Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period
Keywords:
Sleep apnea syndromes, Perioperative period, Child Anesthesia, Physiopathology
Abstract
Introduction:
OSAHS is a respiratory disorder with perioperative complications, which increase morbidity and mortality. The characteristics of the pediatric population require a careful perioperative assessment.
Objective:
This article addresses relevant physiopathology, clinical and paraclinical topics, perioperative treatment and care of pediatric patients with OSAHS.
Materials and methods:
A literature search was conducted in PubMed and Embase databases using the MeSH terms: sleep apnea syndromes, obstructive sleep apnea, physiopathology, perioperative period, and perioperative care. The titles and/or the abstracts of each of the obtained results were reviewed and 60 articles were finally selected.
Results and conclusion:
The knowledge of the physiopathology, the adequate preanesthetic assessment and the pertinent request of paraclinical care, allows for the adjustment of the perioperative care and to improve the results of the patient.
References
1. American Academy of Sleep Medicine. International classification of sleep disorders: diagnostic and coding manual. 2nd ed. American Academy of Sleep Medicine; 2005.
2. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242-52.
3. Brown KA. Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth. 2011;21: 771-80.
4. Tait AR, Voepel-Lewis T, O'Brien LM. Postsurgical behaviors in children with and without symptoms of sleep-disordered breathing. Perioper Med. 2014;3:8.
5. Lerman J. A disquisition on sleep-disordered breathing in children. Paediatr Anaesth. 2009;19 Suppl. 1:100-8.
6. Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D. Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proc Am Thorac Soc. 2008;5:274-82.
7. Farag HM, Bondok RS, Elkader HAA. Anesth Protocol Liver Transplant. 2012;5:5-7.
8. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2014;120:268-86.
9. Kaditis A, Kheirandish-Gozal L, Gozal D. Algorithm for the diagnosis and treatment of pediatric OSA: a proposal of two pediatric sleep centers. Sleep Med. 2012;13:217-27.
10. Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:253-62.
11. Schwengel D, Dalesio NM, Stierer TL. Pediatric obstructive sleep apnea. Anesthesiol Clin. 2014;32:237-61.
12. Isono S. Developmental changes of pharyngeal airway patency: implications for pediatric anesthesia. Paediatr Anaesth. 2006;16:109-22.
13. Karlson KH. What's new in pediatric obstructive sleep apnea? Clin Pulm Med. 2008;15:226-31.
14. Patino M, Sadhasivam S, Mahmoud M, Hemmings HC. Obstructive sleep apnoea in children: perioperative considerations. Br J Anaesth. 2013;111 Suppl. 1:83-95.
15. MacHata AM, Kabon B, Willschke H, Prayer D, Marhofer P. Upper airway size and configuration during propofol-based sedation for magnetic resonance imaging: an analysis of 138 infants and children. Paediatr Anaesth. 2010;20:994-1000.
16. Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature. J Clin Sleep Med. 2012;8:199-207.
17. Schwengel D, Sterni LM, Tunkel DE, Heitmiller ES. Perioperative management of children with obstructive sleep apnea. Anesth Analg. 2009;109:60-75.
18. Kheirandish-Gozal L, Gozal D. Sleep disordered breathing in children. A comprehensive clinical guide to evaluation and treatment. Springer Science; 2012. p. 13-24.
19. Spruyt K, Gozal D. REM and NREM sleep-state distribution of respiratory events in habitually snoring school-aged community children. Sleep Med. 2012;13:178-84.
20. Eikermann M, Martina Grosse-Sundrup SZ, Henry ME, Bittner EA, Hoffmann U, Chamberlin NL. Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. Anesthesiology. 2012;116:35-46.
21. Bonsignore MR, McNicholas WT, Montserrat JM, Eckel J. Adipose tissue in obesity and obstructive sleep apnoea. Eur Respir J. 2012;39:746-67.
22. Kwok K, Ng DK, Chan C. Cardiovascular changes in children with snoring and obstructive sleep apnoea. Ann Acad Med Singapore. 2008;37:715-21.
23. Chou CH, Kang KT, Weng WC, Lee PL, Hsu WC. Central sleep apnea in obese children with sleep-disordered breathing. Int J Obes (Lond). 2014;38:27-31.
24. Mitchell RB, Boss EF. Pediatric obstructive sleep apnea in obese and normal-weight children: impact of adenotonsillectomy on quality-of-life and behavior. Dev Neuropsychol. 2009;34:650-61.
25. Suárez C, Figueroa J, Len F, Mansilla E. Monitoreo grabado de oximetría de pulso en ninos con hipertrofia adenoidea/amigdalina: su utilidad en el diagnóstico del síndrome de apnea obstructiva del sueño. Arch Argent Pediatr. 2013;111:196-201.
26. Robb P, Bew S, Kubba H, Murphy N, Primhak R, Rollin A, et al. Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party. Ann R Coll Surg Engl. 2009;91:371-3.
27. Brown KA. Evaluation of the child with sleep-disordered breathing scheduled for adenotonsillectomy. Sleep Med Clin. 2013;8:149-55.
28. Abdel-Aziz M, Ibrahim N, Ahmed A, El-Hamamsy M, Abdel-Khalik MI, El-Hoshy H. Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management. Int J Pediatr Otorhinolaryngol. 2011;75:1127-31.
29. Madureira N. Obstructive sleep apnea syndrome in children younger than 2 years of age. Sleep Med. 2013;14:e193.
30. Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown Ka. An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg. 2010;110:1093-101.
31. Brown Ka, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology. 2004;100:806-10, discussion 5A.
32. Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: is the riddle solved? Curr Opin Anaesthesiol. 2016;29:134-40.
33. Brooks LJ. Diagnosis and evaluation of obstructive sleep apnoea in children. Ann Acad Med Singapore. 2008;37: 701-5.
34. Isaiah A, Pereira KD. Outcomes after adenotonsillectomy using a fixed anesthesia protocol in children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2015;79: 638-43.
35. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg. 2014;118:1276-83.
36. Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley D. Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature. Anesth Analg. 2016;122:145-51.
37. Benumof JL. Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed. Can J Anesth. 2016;63:3-7.
38. Scholz J, Yaksh TL. Preclinical research on persistent postsurgical pain: what we don't know, but should start studying. Anesthesiology. 2010;112:511-3.
39. Tan H-L, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: a critical update. Nat Sci Sleep. 2013;5:109-23.
40. Nolan JA. Principles of paediatric anaesthesia. Anaesth Intensive Care Med. 2016;17:265-9.
41. Hsu W-C, Kang K-T, Weng W-C, Lee P-L. Impacts of body weight after surgery for obstructive sleep apnea in children. Int J Obes (Lond). 2013;37:527-31.
42. American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep. 1999;22:667-89.
43. Pediatric Pulmonology Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics, clinical practice guideline diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704-71.
44. Brouillette R, Morielli A, Leimanis A, Waters K, Luciano R, Ducharme FM. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics. 2000;105:405-12.
45. Gross J, Bachenberg K, Benumof JL, Al E. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104:1081-93.
46. Huang Y-S, Guilleminault C, Lee L-A, Lin C-H, Hwang F-M. Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study. Sleep. 2014;37:71-7.
47. Whippey A, Kostandoff G, Ma HK, Cheng J, Thabane L, Paul J, et al. Predictors of unanticipated admission following ambulatory surgery in the pediatric population: a retrospective case-control study. Paediatr Anaesth. 2016;26:831-7.
48. Setabutr D, Adi Ea, Chaikhoutdinov I, Carr MM. Impact of the pediatric tonsillectomy and polysomnography clinical practice guidelines. Int J Pediatr Otorhinolaryngol. 2014;78:517-21.
49. Cox RG. Anesthetic management of pediatric adenotonsillectomy. Can J Anesth. 2007;54:1021-3.
50. Sawyer AM, Gooneratne N, Marcu CL, Ofer D, Richards KC, Weaver T. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2012;29:997-1003.
51. Ng DK, Wong JC, Chan C-H, Leung LCK, Leung S-Y. Ambulatory blood pressure before and after adenotonsillectomy in children with obstructive sleep apnea. Sleep Med. 2010;11:721-5.
52. Marcus C, Moore R, Rosen CL. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368:2366.
53. Busino RS, Quraishi H, Aguila H, Montalvo E, Connelly P. The impact of adenotonsillectomy on asthma in children. Laryngoscope. 2010;120 Suppl. 4:2007.
54. Levin J, Gagnon L, He X, Baum ED, Karas DE, Chupp GL. Improvement in asthma control and inflammation in children undergoing adenotonsillectomy. Pediatr Res. 2014;75: 403-8.
55. Saito H, Asakura K, Hata M, Kataura AMK. Does adenotonsillectomy affect the course of bronchial asthma and nasal allergy? Acta Otolaryngol Suppl. 1996;523: 212-5.
56. Ikeda FH, Horta P a DC, Bruscato WL, Dolci JEL. Intellectual and school performance evaluation of children submitted to tonsillectomy and adenotonsillectomy before and after surgery. Braz JOtorhinolaryngol. 2012;78:17-23.
57. Ishman SL. Evidence-based practice. Pediatric obstructive sleep apnea. Otolaryngol Clin North Am. 2012;45:1055-69.
58. Cielo C, Brooks LJ. Therapies for children with obstructive sleep apnea. Sleep Med Clin. 2013;8:483-93.
59. den Herder C, Schmeck J, Appelboom DJK, de Vries N. Risks of general anaesthesia in people with obstructive sleep apnoea. BMJ. 2004;329:955-9.
60. Brown KA, Brouillette RT. The elephant in the room: lethal apnea at home after adenotonsillectomy. Anesth Analg. 2014;118:1157-9.
2. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242-52.
3. Brown KA. Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth. 2011;21: 771-80.
4. Tait AR, Voepel-Lewis T, O'Brien LM. Postsurgical behaviors in children with and without symptoms of sleep-disordered breathing. Perioper Med. 2014;3:8.
5. Lerman J. A disquisition on sleep-disordered breathing in children. Paediatr Anaesth. 2009;19 Suppl. 1:100-8.
6. Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D. Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proc Am Thorac Soc. 2008;5:274-82.
7. Farag HM, Bondok RS, Elkader HAA. Anesth Protocol Liver Transplant. 2012;5:5-7.
8. American Society of Anesthesiologists. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2014;120:268-86.
9. Kaditis A, Kheirandish-Gozal L, Gozal D. Algorithm for the diagnosis and treatment of pediatric OSA: a proposal of two pediatric sleep centers. Sleep Med. 2012;13:217-27.
10. Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:253-62.
11. Schwengel D, Dalesio NM, Stierer TL. Pediatric obstructive sleep apnea. Anesthesiol Clin. 2014;32:237-61.
12. Isono S. Developmental changes of pharyngeal airway patency: implications for pediatric anesthesia. Paediatr Anaesth. 2006;16:109-22.
13. Karlson KH. What's new in pediatric obstructive sleep apnea? Clin Pulm Med. 2008;15:226-31.
14. Patino M, Sadhasivam S, Mahmoud M, Hemmings HC. Obstructive sleep apnoea in children: perioperative considerations. Br J Anaesth. 2013;111 Suppl. 1:83-95.
15. MacHata AM, Kabon B, Willschke H, Prayer D, Marhofer P. Upper airway size and configuration during propofol-based sedation for magnetic resonance imaging: an analysis of 138 infants and children. Paediatr Anaesth. 2010;20:994-1000.
16. Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature. J Clin Sleep Med. 2012;8:199-207.
17. Schwengel D, Sterni LM, Tunkel DE, Heitmiller ES. Perioperative management of children with obstructive sleep apnea. Anesth Analg. 2009;109:60-75.
18. Kheirandish-Gozal L, Gozal D. Sleep disordered breathing in children. A comprehensive clinical guide to evaluation and treatment. Springer Science; 2012. p. 13-24.
19. Spruyt K, Gozal D. REM and NREM sleep-state distribution of respiratory events in habitually snoring school-aged community children. Sleep Med. 2012;13:178-84.
20. Eikermann M, Martina Grosse-Sundrup SZ, Henry ME, Bittner EA, Hoffmann U, Chamberlin NL. Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. Anesthesiology. 2012;116:35-46.
21. Bonsignore MR, McNicholas WT, Montserrat JM, Eckel J. Adipose tissue in obesity and obstructive sleep apnoea. Eur Respir J. 2012;39:746-67.
22. Kwok K, Ng DK, Chan C. Cardiovascular changes in children with snoring and obstructive sleep apnoea. Ann Acad Med Singapore. 2008;37:715-21.
23. Chou CH, Kang KT, Weng WC, Lee PL, Hsu WC. Central sleep apnea in obese children with sleep-disordered breathing. Int J Obes (Lond). 2014;38:27-31.
24. Mitchell RB, Boss EF. Pediatric obstructive sleep apnea in obese and normal-weight children: impact of adenotonsillectomy on quality-of-life and behavior. Dev Neuropsychol. 2009;34:650-61.
25. Suárez C, Figueroa J, Len F, Mansilla E. Monitoreo grabado de oximetría de pulso en ninos con hipertrofia adenoidea/amigdalina: su utilidad en el diagnóstico del síndrome de apnea obstructiva del sueño. Arch Argent Pediatr. 2013;111:196-201.
26. Robb P, Bew S, Kubba H, Murphy N, Primhak R, Rollin A, et al. Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party. Ann R Coll Surg Engl. 2009;91:371-3.
27. Brown KA. Evaluation of the child with sleep-disordered breathing scheduled for adenotonsillectomy. Sleep Med Clin. 2013;8:149-55.
28. Abdel-Aziz M, Ibrahim N, Ahmed A, El-Hamamsy M, Abdel-Khalik MI, El-Hoshy H. Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management. Int J Pediatr Otorhinolaryngol. 2011;75:1127-31.
29. Madureira N. Obstructive sleep apnea syndrome in children younger than 2 years of age. Sleep Med. 2013;14:e193.
30. Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown Ka. An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg. 2010;110:1093-101.
31. Brown Ka, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology. 2004;100:806-10, discussion 5A.
32. Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: is the riddle solved? Curr Opin Anaesthesiol. 2016;29:134-40.
33. Brooks LJ. Diagnosis and evaluation of obstructive sleep apnoea in children. Ann Acad Med Singapore. 2008;37: 701-5.
34. Isaiah A, Pereira KD. Outcomes after adenotonsillectomy using a fixed anesthesia protocol in children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2015;79: 638-43.
35. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg. 2014;118:1276-83.
36. Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley D. Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature. Anesth Analg. 2016;122:145-51.
37. Benumof JL. Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed. Can J Anesth. 2016;63:3-7.
38. Scholz J, Yaksh TL. Preclinical research on persistent postsurgical pain: what we don't know, but should start studying. Anesthesiology. 2010;112:511-3.
39. Tan H-L, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: a critical update. Nat Sci Sleep. 2013;5:109-23.
40. Nolan JA. Principles of paediatric anaesthesia. Anaesth Intensive Care Med. 2016;17:265-9.
41. Hsu W-C, Kang K-T, Weng W-C, Lee P-L. Impacts of body weight after surgery for obstructive sleep apnea in children. Int J Obes (Lond). 2013;37:527-31.
42. American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep. 1999;22:667-89.
43. Pediatric Pulmonology Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics, clinical practice guideline diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704-71.
44. Brouillette R, Morielli A, Leimanis A, Waters K, Luciano R, Ducharme FM. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics. 2000;105:405-12.
45. Gross J, Bachenberg K, Benumof JL, Al E. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104:1081-93.
46. Huang Y-S, Guilleminault C, Lee L-A, Lin C-H, Hwang F-M. Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study. Sleep. 2014;37:71-7.
47. Whippey A, Kostandoff G, Ma HK, Cheng J, Thabane L, Paul J, et al. Predictors of unanticipated admission following ambulatory surgery in the pediatric population: a retrospective case-control study. Paediatr Anaesth. 2016;26:831-7.
48. Setabutr D, Adi Ea, Chaikhoutdinov I, Carr MM. Impact of the pediatric tonsillectomy and polysomnography clinical practice guidelines. Int J Pediatr Otorhinolaryngol. 2014;78:517-21.
49. Cox RG. Anesthetic management of pediatric adenotonsillectomy. Can J Anesth. 2007;54:1021-3.
50. Sawyer AM, Gooneratne N, Marcu CL, Ofer D, Richards KC, Weaver T. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2012;29:997-1003.
51. Ng DK, Wong JC, Chan C-H, Leung LCK, Leung S-Y. Ambulatory blood pressure before and after adenotonsillectomy in children with obstructive sleep apnea. Sleep Med. 2010;11:721-5.
52. Marcus C, Moore R, Rosen CL. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368:2366.
53. Busino RS, Quraishi H, Aguila H, Montalvo E, Connelly P. The impact of adenotonsillectomy on asthma in children. Laryngoscope. 2010;120 Suppl. 4:2007.
54. Levin J, Gagnon L, He X, Baum ED, Karas DE, Chupp GL. Improvement in asthma control and inflammation in children undergoing adenotonsillectomy. Pediatr Res. 2014;75: 403-8.
55. Saito H, Asakura K, Hata M, Kataura AMK. Does adenotonsillectomy affect the course of bronchial asthma and nasal allergy? Acta Otolaryngol Suppl. 1996;523: 212-5.
56. Ikeda FH, Horta P a DC, Bruscato WL, Dolci JEL. Intellectual and school performance evaluation of children submitted to tonsillectomy and adenotonsillectomy before and after surgery. Braz JOtorhinolaryngol. 2012;78:17-23.
57. Ishman SL. Evidence-based practice. Pediatric obstructive sleep apnea. Otolaryngol Clin North Am. 2012;45:1055-69.
58. Cielo C, Brooks LJ. Therapies for children with obstructive sleep apnea. Sleep Med Clin. 2013;8:483-93.
59. den Herder C, Schmeck J, Appelboom DJK, de Vries N. Risks of general anaesthesia in people with obstructive sleep apnoea. BMJ. 2004;329:955-9.
60. Brown KA, Brouillette RT. The elephant in the room: lethal apnea at home after adenotonsillectomy. Anesth Analg. 2014;118:1157-9.
How to Cite
1.
Amézquita-Trujillo Álvaro, Garzón JF. Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period. Colomb. J. Anesthesiol. [Internet]. 2017 Jul. 1 [cited 2024 Apr. 19];45(3):173-81. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/301
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Published
2017-07-01
How to Cite
1.
Amézquita-Trujillo Álvaro, Garzón JF. Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period. Colomb. J. Anesthesiol. [Internet]. 2017 Jul. 1 [cited 2024 Apr. 19];45(3):173-81. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/301
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Narrative review
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