Ecoffey C., Le Verge R. Endotracheal tube cuffs filled with lidocaine as a drug delivery system: in vitro and in vivo investigations. European Journal of Pharmaceutical Sciences. 2001;13(3):319–323. doi: 10.1016/s0928-0987(01)00119-1.
    1. Sconzo J. M., Moscicki J. C., DiFazio C. A. In vitro diffusion of lidocaine across endotracheal tube cuffs. Regional Anesthesia. 1990;15(1):37–40.
    1. Huang C.-J., Tsai M.-C., Chen C.-T., Cheng C.-R., Wu K.-H., Wei T.-T. In vitro diffusion of lidocaine across endotracheal tube cuffs. Canadian Journal of Anesthesia/Journal Canadien D’anesthésie. 1999;46(1):82–86. doi: 10.1007/bf03012520.
    1. Salim B., Rashid S., Ali M. A., Raza A., Khan F. A. Effect of pharmacological agents administered for attenuating the extubation response on the quality of extubation: a systematic review. Cureus. 2019;11(12):p. e6427. doi: 10.7759/cureus.6427.
    1. Lin B.-F., Ju D.-T., Cherng C.-H., et al. Comparison between intraoperative fentanyl and tramadol to improve quality of emergence. Journal of Neurosurgical Anesthesiology. 2012;24(2):127–132. doi: 10.1097/ANA.0b013e31823c4a24.
    1. Benoît Z., Wicky S., Fischer J. F., et al. The effect of increased FIO(2) before tracheal extubation on postoperative atelectasis. Anesthesia and Analgesia. 2002;95(6):p. 1777. doi: 10.1097/00000539-200212000-00058.
    1. Nimmagadda U., Salem M. R., Crystal G. J. Preoxygenation. Anesthesia & Analgesia. 2017;124(2):507–517. doi: 10.1213/ane.0000000000001589.
    1. Lindahl S. G., Mure M. Dosing oxygen: a tricky matter or a piece of cake? Anesthesia & Analgesia. 2002;95(6):1472–1473. doi: 10.1097/00000539-200212000-00002.
    1. King H. K., Lewis K. Guedel oropharyngeal airway does not prevent patient biting on the endotracheal tube. Anaesthesia and Intensive Care. 1996;24(6):729–730.
    1. Falzon D., Foye R., Jefferson P., Ball D. R. Extubation guidelines: guedel oropharyngeal airways should not be used as bite blocks. Anaesthesia. 2012;67(8):p. 919. doi: 10.1111/j.1365-2044.2012.07255.x.
    1. Lee C. M., Song K. S., Morgan B. R., et al. Aspiration of an oropharyngeal airway during nasotracheal intubation. The Journal of Trauma. 2001;50(5):937–938. doi: 10.1097/00005373-200105000-00029.
    1. Zaltzman J., Ferman A. An acute life-threatening complication caused by a Guedel airway. Critical Care Medicine. 1987;15(11):p. 1074. doi: 10.1097/00003246-198711000-00020.
    1. Nunn J. F., Payne J. P. Hypoxaemia after general anaesthesia. Lancet. 1962;2(7257):631–632. doi: 10.1016/s0140-6736(62)92541-2.
    1. Morris R. W., Buschman A., Warren D. L., Philip J. H., Raemer D. B. The prevalence of hypoxemia detected by pulse oximetry during recovery from anesthesia. Journal of Clinical Monitoring. 1988;4(1):16–20. doi: 10.1007/bf01618102.
    1. Tyler I. L., Tantisira B., Winter P. M., Motoyama E. K. Continuous monitoring of arterial oxygen saturation with pulse oximetry during transfer to the recovery room. Anesthesia and Analgesia. 1985;64(11):1108–1112.
    1. Blair I., Holland R., Lau W., McCarthy N., Chiah T. S., Ledwidge D. Oxygen saturation during transfer from operating room to recovery after anaesthesia. Anaesthesia and Intensive Care. 1987;15(2):147–150. doi: 10.1177/0310057x8701500205.
    1. Caruso T. J., Mokhtari T. E., Coughlan M. J., et al. Pediatric postoperative pulse oximetry monitoring during transport to the postanesthesia care unit reduces frequency of hypoxemia. The Joint Commission Journal on Quality and Patient Safety. 2017;43(3):146–150. doi: 10.1016/j.jcjq.2016.12.001.
    1. Kodali B. S. Capnography outside the operating rooms. Anesthesiology. 2013;118(1):192–201. doi: 10.1097/ALN.0b013e318278c8b6.
    1. Maity A., Maulik S., Saha D., Sutradhar M., Swaika S., Choudhury B. Detection of hypoxia in the early postoperative period. Anesthesia: Essays and Researches. 2012;6(1):34–37. doi: 10.4103/0259-1162.103369.
    1. Jain R., Sethi N., Sood J. Loss of integrity of a reinforced endotracheal tube by patient bite. Indian Journal of Anaesthesia. 2013;57(4):p. 424. doi: 10.4103/0019-5049.118520.
    1. Peck M. J., Needleman S. M. Reinforced endotracheal tube obstruction. Anesthesia & Analgesia. 1994;79(1):p. 193. doi: 10.1213/00000539-199407000-00040.
    1. Hoffmann C. O., Swanson G. A. Oral reinforced endotracheal tube crushed and perforated from biting. Anesthesia and Analgesia. 1989;69(4):552–553.
    1. McTaggart R. A., Shustack A., Noseworthy T., Johnston R. Another cause of obstruction in an armored endotracheal tube. Anesthesiology. 1983;59(2):p. 164. doi: 10.1097/00000542-198308000-00036.
    1. Hull J. M. Occlusion of armoured tubes. Anaesthesia. 1989;44(9):p. 790. doi: 10.1111/j.1365-2044.1989.tb09288.x.
    1. Kong C. S. A small child can bite through an armoured tracheal tube. Anaesthesia. 1995;50(3):p. 263. doi: 10.1111/j.1365-2044.1995.tb04579.x.
    1. Liu E. H., Yih P. S. Negative pressure pulmonary oedema caused by biting and endotracheal tube occlusion--a case for oropharyngeal airways. Singapore Medical Journal. 1999;40(3):174–175.
    1. Williams A., Singh G. Tongue bite injury after use of transcranial electric stimulation motor-evoked potential monitoring. Journal of Anaesthesiology Clinical Pharmacology. 2014;30(3):439–440. doi: 10.4103/0970-9185.137297.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir