Skip to main content

Disseminated Intravascular Coagulation in Cardiac Surgery

  • Chapter
  • First Online:
Principles of Pulmonary Protection in Heart Surgery

Abstract

Disseminated intravascular coagulation (DIC) is a complex thrombohemorrhagic disease, secondary to an underlying clinical disease,1 producing both thrombosis and hemorrhage. It is initiated by a number of defined disorders and consists of the following components2: exposure of blood to procoagulants; formation of fibrin in the circulation; fibrinolysis; depletion of clotting factors; and end-organ damage. Systemic activation of coagulation in its most extreme form is known as DIC,3 which occurs in approximately 1% of hospital admissions.4

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 249.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Ho LW, Kam PC, Thong CL. Disseminated intravascular coagulation. Curr Anaesth Crit Care. 2005;16:151-161.

    Article  Google Scholar 

  2. Leung LL. Pathogenesis and etiology of disseminated intravascular coagulation. UpToDate Web site. http://www.uptodate.com/patients/content/topic.do?topicKey=-ourrinG/1tGmgs&selectedTitle=26-90&source=search_result. Accessed 9 Apr 2009

  3. Levi M. Disseminated intravascular coagulation. Crit Care Med. 2007;35:2191-2195.

    Article  PubMed  CAS  Google Scholar 

  4. Matsuda T. Clinical aspects of DIC–disseminated intravascular coagulation. Pol J Pharmacol. 1996;48:73-75.

    PubMed  CAS  Google Scholar 

  5. Raivio P, Suojaranta-Ylinen R, Kuitunen R. Recombinant factor VIIa in the treatment of postoperative hemorrhage after cardiac surgery. Ann Thorac Surg. 2005;80:66-71.

    Article  PubMed  Google Scholar 

  6. Taylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M, Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001;86:1327-1330.

    PubMed  CAS  Google Scholar 

  7. Levi M, ten Cate H. Disseminated intravascular coagulation. N Engl J Med. 1999;341:586-592.

    Article  PubMed  CAS  Google Scholar 

  8. Levi M, van der Poll T, ten Cate H, van Deventer SJ. The cytokine-mediated imbalance between coagulant and anticoagulant mechanisms in sepsis and endotoxaemia. Eur J Clin Invest. 1997;27:3-9.

    Article  PubMed  CAS  Google Scholar 

  9. Spero JA, Lewis JH, Hasiba U. Disseminated intravascular coagulation. Findings in 346 patients. Thromb Haemost. 1980;43:28-33.

    PubMed  CAS  Google Scholar 

  10. Siegal T, Seligsohn U, Aghai E, Modan M. Clinical and laboratory aspects of disseminated intravascular coagulation (DIC): a study of 118 cases. Thromb Haemost. 1978;39:122-134.

    PubMed  CAS  Google Scholar 

  11. Gando S. Disseminated intravascular coagulation in trauma patients. Semin Thromb Hemost. 2001;27:585-592.

    Article  PubMed  CAS  Google Scholar 

  12. Gando S, Nanzaki D, Kemmotsu O. Disseminated intravascular coagulation and sustained systemic inflammatory response syndrome predict organ dysfunctions after trauma: application of clinical decision analysis. Ann Surg. 1999;229:121-127.

    Article  PubMed  CAS  Google Scholar 

  13. Stéphan F, Hollande J, Richard O, Cheffi A, Maier-Redelsperger M, Flahault A. Thrombocytopenia in a surgical ICU. Chest. 1999;115:1363-1370.

    Article  PubMed  Google Scholar 

  14. Aboulafia DM, Aboulafia ED. Aortic aneurysm-induced disseminated intravascular coagulation. Ann Vasc Surg. 1996;10:396-405.

    Article  PubMed  CAS  Google Scholar 

  15. Kazmers A, Jacobs L, Perkins A, Lindenauer SM, Bates E. Abdominal aortic aneurysm repair in Veterans Affairs medical centers. J Vasc Surg. 1996;23:191-200.

    Article  PubMed  CAS  Google Scholar 

  16. Karkouti K, Cohen MM, McCluskey SA, Sher GD. A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery. Transfusion. 2001;41:1193-2003.

    Article  PubMed  CAS  Google Scholar 

  17. Sellman M, Intonti MA, Ivert T. Reoperations for bleeding after coronary artery bypass procedures during 25 years. Eur J Cardiothorac Surg. 1997;11:521-527.

    Article  PubMed  CAS  Google Scholar 

  18. Munoz JJ, Birkmeyer NJ, Dacey LJ, et al. Trends in rates of reexploration for hemorrhage after coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 1999;68:1321-1325.

    Article  PubMed  CAS  Google Scholar 

  19. Fiser SM, Tribble CG, Kern JA, Long SM, Kaza AK, Kron IL. Cardiac reoperation in the intensive care unit. Ann Thorac Surg. 2001;71:1888-1892.

    Article  PubMed  CAS  Google Scholar 

  20. Ferraris VA, Ferraris SP, Saha SP, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg. 2007;83:S27-S86.

    Article  PubMed  Google Scholar 

  21. Woodman RC, Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood. 1990;76:1680-1697.

    PubMed  CAS  Google Scholar 

  22. Hambleton J, Leung LL, Levi M. Coagulation: consultative hemostasis. Hematology Am Soc Hematol Educ Program 2002;335–352.

    Google Scholar 

  23. Gando S, Nanzaki S, Sasaki S, Kemmotsu O. Significant correlations between tissue factor and thrombin markers in trauma and septic patients with disseminated intravascular coagulation. Thromb Haemost. 1998;79:1111-1115.

    PubMed  CAS  Google Scholar 

  24. Osterud B, Flaegstad T. Increased tissue thromboplastin activity in monocytes of patients with meningococcal infection: related to an unfavourable prognosis. Thromb Haemost. 1983;49:5-7.

    PubMed  CAS  Google Scholar 

  25. Giesen PL, Rauch U, Bohrmann B, et al. Blood-borne tissue factor: another view of thrombosis. Proc Natl Acad Sci U S A. 1999;96:2311-2315.

    Article  PubMed  CAS  Google Scholar 

  26. Levi M, ten Cate H, van der Poll T. Endothelium: interface between coagulation and inflammation. Crit Care Med. 2002;30:S220-S224.

    Article  PubMed  Google Scholar 

  27. Esmon CT. The regulation of natural anticoagulant pathways. Science. 1987;235:1348-1352.

    Article  PubMed  CAS  Google Scholar 

  28. Levi M, de Jonge E, van der Poll T. Rationale for restoration of physiological anticoagulant pathways in patients with sepsis and disseminated intravascular coagulation. Crit Care Med. 2001;29:S90-S94.

    Article  PubMed  CAS  Google Scholar 

  29. Levi M. Current understanding of disseminated intravascular coagulation. Br J Haematol. 2004;124:567-576.

    Article  PubMed  Google Scholar 

  30. Esmon CT. Role of coagulation inhibitors in inflammation. Thromb Haemost. 2001;86:51-56.

    PubMed  CAS  Google Scholar 

  31. Levi M. The imbalance between tissue factor and tissue factor pathway inhibitor in sepsis. Crit Care Med. 2002;30:1914-1915.

    Article  PubMed  Google Scholar 

  32. Creasey AA, Chang AC, Feigen L, Wün TC, Taylor FB Jr, Hinshaw LB. Tissue factor pathway inhibitor reduces mortality from Escherichia coli septic shock. J Clin Invest. 1993;91:2850-2860.

    Article  PubMed  CAS  Google Scholar 

  33. Shimura M, Wada H, Wakita Y, et al. Plasma tissue factor and tissue factor pathway inhibitor levels in patients with disseminated intravascular coagulation. Am J Hematol. 1997;55:169-174.

    Article  PubMed  CAS  Google Scholar 

  34. van Hinsbergh VW, Bauer KA, Kooistra T, et al. Progress of fibrinolysis during tumor necrosis factor infusions in humans. Concomitant increase in tissue-type plasminogen activator, plasminogen activator inhibitor type-1, and fibrin(ogen) degradation products. Blood. 1990;76:2284-2289.

    PubMed  Google Scholar 

  35. Levi M, de Jonge E, van der Poll T, ten Cate H. Disseminated intravascular coagulation. Thromb Haemost. 1999;82:695-705.

    PubMed  CAS  Google Scholar 

  36. Collins PW, Noble KE, Reittie JR, Hoffbrand AV, Pasi KJ, Yong KL. Induction of tissue factor expression in human monocyte/endothelium cocultures. Br J Haematol. 1995;91:963-970.

    Article  PubMed  CAS  Google Scholar 

  37. Todoroki H, Nakamura S, Higure A, et al. Neutrophils express tissue factor in a monkey model of sepsis. Surgery. 2000;127:209-216.

    Article  PubMed  CAS  Google Scholar 

  38. van der Poll T, de Jonge E, Levi M. Regulatory role of cytokines in disseminated intravascular coagulation. Semin Thromb Hemost. 2001;27:639-651.

    Article  PubMed  Google Scholar 

  39. Leung LL. Clinical features, diagnosis and treatment of disseminated intravascular coagulation in adults. UpToDate Web site. http://www.uptodate.com/patients/content/topic.do?topicKey=-eLIUMBy0Hvb0ZFS. Accessed 9 Apr 2009

  40. Bick RL. Disseminated intravascular coagulation and related syndromes: a clinical review. Semin Thromb Hemost. 1988;14:299-338.

    Article  PubMed  CAS  Google Scholar 

  41. Bernard GR, Margolis BD, Shanies HM, et al. Extended Evaluation of Recombinant Human Activated Protein C United States Trial (ENHANCE US): a single-arm, phase 3B, multicenter study of drotrecogin alfa (activated) in severe sepsis. Chest. 2004;125:2206-2216.

    Article  PubMed  CAS  Google Scholar 

  42. Strauss R, Wehler M, Mehler K, Kreutzer D, Koebnick C, Hahn EG. Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med. 2002;30:1765-1771.

    Article  PubMed  Google Scholar 

  43. Bick RL. Disseminated intravascular coagulation current concepts of etiology, pathophysiology, diagnosis, and treatment. Hematol Oncol Clin North Am. 2003;17:149-176.

    Article  PubMed  Google Scholar 

  44. Bick RL. Disseminated intravascular coagulation. Objective criteria for diagnosis and management. Med Clin North Am. 1994;78:511-543.

    PubMed  CAS  Google Scholar 

  45. Robboy SJ, Major MC, Colman RW, Minna JD. Pathology of disseminated intravascular coagulation (DIC). Analysis of 26 cases. Hum Pathol. 1972;3:327-343.

    Article  PubMed  CAS  Google Scholar 

  46. Shimamura K, Oka K, Nakazawa M, Kojima M. Distribution patterns of microthrombi in disseminated intravascular coagulation. Arch Pathol Lab Med. 1983;107:543-547.

    PubMed  CAS  Google Scholar 

  47. Regoeczi E, Brain MC. Organ distribution of fibrin in disseminated intravascular coagulation. Br J Haematol. 1969;17:73-81.

    Article  PubMed  CAS  Google Scholar 

  48. Toh CH. Laboratory testing in disseminated intravascular coagulation. Semin Thromb Hemost. 2001;27:653-656.

    Article  PubMed  CAS  Google Scholar 

  49. Bakhtiari K, Meijers JC, de Jonge E, Levi M. Prospective validation of the International Society of Thrombosis and Haemostasis scoring system for disseminated intravascular coagulation. Crit Care Med. 2004;32:2416-2421.

    Article  PubMed  Google Scholar 

  50. Toh CH, Hoots WK. The scoring system of the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation of the International Society on Thrombosis and Haemostasis: a 5-year overview. J Thromb Haemost. 2007;5:604-606.

    Article  PubMed  CAS  Google Scholar 

  51. Gando S, Saitoh D, Ogura H, et al. Natural history of disseminated intravascular coagulation diagnosed based on the newly established diagnostic criteria for critically ill patients: results of a multicenter, prospective survey. Crit Care Med. 2008;36:145-150.

    Article  PubMed  Google Scholar 

  52. Levi M, de Jonge E, Meijers J. The diagnosis of disseminated intravascular coagulation. Blood Rev. 2002;16:217-223.

    Article  PubMed  Google Scholar 

  53. Bredbacka S, Blombäck M, Wiman B. Soluble fibrin: a predictor for the development and outcome of multiple organ failure. Am J Hematol. 1994;46:289-294.

    Article  PubMed  CAS  Google Scholar 

  54. Okajima K, Uchiba M, Murakami K, Okabe H, Takatsuki K. Determination of plasma soluble fibrin using a new ELISA method in patients with disseminated intravascular coagulation. Am J Hematol. 1996;51:186-191.

    Article  PubMed  CAS  Google Scholar 

  55. Horan JT, Francis CW. Fibrin degradation products, fibrin monomer and soluble fibrin in disseminated intravascular coagulation. Semin Thromb Hemost. 2001;27:657-666.

    Article  PubMed  CAS  Google Scholar 

  56. Bick RL. Disseminated intravascular coagulation: pathophysiological mechanisms and manifestations. Semin Thromb Hemost. 1998;24:3-18.

    Article  PubMed  CAS  Google Scholar 

  57. Mammen EF. Disseminated intravascular coagulation (DIC). Clin Lab Sci. 2000;13:239-245.

    PubMed  CAS  Google Scholar 

  58. Wada H, Minamikawa K, Wakita Y, et al. Hemostatic study before onset of disseminated intravascular coagulation. Am J Hematol. 1993;43:190-194.

    Article  PubMed  CAS  Google Scholar 

  59. Akca S, Haji-Michael P, de Mendonça A, Suter P, Levi M, Vincent JL. Time course of platelet counts in critically ill patients. Crit Care Med. 2002;30:753-756.

    Article  PubMed  Google Scholar 

  60. Fourrier F, Chopin C, Goudemand J, et al. Septic shock, multiple organ failure, and disseminated intravascular coagulation. Compared patterns of antithrombin III, protein C, and protein S deficiencies. Chest. 1992;101:816-823.

    Article  PubMed  CAS  Google Scholar 

  61. Mesters RM, Helterbrand J, Utterback BG, et al. Prognostic value of protein C concentrations in neutropenic patients at high risk of severe septic complications. Crit Care Med. 2000;28:2209-2216.

    Article  PubMed  CAS  Google Scholar 

  62. Gando S, Nakanishi Y, Tedo I. Cytokines and plasminogen activator inhibitor-1 in posttrauma disseminated intravascular coagulation: relationship to multiple organ dysfunction syndrome. Crit Care Med. 1995;23:1835-1842.

    Article  PubMed  CAS  Google Scholar 

  63. Toh CH, Downey C, Dwyre L. Thromboplastin sensitivity in waveform analysis. Thromb Haemost. 2000;84:517-518.

    PubMed  CAS  Google Scholar 

  64. Downey C, Kazmi R, Toh CH. Early identification and prognostic implications in disseminated intravascular coagulation through transmittance waveform analysis. Thromb Haemost. 1998;80:65-69.

    PubMed  CAS  Google Scholar 

  65. Toh CH. Transmittance waveform of routine coagulation tests is a sensitive and specific method for diagnosing nonovert disseminated intravascular coagulation. Blood Rev. 2002;16:S11-S14.

    PubMed  Google Scholar 

  66. Wada H, Wakita Y, Nakase T, et al. Outcome of disseminated intravascular coagulation in relation to the score when treatment was begun. Mie DIC Study Group. Thromb Haemost. 1995;74:848-852.

    PubMed  CAS  Google Scholar 

  67. Toh CH, Downey C. Performance and prognostic importance of a new clinical and laboratory scoring system for identifying non-overt disseminated intravascular coagulation. Blood Coagul Fibrinolysis. 2005;16:69-74.

    Article  PubMed  Google Scholar 

  68. Gando S, Iba T, Eguchi Y, et al. A multicenter, prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients: comparing current criteria. Crit Care Med. 2006;34:625-631.

    PubMed  Google Scholar 

  69. Wada H, Gabazza EC, Asakura H, et al. Comparison of diagnostic criteria for disseminated intravascular coagulation (DIC): diagnostic criteria of the International Society of Thrombosis and Haemostasis and of the Japanese Ministry of Health and Welfare for Overt DIC. Am J Hematol. 2003;74:17-22.

    Article  PubMed  Google Scholar 

  70. Carey MJ, Rodgers GM. Disseminated intravascular coagulation: clinical and laboratory aspects. Am J Hematol. 1998;59:65-73.

    Article  PubMed  CAS  Google Scholar 

  71. Pernerstorfer T, Hollenstein U, Hansen J, et al. Heparin blunts endotoxin-induced coagulation activation. Circulation. 1999;100:2485-2490.

    Article  PubMed  CAS  Google Scholar 

  72. Feinstein DI. Diagnosis and management of disseminated intravascular coagulation: the role of heparin therapy. Blood. 1982;60:284-287.

    PubMed  CAS  Google Scholar 

  73. Sakuragawa N, Hasegawa H, Maki M, Nakagawa M, Nakashima M. Clinical evaluation of low-molecular-weight heparin (FR-860) on disseminated intravascular coagulation (DIC)–a multicenter co-operative double-blind trial in comparison with heparin. Thromb Res. 1993;72:475-500.

    Article  PubMed  CAS  Google Scholar 

  74. Abraham E, Reinhart K, Svoboda P, et al. Assessment of the safety of recombinant tissue factor pathway inhibitor in patients with severe sepsis: a multicenter, randomized, placebo-controlled, single-blind, dose escalation study. Crit Care Med. 2001;29:2081-2089.

    Article  PubMed  CAS  Google Scholar 

  75. Abraham E, Reinhart K, Opal S, et al. Efficacy and safety of tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis: a randomized controlled trial. JAMA. 2003;290:238-247.

    Article  PubMed  CAS  Google Scholar 

  76. Warren BL, Eid A, Singer P, et al. Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial. JAMA. 2001;286:1869-1878.

    Article  PubMed  CAS  Google Scholar 

  77. Kienast J, Juers M, Wiedermann CJ, et al. Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation. J Thromb Haemost. 2006;4:90-97.

    Article  PubMed  CAS  Google Scholar 

  78. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699-709.

    Article  PubMed  CAS  Google Scholar 

  79. Dhainaut JF, Yan SB, Joyce DE, et al. Treatment effects of drotrecogin alfa (activated) in patients with severe sepsis with or without overt disseminated intravascular coagulation. J Thromb Haemost. 2004;2:1924-1933.

    Article  PubMed  CAS  Google Scholar 

  80. de Pont AC, Bakhtiari K, Hutten BA, et al. Recombinant human activated protein C resets thrombin generation in patients with severe sepsis-a case control study. Crit Care. 2005;9:R490-R497.

    Article  PubMed  Google Scholar 

  81. Abraham E, Laterre PF, Garg R, et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. 2005;353:1332-1341.

    Article  PubMed  CAS  Google Scholar 

  82. Ratnoff OD. Epsilon aminocaproic acid – a dangerous weapon. N Engl J Med. 1969;280:1124-1125.

    Article  PubMed  CAS  Google Scholar 

  83. Brown JR, Birkmeyer NJ, O’Connor GT. Meta-analysis comparing the effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery. Circulation. 2007;115:2801-2813.

    Article  PubMed  CAS  Google Scholar 

  84. Sedrakyan A, Treasure T, Elefteriades JA. Effect of aprotinin on clinical outcomes in coronary artery bypass graft surgery: a systematic review and meta-analysis of randomized clinical trials. J Thorac Cardiovasc Surg. 2004;128:442-448.

    Article  PubMed  CAS  Google Scholar 

  85. Ray MJ, O’Brien MF. Comparison of epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg. 2001;71:838-843.

    Article  PubMed  CAS  Google Scholar 

  86. Karkouti K, Beattie WS, Dattilo KM, et al. A propensity score case-control comparison of aprotinin and tranexamic acid in high-transfusion-risk cardiac surgery. Transfusion. 2006;46:327-338.

    Article  PubMed  CAS  Google Scholar 

  87. Fergusson DA, Hébert PC, Mazer CD, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358:2319-2331.

    Article  PubMed  CAS  Google Scholar 

  88. Ray WA. Learning from aprotinin–mandatory trials of comparative efficacy and safety needed. N Engl J Med. 2008;358:840-842.

    Article  PubMed  CAS  Google Scholar 

  89. Aranki S, Cutlip D, Aroesty JM. Early noncardiac complications of coronary artery bypass graft surgery. UpToDate Web site. http://www.uptodate.com/patients/content/topic.do?topicKey=-f55Cyv91Fhhx.I. Accessed 9 Apr 2009

  90. Levi M, Opal SM. Coagulation abnormalities in critically ill patients. Crit Care. 2006;10:222.

    Article  PubMed  Google Scholar 

  91. Mannucci PM, Levi M. Prevention and treatment of major blood loss. N Engl J Med. 2007;356:2301-2311.

    Article  PubMed  CAS  Google Scholar 

  92. Levi M, Peters M, Büller HR. Efficacy and safety of recombinant factor VIIa for treatment of severe bleeding: a systematic review. Crit Care Med. 2005;33:883-890.

    Article  PubMed  CAS  Google Scholar 

  93. Pavie A, Szefner J, Leger P, Gandjbakhch I. Preventing, minimizing, and managing postoperative bleeding. Ann Thorac Surg. 1999;68:705-710.

    Article  PubMed  CAS  Google Scholar 

  94. Furie B, Furie BC. Mechanisms of thrombus formation. N Engl J Med. 2008;359:938-949.

    Article  PubMed  CAS  Google Scholar 

  95. Gando S, Kameue T, Nanzaki S, Nakanishi Y. Disseminated intravascular coagulation is a frequent complication of systemic inflammatory response syndrome. Thromb Haemost. 1996;75:224-228.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Renato Delascio Lopes .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2010 Springer London

About this chapter

Cite this chapter

Vendrame, L.S., Guimaraes, H.P., Lopes, R.D. (2010). Disseminated Intravascular Coagulation in Cardiac Surgery. In: Gabriel, E., Salerno, T. (eds) Principles of Pulmonary Protection in Heart Surgery. Springer, London. https://doi.org/10.1007/978-1-84996-308-4_20

Download citation

  • DOI: https://doi.org/10.1007/978-1-84996-308-4_20

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-84996-307-7

  • Online ISBN: 978-1-84996-308-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics