Perioperative Care of the Cancer Patient

Perioperative Care of the Cancer Patient

1st Edition - March 26, 2022

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  • Editors: Carin Hagberg, Joseph Nates, Berhard Riedel, Vijaya Gottumukkala, Donal Buggy
  • Hardcover ISBN: 9780323695848
  • eBook ISBN: 9780323695855

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Description

More than 80% of patients with cancer will need the services of anesthesiology and perioperative medicine, intensive care medicine, and pain management specialists during their cancer journey for diagnostic, therapeutic, and symptom management needs, as well as for the management of recurrent disease, secondary cancers, and ongoing non-oncologic surgical needs during survivorship. Perioperative Care of the Cancer Patient is today’s most up-to-date, authoritative, comprehensive reference on the acute care of surgical patients with cancer, from a team of international experts in this emerging and dynamic specialty.

Table of Contents

  • Cover Image
  • Title Page
  • Copyright
  • Dedication
  • Contributors
  • Preface
  • Contents
  • Section 1 Basic Principles (Epidemiology; Cancer Biology; Overview of Cancer Therapies)
  • Chapter 1 Cancer Epidemiology, Prevention, and Survivorship
  • Introduction
  • Cancer Epidemiology
  • Cancer Prevention and Early Detection
  • Cancer Survivorship
  • References
  • Chapter 2 Global Cancer Surgery—The Lancet Commission
  • Introduction
  • The Global Surgical and Anesthesia Crisis
  • Perioperative Management
  • Cancer Anesthesia and Surgery
  • Pain Management
  • Future Advances for the Surgical and Anesthesia Management of Cancer Patients in Low-Income Countries
  • Recommendations
  • Conclusions
  • References
  • Chapter 3 Cancer Biology and Implications for the Perioperative Period
  • Introduction
  • Development of a Tumor
  • Nature of a Tumor
  • The Tumor Microenvironment
  • Invasion and Metastasis
  • Approaching Cancer Biology in Perioperative Medicine
  • References
  • Chapter 4 Traditional Cancer Therapies and Perioperative Implications
  • Introduction
  • Cardiovascular
  • Pulmonary
  • Renal
  • Nervous System
  • Gastrointestinal
  • Hematologic
  • Endocrine
  • Premature Aging
  • Conclusion
  • References
  • Chapter 5 Newer Cancer Therapies and Perioperative Implications
  • Introduction
  • Surgical Considerations
  • Chemotherapy and Targeted Therapy
  • Newer Systemic Treatments: Immunotherapy
  • Radiation Therapy and Newer Techniques
  • Conclusion
  • References
  • Chapter 6 Cancer and Heart Disease
  • Introduction
  • Quantification of Systolic Function in Cardio-oncology
  • Cardiac Mechanics in Cardio-oncology
  • Cardiac Dysfunction and the Heart Failure Spectrum
  • Considerations in Radiation-Induced Heart Disease
  • Cardiac Tumors
  • Acute Coronary Syndromes
  • Acute Pericarditis
  • Pericardial Effusion and Cardiac Tamponade
  • Conclusion
  • References
  • Chapter 7 Personalized Cancer Care
  • Introduction
  • Multidisciplinary Care
  • The Multidisciplinary Team
  • Imaging
  • Computed Tomography
  • Positron Emission Tomography
  • Molecular Aspects and Personalized Therapy
  • Treatment Modalities
  • Conclusion
  • References
  • Section 2 Inflammatory-Immune Responses, Perioperative Period, and Cancer Outcomes
  • Chapter 8 Anemia, Thrombosis, Transfusion Therapy, and Cancer Outcomes
  • Introduction
  • Anemia
  • Transfusion- and Cancer-Related Outcomes
  • Thrombosis
  • Conclusion
  • References
  • Chapter 9 Improving Cancer Survival Through Perioperative Attenuation of Adrenergic-Inflammatory Signaling
  • The Perioperative Period—An Underutilized “Window-of-Opportunity” to Prevent Metastatic Disease
  • Perioperative Stress-Inflammatory Responses: the Prometastatic Edge of the Sword
  • Addressing Perioperative Inflammation and Adrenergic Stress Responses
  • Conclusion
  • References
  • Chapter 10 Local Anesthetics and Cancer
  • The Perioperative Period Is Critical for Postsurgical Cancer Outcomes
  • Potential Detrimental Effects of Anesthetics and Opioid Analgesics
  • Indirect Benefits of Perioperative Local Anesthetics
  • Direct Effects of Local Anesthetics on Cancer Cells
  • NaV1.5 Structure and Function
  • Conclusion
  • References
  • Chapter 11 Volatile and Intravenous Anesthetics and Cancer
  • General Introduction: Anesthesia and Cancer Progression
  • Mechanisms of Cancer Development and Progression
  • Molecular Actions of Anesthetics and Cancers
  • Preclinical In Vitro and In Vivo Studies of Cancer and Anesthetics
  • Clinical Studies
  • Ongoing Clinical Trials
  • Implication and Conclusions
  • References
  • Chapter 12 Opioids and Cancer
  • Introduction
  • Mechanisms
  • Effect of Opioids in Clinically Diverse Patient Groups
  • Complexities of Linking Opioid Use and Cancer Risk
  • Future Outlook and Conclusion
  • References
  • Chapter 13 Can Regional Anesthesia and Analgesia Influence the Risk of Cancer Recurrence?
  • What Is Regional Anesthesia?
  • General Benefits of Regional Anesthesia
  • How Regional Anesthesia Might Influence Cancer
  • Evidence for a Benefit of Regional Anesthesia in Cancer Surgery
  • Translational Studies
  • Retrospective Analysis
  • Prospective Evidence
  • Peripheral Nerve Blocks and Cancer Recurrence
  • Systematic Reviews and Meta-analysis
  • Conclusion
  • References
  • Section 3 Perioperative/Periprocedural Care in the Cancer Patient
  • Chapter 14 Preoperative Evaluation and Medical Optimization of the Cancer Patient
  • Introduction
  • History and Physical Examination
  • Preoperative Testing
  • Cardiovascular Risk Assessment
  • Pulmonary Risk Assessment
  • The Older Patient
  • Cancer-Specific Concerns
  • Conclusion
  • References
  • Chapter 15 Functional Assessment and Prehabilitation
  • The Physiologic Impact of Cancer and Surgery on Patient Function
  • The Surgical Insult and the Importance of Preparing Patients for Stress
  • Functional Assessment and Risk Stratification
  • Prehabilitation
  • Exercise and Physical Activity for the Surgical Cancer Patient
  • Nutrition and the Importance of Protein for the Colorectal Cancer Patient
  • Psychologic Support
  • Medical Optimization: Glycemic Control, Anemia
  • Literature on Prehabilitation and Impact on Outcome
  • Prehabilitation as a Compelling Strategy: Successes and Challenges Ahead
  • References
  • Chapter 16 Redesign of Perioperative Care Pathways
  • Introduction
  • Drivers for Pathway-Based Care
  • Pathway Reengineering
  • Implications of Pathway-Focused Care
  • Conclusion
  • References
  • Chapter 17 Airway Management in Special Situations
  • Management of Unanticipated Difficult Airway
  • Extubation of the Difficult Airway
  • Management of Upper Airway Bleeding
  • Conclusion
  • References
  • Chapter 18 Procedural Care of the Adult Cancer Patient Outside of the Operating Room
  • Introduction
  • Practice Guidelines
  • Screening
  • Scheduling
  • Anesthesia Provider Evaluation
  • Non-operating Room Anesthesia
  • Basic Anesthesia Monitoring
  • Intraprocedural Anesthetic Plan
  • Positioning
  • Respiratory Compromise
  • Post procedure Recovery
  • Conclusion
  • References
  • Chapter 19 Perioperative Care of the Surgical Patient: Brain
  • Introduction
  • Preoperative Assessment
  • Intraoperative Planning
  • General Anesthesia for Asleep Craniotomy
  • Awake Craniotomy
  • Intraoperative Considerations and Management
  • Postoperative Management and Pain Control
  • Conclusion
  • References
  • Chapter 20 Anesthesia for Spine Cancer Surgery
  • Introduction
  • Surgery for Spinal Metastases
  • Staging and Scoring Systems
  • Hematologic Malignancies
  • Cement Augmentation, Kyphoplasty, Vertebroplasty
  • Stereotactic Radiosurgery and Intensity-Modulated Radiotherapy
  • Separation Surgery
  • Decompressive and Stabilization Surgery
  • En Bloc Resection
  • Prognosis
  • Anesthetic Considerations
  • Preoperative Evaluation
  • Anesthetic Technique
  • Airway Management
  • Positioning
  • Bleeding
  • Postoperative Considerations
  • Venous Thromboembolism
  • Conclusion
  • References
  • Chapter 21 Anesthesia for Head and Neck Cancer Surgeries
  • Introduction
  • Cancer Surgery
  • Applied Anatomy
  • Preoperative Assessment and Optimization
  • Patient Education and Counseling
  • Intraoperative Management
  • Postoperative Management
  • Postoperative Complications
  • Care of the Patient With a Tracheostomy
  • Postoperative Rehabilitation
  • Special Considerations for Specific Surgeries
  • References
  • Chapter 22 Perioperative Care of the Surgical Patient: Heart, Lung, and Mediastinum Procedures
  • Anesthetic Management for Thoracic Procedures in the Cancer Patient
  • Postoperative Management
  • Mediastinal Masses
  • Conclusion
  • References
  • Chapter 23 Perioperative Care of the Cancer Patient: Breast Procedures
  • Background
  • Management of the Breast Cancer Patient
  • Plastic and Reconstructive Surgery
  • Types of Breast Reconstruction Modalities
  • Anesthesia for Breast Surgery
  • Conclusions
  • References
  • Chapter 24 Intraoperative Care of the Surgical Patient: Upper Gastrointestinal Cancers
  • Introduction
  • Chemotherapeutic Toxicity
  • Esophageal Cancer
  • Prevention of Pulmonary Complications
  • Cancers of the Duodenum
  • Cancers of the Oropharynx
  • Other Upper Gastrointestinal Tumors
  • Conclusion
  • References
  • Chapter 25 Perioperative Care of the Colorectal Cancer Patient
  • Introduction
  • Presentation, Diagnosis, and Treatment
  • Perioperative Considerations of Neoadjuvant Chemotherapy
  • Anemia and Perioperative Blood Transfusion
  • Preoperative Exercise and Prehabilitation
  • Enhanced Recovery After Surgery (ERAS) Protocols
  • Operative Risk Assessment
  • Surgery—Open, Laparoscopic-Assisted, or Robotic-Assisted Laparoscopic Approaches
  • Choice of Anesthesia and Analgesia and Effect on Clinical Outcomes
  • References
  • Chapter 26 Perioperative Care of the Surgical Patient: Genitourinary Cancers
  • Introduction
  • Perioperative Assessment and Optimization
  • Enhanced Recovery and Postoperative Care
  • Common Complications and Causes for Readmission
  • Thromboprophylaxis
  • Opioid-Sparing Surgery
  • Conclusion
  • References
  • Chapter 27 Perioperative Care of the Surgical Cancer Patient: Gynecologic Cancers
  • Introduction
  • Ovarian Cancer
  • Cervical Cancer
  • Endometrial Carcinoma
  • Vulval Cancer
  • Perioperative Considerations
  • Postoperative Considerations
  • Conclusion
  • References
  • Chapter 28 Anesthesiology and Perioperative Management of Patients Presenting for Surgical Excision of Endocrine Tumors
  • General Introduction
  • Perioperative Management of Thyroid Tumor Resection
  • Pheochromocytoma
  • Cushing’s Syndrome
  • Twenty-four Hours Urinary Free Cortisol
  • Late-night Salivary Cortisol
  • Dexamethasone Suppression Test
  • Pituitary Adenomas
  • References
  • Chapter 29 Anesthesia and Surgery for Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
  • Introduction
  • Epidemiology and Cancer Subtypes
  • Strategy in Cytoreductive Surgery and HIPEC
  • HIPEC Rationale
  • The Dedrick Diffusion Model
  • Techniques of HIPEC
  • Chemotherapeutic Agents Employed During HIPEC
  • Conduct of Anesthesia for HIPEC
  • Intraoperative Management
  • Postoperative Management
  • Conclusion
  • References
  • Chapter 30 Perioperative Care: Sarcoma and Melanoma
  • Perioperative Care: Sarcoma
  • Perioperative Care: Melanoma
  • Conclusion
  • References
  • Chapter 31 Perioperative Care of the Surgical Patient: Bone and Soft Tissue Tumors
  • Introduction
  • Oncoanesthesia and Some of the Crucial Steps for Better Perioperative Outcomes
  • Orthopedic Cancers
  • Regional Anesthesia and Cancer
  • Anesthetic Agents and Impact on the Immune System
  • Conclusions
  • References
  • Chapter 32 Perioperative Care of the Surgical Patient: Reconstructive Surgery
  • Applied Surgical, Pathologic, and Physiologic Concepts
  • Perioperative Considerations
  • Conclusion
  • References
  • Chapter 33 Perioperative Care of the Surgical Patient: Surgical Emergencies in Cancer
  • Background
  • Triage
  • Risk Stratification
  • Care Processes to Improve Patient Outcomes
  • Optimizing Patient Condition
  • Preoperative Airway Assessment
  • Airway Management in the Emergency Onco-surgical Patient
  • Airway Emergencies in Cancer Patients—Anesthetic Management
  • Carotid Blowout Syndrome
  • Intra-abdominal and Intra-thoracic Surgeries
  • Management of Patients With Emergency Colorectal Surgeries
  • Raised Intracranial Pressure
  • Spinal Cord Compression
  • Summary
  • Acknowledgment
  • References
  • Chapter 34 Palliative Surgery in Cancer Patients
  • Introduction
  • Preoperative Assessment
  • Interventional Radiology
  • Esophagus
  • Stomach
  • Pancreas
  • Biliary Tract/Liver
  • Small and Large Bowel and Rectum
  • Brain and Vertebral Column
  • Head and Neck
  • Pleura, Chest Wall, Lung, and Mediastinum
  • Breast
  • Thyroid Gland
  • Adrenal Gland
  • Urology
  • Gynecology
  • Orthopedics
  • Conclusions
  • Key Points
  • References
  • Chapter 35 Frailty in the Perioperative Setting for Cancer Patients
  • Introduction
  • Frailty in Cancer Patients
  • Principles of Frailty and Geriatric Syndromes
  • Frailty Screening and Measurement Tools
  • Nutrition and How It Impacts on Surgery
  • Perioperative Care for Older Cancer Patients: Clinical Implications
  • Conclusion
  • References
  • Chapter 36 Delivering Perioperative Care for Older Patients Undergoing Cancer Surgery
  • Introduction
  • Core Components of Perioperative Care for Older Patients Undergoing Cancer Surgery
  • Current Models of Perioperative Care for Older People Undergoing Cancer Surgery
  • Geriatrician-Led Model
  • References
  • Section 4 Acute Postoperative and Intensive Care of the Cancer Patient
  • Chapter 37 Special Considerations in the Postoperative Care of the Cancer Patient
  • Nutrition
  • Functional Status
  • Prehabilitation
  • Wound Healing
  • Adjuvant Therapy
  • Postoperative Quality of Life in Cancer Patients
  • References
  • Chapter 38 Early Warning and Rapid Response Systems
  • Introduction
  • The Rapid Response System
  • Composition
  • Evidence
  • Oncology-Related Issues
  • Future Directions
  • Summary
  • References
  • Chapter 39 Intensive Care Considerations of the Cancer Patient
  • The Surgical Oncologic Patient
  • Patients Requiring Monitoring
  • Postoperative Considerations
  • High-Flow Nasal Cannula
  • Non-invasive Positive Pressure Ventilation
  • References
  • Chapter 40 The Challenges of Novel Therapies in the Care of the Critically Ill Cancer Patient
  • Basic Sciences
  • Novel Cancer Therapies
  • Novel Agent Toxicity
  • Conclusion
  • References
  • Section 5 Pain and Palliative/Integrative Medicine
  • Chapter 41 Acute Postsurgical Pain Management in Patients with Cancer
  • Introduction
  • Postoperative Pain Management in Cancer Patients
  • Various Analgesic Modalities
  • Neuraxial Modalities
  • Regional Anesthesia
  • Side Effects and Complications
  • Postoperative and Postdischarge Follow-up
  • Conclusion
  • References
  • Chapter 42 Chronic and Interventional Pain Management in Patients With Cancer
  • Introduction
  • Evaluating the Patient With Cancer-Related Pain
  • Pharmacologic Management of Cancer-Related Pain
  • Interventional Management of Cancer Pain
  • Conclusion
  • References
  • Chapter 43 Rehabilitation, Palliative Care, and Integrative Medicine Interventions in Cancer
  • Rehabilitation Interventions in Patients With Cancer
  • Palliative Care Interventions in Patients With Cancer
  • Integrative Medicine Interventions in Patients With Cancer
  • References
  • Chapter 44 Integrating Rehabilitative and Palliative Care Principles Within Acute Care Practice
  • Introduction
  • Palliative Care
  • Rehabilitation
  • Conclusion
  • References
  • Section 6 Perioperative/Periprocedural Care of the Pediatric Patients With Cancer
  • Chapter 45 Overview of Pediatric Cancers
  • Introduction
  • Acute Lymphoblastic Leukemia
  • Acute Myeloid Leukemia
  • Pediatric Lymphomas
  • Bone Sarcomas
  • Rhabdomyosarcoma
  • Solid-Organ Tumors: Wilms Tumor and Hepatoblastoma
  • Central Nervous System Tumors
  • Preoperative Care for the Pediatric Patient With Cancer
  • References
  • Chapter 46 Preoperative Assessment of the Pediatric Patient With Cancer
  • Introduction
  • Neurologic Evaluation
  • Cardiac Evaluation
  • Pulmonary Evaluation
  • Gastrointestinal Evaluation
  • Hepatic/Renal Evaluation
  • Endocrine Evaluation
  • Hematologic Evaluation
  • Pain Evaluation
  • Preoperative Laboratory Testing
  • Fasting Guidelines
  • Parental Concerns
  • Special Considerations
  • Syndromes Related to Cancer
  • Vascular Access
  • Conclusion
  • References
  • Chapter 47 Intraoperative Management: Considerations for Specific Procedures in Children with Cancer
  • Anesthetic Management of the Child with an Anterior Mediastinal Mass
  • Anesthesia for Pediatric Radiotherapy
  • Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy
  • Conclusion
  • References
  • Chapter 48 General Principles for Intensive Care Management of Pediatric Patients With Cancer
  • Introduction/Overview
  • References
  • Chapter 49 Anesthesia for Procedures Outside of the Operating Room
  • Introduction
  • Locations Requiring NORA
  • Challenges Associated With NORA
  • Who Should be Administering Sedation and Anesthesia?
  • Patient Evaluation, Preparation, and Preprocedure Checklist
  • Minimum Monitoring Standards
  • Anesthesia Techniques
  • Complications
  • Postprocedural Care
  • Conclusion and Key Messages
  • References
  • Chapter 50 Do Not Resuscitate and the Terminally Ill Child
  • Introduction
  • Decision-Making in Pediatrics
  • Advanced Care Planning
  • Palliative Procedures
  • Care at End of Life
  • References
  • Chapter 51 Chronic Pain and Palliative Care in the Pediatric Patient
  • Introduction
  • Pain Presentations
  • Palliative Care
  • References
  • Chapter 52 Special Considerations for Intensive Care Management of Pediatric Patients With Cancer
  • Neurologic Diagnoses in the Pediatric Oncologic Critical Care Patient
  • Anterior Mediastinal Masses
  • Intraabdominal Tumors
  • Transfusion Medicine
  • Enhanced Recovery After Surgery
  • References
  • Section 7 Value Proposition and Research in Perioperative Cancer Care
  • Chapter 53 Value Proposition in Cancer Care: Quantifying Patient-Centered Value in a Comprehensive Cancer Care Center
  • Radar Plots
  • A Comprehensive Value Equation for a Comprehensive Cancer Center
  • Defining the Value Equation
  • The Value Equation: Summary
  • Collecting Data
  • Visualizing and Comparing Value
  • The Value Equation Payoff
  • References
  • Chapter 54 Enhanced Surgical Recovery and Cancer
  • Introduction
  • Preoperative Preparation
  • Intraoperative Management
  • Postoperative Care
  • Conclusion
  • References
  • Chapter 55 Symptom Assessment, Patient-Reported Outcomes, and Quality of Life Considerations in Perioperative Care for Patients With Cancer
  • Introduction
  • Defining PRO concepts
  • Clinical Research on Pro Application in Perioperative Care
  • Methodologies for Applying Pro Measures in Perioperative Care
  • Future Considerations Regarding the Use of PROs in Perioperative Care
  • Conclusion
  • References
  • Chapter 56 Shared Decision-Making and Advance Care Planning in the Cancer Care Journey
  • Introduction
  • What Is Shared Decision-Making?
  • Why Is Shared Decision-Making Needed?
  • What Elements Are Required to Make Shared Decision-Making Successful?
  • Individual and Societal Advantages of Shared Decision-Making
  • How Does Advance Care Planning Fit Into Shared Decision-Making?
  • Conclusion and Key Points
  • References
  • Chapter 57 Ethics in Cancer Care Delivery—Do Not Resuscitate
  • Introduction
  • Cardiopulmonary Resuscitation
  • Law, Regulations, and Guidelines
  • Intraoperative CPR Outcomes
  • Outcomes of CPR in Cancer Patients
  • Outcomes of Palliative and Rescue Surgery in Cancer Patients
  • Outcomes of Patients with DNR Orders
  • Ethical Considerations on Sustaining or Withholding DNR Status During Palliative Surgical Procedures
  • Advance Care Planning—Communicating and Defining Goals of Care
  • Conclusion
  • References
  • Chapter 58 Economics of Cancer Care Delivery: Opportunities and Challenges
  • Introduction
  • Cost of Treatments
  • Current Strategies to Reduce Cost
  • Conclusion
  • References
  • Chapter 59 The Costs of Postoperative Complications After Major Abdominal Surgery: Opportunities and Challenges
  • Key Points
  • Introduction
  • Rectal Resection Surgery
  • Colonic Resection Surgery
  • Liver Resection
  • Pancreatic Resection
  • Discussion
  • Conclusion
  • References
  • Chapter 60 Research in Perioperative Care of the Cancer Patient: Opportunities and Challenges
  • Basic Science and Translational Studies
  • Clinical Endpoints
  • Retrospective and Population Database Studies
  • Randomized Controlled Trials
  • Conclusion
  • Key Points
  • References
  • Chapter 61 Big Data, Advances in Computational Sciences, and Oncology Care
  • Little Data to Big Data
  • NoSQL Technology
  • Computational Advances
  • Cloud Computing
  • Analytics and Visualization
  • Augmented Decision Support
  • Machine Learning and Artificial Intelligence
  • Neural Networks and Deep Learning
  • Genomic Data
  • Population Health
  • Impact on Anesthesia
  • Conclusions
  • References
  • Chapter 62 The MD Anderson Cancer Center Moon Shots Program®: A Global Priority
  • Introduction
  • Lung Cancer Moon Shot: Smoking Cessation Initiatives
  • HPV Cancer Moon Shot: The Global Burden of HPV-Associated Cancers
  • Pancreatic Cancer Moon Shot: The Quest for Early Detection
  • Conclusion
  • References
  • Index

Product details

  • No. of pages: 656
  • Language: English
  • Copyright: © Elsevier 2022
  • Published: March 26, 2022
  • Imprint: Elsevier
  • Hardcover ISBN: 9780323695848
  • eBook ISBN: 9780323695855

About the Editors

Carin Hagberg

Affiliations and Expertise

Chief Academic Officer, Immediate Past Division Head, Division of Anesthesiology, Critical Care & Pain Medicine, Bud Johnson Clinical Distinguished Chair, Department of Anesthesiology & Perioperative Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas

Joseph Nates

Affiliations and Expertise

Professor, Deputy Chair, SICU and MICU Medical Director, Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center

Berhard Riedel

Affiliations and Expertise

Director, Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Center, Melbourne, Australia

Vijaya Gottumukkala

Affiliations and Expertise

Department of Critical Care, Division of Anesthesiology & PeriOperative Medicine, Critical Care, and Pain Medicine, The University of Texas MD Anderson, Houston Texas, USA

Donal Buggy

Affiliations and Expertise

Professor of Anaesthesiology & Perioperative Medicine Mater University Hospital, School of Medicine University College Dublin, Ireland

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