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Introduction: Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data 

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In the assessment, the case of Mary Jones (68yrs) has been discussed who was admitted to the ICU after she was found collapsed by her son. According to her son, the lady was having problems in her urinal passage past few days. The lady was diagnosed with Type2 Diabetes Mellitus, and she was suffering from hypertension as her BP was measured to be 145/86 mmHg in the clinical investigation. The lady recently lost her husband and since then his son admitted that she has not been able to take good care of herself. She was admitted to the ICU being pyrexial and hypotensive. Her GCS was 9/15 (E2, V2, M5) and had vomited. She was incubated, ventilated and had was administered with antibiotics and 2 litres crystalloid. She had a wide bore NG inserted at the time of her admission to emergency department. Further, in the Intensive Care Unit, then she had a right internal jugular central line and an arterial line (right dorsarlispedis) inserted. At the time of her clinical investigation, her height was measured to be 1.7m tall and her actual body weight was measured to be 56 kgs. The investigation further defragments her clinical investigation that has been recorded initially. A critical analysis of the patient’s condition has been done on the basis of various literary arguments. Furthermore, the study investigates possible deviation in the records that may be possible in this clinical investigation for a better medical treatment of the patient.

As, the patients’ medical history suggest, clearly she was suffering from hypotension due to low blood pressure and type 2 diabetes. Her condition during the clinical investigation remained remarkable since, she recently had lost her husband and had urinal problems due to her diabetes. Her blood pressure remained abnormally low and she remained mentally disturbed because of the loss she had to face recently and the same was being reflected in her daily routine as reported by her son. She had her body temperature also elevated at the time of her admission to the intensive care unit. Her GCS determined that she had been suffering from acute medical conditions and trauma. The lady had vomited at the time of her admission to the ICU where she had been inserted with a Nasogastric tube inserted. A mechanical ventilation support has been provided to the patient with pressure control and pressure support ventilation. Her respiratory rate was measured to be 18 bpm and fraction of inspired oxygen was measured to be 0.40. 

Diabetes mellitus builds the danger of cardiovascular illness by a factor of a few at each degree of systolic blood pressure. Because cardiovascular danger in patients with diabetes is reviewed and consistent across the whole scope of levels of systolic pulse, even at prehypertensive levels, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure suggested starting medication treatment in patients with diabetes who have systolic blood tensions of 145 mm Hg or higher, with a treatment objective of diminishing systolic circulatory strain to under 130 mm Hg.1-3 There is, nonetheless, a scarcity of proof from randomized clinical preliminaries to help these proposals. The Action to Control Cardiovascular Risk in Diabetes pulse preliminary tried the impact of an objective systolic circulatory strain less than 120 mm Hg on major cardiovascular occasions among high-hazard people with type 2 diabetes (Tibballs, et. al., 2005).

Type 2 diabetes mellitus is a metabolic sickness that is analyzed based on supported hyperglycemia. Individuals with type 2 diabetes are at raised danger for various genuine medical conditions, including cardiovascular illness, sudden passing, visual impairment, kidney disappointment, removals, cracks, slightness, misery, and intellectual decline. In forthcoming epidemiologic examinations, the occurrence of large numbers of these results is straightforwardly connected with the level of hyperglycemia, as estimated by the plasma glucose or the glycated hemoglobin level, a proportion of the mean blood glucose level during the past 2 to 90 days. Hence, after change for other danger factors, an expansion of 1% in the glycated hemoglobin level is related with an increment of 18% in the danger of cardiovascular events, an increment of 12 to 14% in the danger of death,3,4 and an increment of 37% in the danger of retinopathy or renal failure. 

The evaluated connection between the glycated hemoglobin level and cardiovascular occasions and passing recommended that a restorative technique to bring down glycated hemoglobin levels may diminish these results. This speculation was upheld by discoveries from yet not all past clinical trials. However, the theory was not unequivocally tried in sufficiently fueled, randomized preliminaries zeroing in on cardiovascular results. By and by, information from science, epidemiologic investigation, and restricted preliminaries have been utilized to help rule suggestions to focus close ordinary degrees of glycated hemoglobin and glucose in chose patients with type 2 diabetes mellitus, notwithstanding a lack of proof in regards to the dangers and advantages of doing as such with at present accessible treatments (Drew, et. al., 2010). 

The Action to Control Cardiovascular Risk in Diabetes preliminary was explicitly intended to decide if a helpful procedure focusing on typical glycated hemoglobin levels would diminish the pace of cardiovascular occasions, as contrasted and a system focusing on glycated hemoglobin levels from in moderately aged and more seasoned individuals with type 2 diabetes mellitus and either settled cardiovascular illness or extra cardiovascular danger factors. It reports the impact of the concentrated mediation on such fatalities and the essential composite result of major cardiovascular occasions in the patient.

The most recent years has seen the acknowledgment of type 2 diabetes as a complex heterogeneous illness that outcomes from cooperation between ecological elements and hereditary inclinations. As its pathophysiology has been unfurled by the advances in clinical science, so its predominance has expanded drastically, and it is currently one of the significant individual furthermore, general medical conditions around the world. Helpful ways to deal with address insulin obstruction and beta-cell brokenness have strengthened and enhanced during the last decade, driven by undeniable proof that the treatment objectives incorporate both glycaemic control and regard for all vascular danger factors. Advances in fundamental what's more, clinical exploration throughout the most recent fifty years have finished in adequate procedures and pharmacological specialists to begin to accomplish these objectives. Similarly as significant, they have established the framework for what guarantee to be exceptional future turns of events (Warltier, et. al., 2003).

One perspective on is as 'an evaluation between options. Maule proposes that the course of judgment includes the incorporation of various parts of data about an individual, object or circumstance to show up at a general assessment. Consequently the focal inquiry for those exploring judgment is, 'The way do medical attendants utilize various kinds of clinical data about the patient (what they look like, their fundamental sign readings, their clinical condition, their conduct) to show up at a judgment of the patient's present wellbeing status?'. This field of exploration moreover thinks about how people make expectations about hazard, such as how logical it is that a patient will foster a strain ulcer. Instead of the appraisal of data, choices have been characterized as 'a decision between options. The examination accentuation here is the means by which individuals pick specific approaches, particularly in circumstances of vulnerability where the outcomes of their activities are obscure. In nursing an illustration of a clinical choice may be the decision of wound care item for use with a singular patient. Recognize these two ideas. For example an attendant or birthing assistant might make an exact judgment (for example 'this patient is in outrageous torment') however at that point pick a low quality activity, for example settle on a 'terrible' choice (for example I'll give them a warmth cushion). Similarly they might make a poor judgment ('this present individual's chest torment is because of acid reflux', when really it is cardiovascular agony) however settle on a decent choice on the premise of the misguided thinking ('I'll give them drug for heartburn'). In this case the medical caretaker made an impeccably sensible choice given the data accessible: the wrong finding. Obviously, what most clinicians take a stab at is the synergistic condition of the two decisions and choices being of 'good' quality. For instance, the singular's current circumstance is surveyed precisely and suitable activity taken based on that evaluation ('this individual has outrageous chest torment, so I will give them morphine and do an ECG').

One hypothetical structure joining these suspicions and giving a method of estimating judgment precision is social judgment hypothesis (SJT). Key to this is the possibility that an person's judgment identify with the truth of a social climate and can be conceptualized as a 'focal point'. Additionally, this thought of a focal point (Figure 1) can be utilized to demonstrate the routes in which different types of data identify with the 'truth' of a given judgment climate and how people use data to show up at their decisions. The model proposes that the 'environmental' circumstance (what's up with the patient for example) is on the left hand side of the model. There are a wide range of snippets of data (prompts) that are probabilistically identified with this biological circumstance (for example the patient's signs and side effects), with various significance or weight appended to them. The appointed authority utilizes these signs to make a judgment (the right hand side of the model). The judgment result is a component of how the signals have been utilized. On the off chance that the signals are weighted similarly by the adjudicator as they are connected to the natural circumstance, then, at that point, the judgment will be more exact. On the off chance that the adjudicator loads the signs in an unexpected way, their judgment won't mirror the environmental circumstance and be less exact. Relapse procedures are utilized to infer a factual condition or calculation uncovering how much weight is connected to everything of data identified with the biological circumstance, or utilized in the judgment. 

Essential rationale ways to deal with estimating judgment depend on the meaning of the judgment task, estimating the basis, freely estimating the subject's judgment and contrasting the judgment and the measure. This should be possible in two ways: through friendly judgment draws near or probabilistic strategies. Social judgment approaches utilize the connection between the data and results of interest as the reason for setting up the rule (the left hand side of the focal point). The way this is regularly addressed is using direct models, created through relapsing data prompts onto the measure. Straight models developed in this way give a proportion of assignment consistency, giving an furthest breaking point on how well we would then be able to anticipate a person judge to perform when they are making decisions inside this specific setting. For instance, just 80% of all falls in more seasoned patients are unsurprising. In this occasion a model of being ready to anticipate 80% of the falls that happen would show precise judgment. Patients are then surveyed against a judgment task dependent on the displayed ecological reality.

There are various manners by which choices can be assessed, including analyzing the result of the choice, the choice interaction itself, or contrasting choices either with some type of standardizing model or to another person. As has as of now been featured, assessing the result of a choice can be hazardous as it very well may be controlled by chance occasions. Notwithstanding, proposes it could be sensible to assess the chief concerning the results of numerous choices (as one would then be able to think about normal execution). On the off chance that the choice interaction is being assessed as a proportion of quality, then, at that point, a thought of what ought to be remembered for that measure is fundamental. It is recommend that the cycle ought to be unequivocal, characterize the choice issue, distinguish the objectives of the leader, indicate the results and relative upsides of the results for each choice, inspect the compromises between every one of the methodologies what's more, remember all important gatherings for the interaction (Nichol, et. al., 2010). When contrasting choices with a regularizing model, for example, SEUT, it is expected that the regulating model is following a 'decent' choice cycle. In the event that the decision the leader has made is thought about in contrast to the suggestion of the regulating model and they concur, then, at that point, it very well may be considered 'acceptable'. Nonetheless, it is important to know that the understanding might have come about by some coincidence. In the event that choices are looked at between chiefs, maybe with some type of master execution as a highest quality level, then, at that point, what is being recommended is that the master is utilizing what is viewed as a 'decent' measure. Be that as it may, comparable worries to those brought up in the area on judgment quality are connected to utilizing between judge correlations as a method for surveying choice quality (Drew, et. al., 2004).

The estimation of the nature of judgment and decisionmaking in nursing practice is profoundly confounded, and concentrates on that endeavor to inspect medical caretakers' training need to recognize both the qualities and impediments of the methodologies they utilize. Existing investigation into nursing decisions has utilized shortsighted proportions of patient result as a model. Such measures neglect to recognize the intrinsic vulnerability in judgment circumstances, or depend on between judge examinations that can prompt orderly blunders (Figueroa, 2013).

Indicative mistakes are an underrecognized wellspring of patient damage, and cardiovascular illness can be trying to analyze in the walking setting. Despite the fact that misbehavior information can educate demonstrative blunder decrease endeavors, no investigations have inspected outpatient cardiovascular negligence cases inside and out. A review was directed to analyze the attributes of outpatient cardiovascular negligence bodies of evidence brought against general medication specialists (Rauen, 2004).

According to (Quinn, 2017) at the point when just symptomatic mistakes including a last conclusion of myocardial localized necrosis or coronary vein illness (n = 138) were investigated, most of cases (59%) had vague determinations or normal impersonates of myocardial dead tissue and coronary supply route infection (esophageal or gastrointestinal issues or musculoskeletal torment) as introductory findings. Of the 11 musculoskeletal aggravation analyze in this gathering, 6 were appendage or shoulder torment, 4 were back torment or radiculopathy, and 1 was musculoskeletal agony without a predetermined site. Likewise, when just demonstrative blunders including a last analysis of pneumonic embolism (n = 46) were investigated, by far most (78%) of cases had vague conclusions or normal impersonates of aspiratory embolism (respiratory contaminations, constant obstructive pneumonic sickness, asthma, or musculoskeletal agony) as starting judgments. Of the 5 musculoskeletal aggravation analyze in this gathering, 4 were lower appendage torment and 1 was musculoskeletal torment without a predefined site (Batistini, et. al., 2020).

discoveries show that patients with low pretest likelihood of cardiovascular infection make up the minority of missed determinations of cardiovascular sickness that ultimately become misbehavior arguments against outpatient general medication specialists. Indeed, right around one fourth of patients in our investigation who were ultimately determined to have myocardial localized necrosis or coronary atherosclerosis had a past filled with earlier cardiovascular sickness—one of the greatest pretest indicators of cardiovascular disease,10, 11 Our review proposes that patients who have heart hazard factors and beginning determinations that are vague or normal cardiovascular emulates may address a high return opportunity for forestalling analytic mistakes in the outpatient general medication setting. Without a doubt, in our data set, the misbehavior cases including symptomatic blunder are frequently connected with a disappointment or postponement in requesting an indicative test, disappointment or deferral in getting a counsel or reference, and inability to set up a differential determination. We accept that this gathering might be an optimal objective for centered quality improvement endeavors. 

There have been quality improvement drives to diminish demonstrative mistakes in the outpatient setting, however few have zeroed in on early conclusion of cardiovascular disease.12, 30 The PROMISES Project tried to lessen security and negligence hazard in the outpatient setting by overhauling the administration of references, drugs, and test results, just as correspondence among staff and patients30 Although the aftereffects of this task have not been completely delivered, the focal point of the review is on upgrade for high-hazard cycles of care instead of focusing on high-hazard diagnoses.30, 31 Our review proposes that analyze that outcome in high-seriousness patient wounds when missed, have obvious danger components and normal introducing side effects (like cardiovascular infection) and might be an extra objective for wellbeing decrease endeavors in ongoing investigations (Hardin and Kaplow, 2019). 

The electronic wellbeing record (EHR) framework has been recognized as a device to further develop demonstrative exactness utilizing such provisions as choice help or other intercession endeavors that can be straightforwardly modified into the system. However, endeavors to utilize electronic cautions to support cardiovascular finding in the outpatient setting have not been consistently fruitful. Sequist et al. played out a randomized controlled preliminary surveying the adequacy of an electronic caution to doctors dependent on the Framingham Risk Score in patients giving chest torment in the walking setting. Providers were randomized to get makes that energized them aware of play out an electrocardiogram and consider headache medicine treatment in patients with high Framingham Risk Scores and debilitate the utilization of heart stress testing in patients with low Framingham Risk Scores. There was no contrast among intercession and control bunches in performing electrocardiograms or treating with headache medicine among high-hazard patients, or utilizing heart stress testing among generally safe patients. Nonetheless, the patients in this review were distinguished via prepared clinical associates dependent on the patient's expressed boss grievance of chest pain.12 Our review proposes that a superior objective for electronic supplier alarms might be doctors who code vague findings or normal emulates of coronary vein infection in patients who have hazard factors for cardiovascular illness. This is upheld by our discoveries that many missed cardiovascular analyses were expected partially to an inability to arrange a demonstrative test, inability to make an expert reference, or inability to make a differential conclusion in patients who were at high danger for cardiovascular sickness (Nolan et. al., 2008). 

The greatest limit to this review is that in just incorporate cases that brought about a misbehaviour guarantee, in this manner restricting our capacity to offer authoritative expressions about clinical situations that were remembered for our negligence claims information base. Blunders that don't bring about a misbehavior guarantee, including close to misses for patient mischief, would not have been caught in our investigation. Missed analyses of cardiovascular sickness in patients without heart hazard variables may likewise be less inclined to bring about negligence claims than those with hazard factors, despite the fact that we included cases regardless of whether they were subsequently dropped or excused. These impediments might influence generalizability, however they don't reduce any of our discoveries among blunders in outpatient general medication that ultimately become negligence claims. Despite the fact that negligence cases might be just a "glimpse of something larger," we accept they actually address a significant window into patient security issues across clinical settings (van der Kolk, et. al., 2017). 

The broadness of a portion of our correlations is restricted by the measure of information coded for each situation. For instance, patient comorbidities could be broke down for cardiovascular infection cases, yet the rates could not measure up against noncardiovascular cases since comorbidities are coded just when the coder considers them pertinent to the case's basic finding. There may likewise be variety among states and topographical districts in the complete case cost of misbehavior because of contrasts in neighborhood laws that are not caught in our data set. Nonetheless, the misbehavior protection supplier (which is regularly provincial) was not a huge indicator variable when added to both of our relapse models. None of these limits inborn to our data set are probably going to influence our general outcomes and ends (Quinn, et. al., 2017).

Missed conclusion of cardiovascular sickness in the outpatient general medication setting addresses a significant patient danger. Our investigation of the biggest negligence data set with itemized coding clarifies that cardiovascular misbehavior claims in outpatient general medication happen overwhelmingly in patients with average danger components of heart sickness instead of in okay patients, in spite of narrative negligence concerns. These outcomes feature the need to consider a cardiovascular reason in patients with comorbidities before diagnosing esophageal illness or utilizing a vague analysis in mobile patients. Our discoveries might assist with directing quality improvement endeavors pointed toward diminishing indicative blunders and working on understanding security in the outpatient general medication setting. Further exploration is required into planning straightforward, adaptable, and effectively carried out intercessions to forestall mistakes in analysis of patients at high danger of cardiovascular illness (Morton,et. al., 2005).

During the past decade, awareness and understanding of clinical mistakes have extended quickly, with a vigorous patient security development advancing more secure medical care through "frameworks" arrangements. Endeavors have zeroed in on making an interpretation of proof into work on, alleviating risks from treatments, and further developing society and correspondence. Analytic blunders have gotten moderately little consideration. Albeit the study of mistake estimation is immature, indicative blunders are a significant wellspring of preventable harm.1-3 In this Commentary, we offer definitions for symptomatic mistake and misdiagnosis-related mischief, present an outline of the size of indicative blunders, and give ideas for how exploration can develop. 

Recognizing Errors From Harms In thinking about indicative blunders, recognize the mistake (a cycle) and the subsequent damage (a result). Symptomatic blunder can be characterized as an analysis that is missed, wrong, or deferred, as recognized by a few resulting conclusive test or finding.1 However, not all misdiagnoses bring about mischief, and damage might be expected to by the same token infection or mediation. Misdiagnosis-related damage can be characterized as preventable mischief that outcomes from the postponement or inability to treat a condition really present (when the functioning determination wasn't right or obscure) or from treatment accommodated a condition not really present. An expected 40 000 to 80 000 US medical clinic passings result from misdiagnosis annually.4 Roughly 5% of post-mortems uncover deadly analytic blunders for which a right analysis combined with treatment might have deflected death. In the Harvard Medical Practice Study, doctor mistakes coming about in unfavorable occasions were bound to be analytic than drugrelated (14% versus 9%), and misdiagnoses were bound to be considered careless (75% versus 53%) and to bring about genuine inability (47% versus 14%) (Santschi, et. al., 2011).

As anyone might expect, misdeed claims for indicative mistakes are almost twice as normal as cases for prescription mistakes and result in the biggest payouts. As with a wide range of clinical mistake, the human cost of misdiagnosis on an individual or family can be gigantic, especially when a sound patient encounters an antagonistic occasion. Symptomatic blunders regularly are unnoticed or unreported, and the study of estimating these mistakes (and their belongings) is underdeveloped.1,2Available measurements consider neither passings due to misdiagnosis in outpatients nor misdiagnosis-related dreariness and related expenses. For instance, stroke, the main reason for genuine, long haul handicap in the United States, influences 780 000 Americans annually.8 Opportunities to forestall incapacitating stroke are missed when patients encountering gentle or on the other hand transient admonition indications get misdiagnoses. As per a new orderly audit, 9% of all cerebrovascular occasions are missed at first, and the chances of misdiagnosis increment something like 5-overlay when side effects are gentle or transient (Wynne and Botti, 2004).


Quinn, G.R., Ranum, D., Song, E., Linets, M., Keohane, C., Riah, H. and Greenberg, P., 2017. Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data. The Joint Commission Journal on Quality and Patient Safety, 43(10), pp.508-516.

Morton, P.G., Fontaine, D.K., Hudak, C.M. and Gallo, B.M., 2005. Critical care nursing: a holistic approach (Vol. 1). Philadelphia: Lippincott Williams & Wilkins.

Hardin, S.R. and Kaplow, R., 2019. Cardiac surgery essentials for critical care nursing. Jones & Bartlett Learning.

Drew, B.J., Califf, R.M., Funk, M., Kaufman, E.S., Krucoff, M.W., Laks, M.M., Macfarlane, P.W., Sommargren, C., Swiryn, S. and Van Hare, G.F., 2004. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation, 110(17), pp.2721-2746.

Drew, B.J., Ackerman, M.J., Funk, M., Gibler, W.B., Kligfield, P., Menon, V., Philippides, G.J., Roden, D.M., Zareba, W., American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology and Council on Cardiovascular Nursing, 2010. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation endorsed by the American Association of Critical-Care Nurses and the International Society for Computerized Electrocardiology. Journal of the American College of Cardiology, 55(9), pp.934-947.

Warltier, D.C., Myles, P.S., Daly, D.J., Djaiani, G., Lee, A. and Cheng, D.C., 2003. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. The Journal of the American Society of Anesthesiologists, 99(4), pp.982-987.

Tibballs, J., Kinney, S., Duke, T., Oakley, E. and Hennessy, M., 2005. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Archives of disease in childhood, 90(11), pp.1148-1152.

van der Kolk, M., van den Boogaard, M., ter Brugge?Speelman, C., Hol, J., Noyez, L., van Laarhoven, K., van der Hoeven, H. and Pickkers, P., 2017. Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit: effects on protocol adherence. Journal of evaluation in clinical practice, 23(6), pp.1289-1298.

Santschi, V., Chiolero, A., Burnand, B., Colosimo, A.L. and Paradis, G., 2011. Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials. Archives of internal medicine, 171(16), pp.1441-1453.

Figueroa, M.I., Sepanski, R., Goldberg, S.P. and Shah, S., 2013. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary team using simulation-based team training. Pediatric cardiology, 34(3), pp.612-619.

Rauen, C.A., 2004. Simulation as a teaching strategy for nursing education and orientation in cardiac surgery. Critical care nurse, 24(3), pp.46-51.

Batistini, H.C., de Sant’Anna, A.L.G.G., Dellacrode Giovanazzi, R.S., Rosa de Freitas, V., Martins da Costa, S.A.C. and Machado, R.C., 2020. Checklist validation for care provided to patients in the immediate postoperative period of cardiac surgery. Journal of Clinical Nursing, 29(21-22), pp.4171-4179.

Nichol, G., Aufderheide, T.P., Eigel, B., Neumar, R.W., Lurie, K.G., Bufalino, V.J., Callaway, C.W., Menon, V., Bass, R.R., Abella, B.S. and Sayre, M., 2010. Regional systems of care for out-of-hospital cardiac arrest: a policy statement from the American Heart Association. Circulation, 121(5), pp.709-729.

Nolan, J.P., Neumar, R.W., Adrie, C., Aibiki, M., Berg, R.A., Böttiger, B.W., Callaway, C., Clark, R.S., Geocadin, R.G., Jauch, E.C. and Kern, K.B., 2008. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a scientific statement from the International liaison Committee on Resuscitation; the American Heart Association Emergency cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on cardiopulmonary, Perioperative, and Critical Care; the Council on clinical cardiology; the Council on Stroke. Resuscitation, 79(3), pp.350-379.

Wynne, R. and Botti, M., 2004. Postoperative pulmonary dysfunction in adults after cardiac surgery with cardiopulmonary bypass: clinical significance and implications for practice. American journal of critical care, 13(5), pp.384-393.

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