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Erschienen in: European Journal of Trauma and Emergency Surgery 6/2020

24.05.2019 | Original Article

Cerebral effects of resuscitation with either epinephrine or vasopressin in an animal model of hemorrhagic shock

verfasst von: Jan Küchler, Stephan Klaus, Ludger Bahlmann, Nils Onken, Alexander Keck, Emma Smith, Jan Gliemroth, Claudia Ditz

Erschienen in: European Journal of Trauma and Emergency Surgery | Ausgabe 6/2020

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Abstract

Purpose

The use of epinephrine (EN) or vasopressin (VP) in hemorrhagic shock is well established. Due to its specific neurovascular effects, VP might be superior in concern to brain tissue integrity. The aim of this study was to evaluate cerebral effects of either EN or VP resuscitation after hemorrhagic shock.

Methods

After shock induction fourteen pigs were randomly assigned to two treatment groups. After 60 min of shock, resuscitation with either EN or VP was performed. Hemodynamics, arterial blood gases as well as cerebral perfusion pressure (CPP) and brain tissue oxygenation (PtiO2) were recorded. Interstitial lactate, pyruvate, glycerol and glutamate were assessed by cerebral and subcutaneous microdialysis. Treatment-related effects were compared using one-way ANOVA with post hoc Bonferroni adjustment (p < 0.05) for repeated measures.

Results

Induction of hemorrhagic shock led to a significant (p < 0.05) decrease of mean arterial pressure (MAP), cardiac output (CO) and CPP. Administration of both VP and EN sufficiently restored MAP and CPP and maintained physiological PtiO2 levels. Brain tissue metabolism was not altered significantly during shock and subsequent treatment with VP or EN. Concerning the excess of glycerol and glutamate, we found a significant EN-related release in the subcutaneous tissue, while brain tissue values remained stable during EN treatment. VP treatment resulted in a non-significant increase of cerebral glycerol and glutamate.

Conclusions

Both vasopressors were effective in restoring hemodynamics and CPP and in maintaining brain oxygenation. With regards to the cerebral metabolism, we cannot support beneficial effects of VP in this model of hemorrhagic shock.
Literatur
1.
Zurück zum Zitat Chen RY, Fan FC, Schuessler GB, Simchon S, Chien S. Regional cerebral blood flow and oxygen consumption of the canine brain during hemorrhagic hypotension. Stroke. 1984;15(2):343–50.PubMed Chen RY, Fan FC, Schuessler GB, Simchon S, Chien S. Regional cerebral blood flow and oxygen consumption of the canine brain during hemorrhagic hypotension. Stroke. 1984;15(2):343–50.PubMed
2.
Zurück zum Zitat Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2):R76.PubMedPubMedCentral Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2):R76.PubMedPubMedCentral
3.
Zurück zum Zitat Sperry JL, Minei JP, Frankel HL, West MA, Harbrecht BG, Moore EE, et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008;64(1):9–14.PubMed Sperry JL, Minei JP, Frankel HL, West MA, Harbrecht BG, Moore EE, et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008;64(1):9–14.PubMed
4.
Zurück zum Zitat Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 1. Executive summary. Resuscitation. 2015;95:1–80.PubMed Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 1. Executive summary. Resuscitation. 2015;95:1–80.PubMed
5.
Zurück zum Zitat Ditchey RV, Lindenfeld J. Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs. Circulation. 1988;78(2):382–9.PubMed Ditchey RV, Lindenfeld J. Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs. Circulation. 1988;78(2):382–9.PubMed
6.
Zurück zum Zitat Dünser MW, Mayr AJ, Ulmer H, Knotzer H, Sumann G, Pajk W, et al. Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation. 2003;107(18):2313–9.PubMed Dünser MW, Mayr AJ, Ulmer H, Knotzer H, Sumann G, Pajk W, et al. Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation. 2003;107(18):2313–9.PubMed
7.
Zurück zum Zitat Morales D, Madigan J, Cullinane S, Chen J, Heath M, Oz M, et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation. 1999;3(100):226–9. Morales D, Madigan J, Cullinane S, Chen J, Heath M, Oz M, et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation. 1999;3(100):226–9.
8.
Zurück zum Zitat Raedler C, Voelckel WG, Wenzel V, Krismer AC, Schmittinger CA, Herff H, et al. Treatment of uncontrolled hemorrhagic shock after liver trauma: fatal effects of fluid resuscitation versus improved outcome after vasopressin. Anesth Analg. 2004;98(6):1759–66.PubMed Raedler C, Voelckel WG, Wenzel V, Krismer AC, Schmittinger CA, Herff H, et al. Treatment of uncontrolled hemorrhagic shock after liver trauma: fatal effects of fluid resuscitation versus improved outcome after vasopressin. Anesth Analg. 2004;98(6):1759–66.PubMed
9.
Zurück zum Zitat Stadlbauer KH, Wagner-Berger HG, Raedler C, Voelckel WG, Wenzel V, Krismer AC, et al. Vasopressin, but not fluid resuscitation, enhances survival in a liver trauma model with uncontrolled and otherwise lethal hemorrhagic shock in pigs. Anesthesiology. 2003;98(3):699–704.PubMed Stadlbauer KH, Wagner-Berger HG, Raedler C, Voelckel WG, Wenzel V, Krismer AC, et al. Vasopressin, but not fluid resuscitation, enhances survival in a liver trauma model with uncontrolled and otherwise lethal hemorrhagic shock in pigs. Anesthesiology. 2003;98(3):699–704.PubMed
10.
Zurück zum Zitat Voelckel WG, Raedler C, Wenzel V, Lindner KH, Krismer AC, Schmittinger CA, et al. Arginine vasopressin, but not epinephrine, improves survival in uncontrolled hemorrhagic shock after liver trauma in pigs. Crit Care Med. 2003;31(4):1160–5.PubMed Voelckel WG, Raedler C, Wenzel V, Lindner KH, Krismer AC, Schmittinger CA, et al. Arginine vasopressin, but not epinephrine, improves survival in uncontrolled hemorrhagic shock after liver trauma in pigs. Crit Care Med. 2003;31(4):1160–5.PubMed
11.
Zurück zum Zitat Holmes CL, Patel BM, Russell JA, Walley KR. Physiology of vasopressin relevant to management of septic shock. Chest. 2001;120(3):989–1002.PubMed Holmes CL, Patel BM, Russell JA, Walley KR. Physiology of vasopressin relevant to management of septic shock. Chest. 2001;120(3):989–1002.PubMed
12.
Zurück zum Zitat Sanui M, King DR, Feinstein AJ, Varon AJ, Cohn SM, Proctor KG. Effects of arginine vasopressin during resuscitation from hemorrhagic hypotension after traumatic brain injury. Crit Care Med. 2006;34(2):433–8.PubMed Sanui M, King DR, Feinstein AJ, Varon AJ, Cohn SM, Proctor KG. Effects of arginine vasopressin during resuscitation from hemorrhagic hypotension after traumatic brain injury. Crit Care Med. 2006;34(2):433–8.PubMed
13.
Zurück zum Zitat Cavus E, Meybohm P, Doerges V, Hugo HH, Steinfath M, Nordstroem J, et al. Cerebral effects of three resuscitation protocols in uncontrolled haemorrhagic shock: a randomised controlled experimental study. Resuscitation. 2009;80(5):567–72.PubMed Cavus E, Meybohm P, Doerges V, Hugo HH, Steinfath M, Nordstroem J, et al. Cerebral effects of three resuscitation protocols in uncontrolled haemorrhagic shock: a randomised controlled experimental study. Resuscitation. 2009;80(5):567–72.PubMed
14.
Zurück zum Zitat Clark JD, Gebhart GF, Gonder JC, Keeling ME, Kohn DF. Special report: the 1996 guide for the care and use of laboratory animals. ILAR J. 1997;38(1):41–8.PubMed Clark JD, Gebhart GF, Gonder JC, Keeling ME, Kohn DF. Special report: the 1996 guide for the care and use of laboratory animals. ILAR J. 1997;38(1):41–8.PubMed
15.
Zurück zum Zitat Wiggers HC, Inhraham RC, Dille J. Hemorrhagic-hypotension shock in locally anesthetized dogs. Am J Physiol. 1945;143:126–33. Wiggers HC, Inhraham RC, Dille J. Hemorrhagic-hypotension shock in locally anesthetized dogs. Am J Physiol. 1945;143:126–33.
16.
Zurück zum Zitat Plurad DS, Talving P, Lam L, Inaba K, Green D, Demetriades D. Early vasopressor use in critical injury is associated with mortality independent from volume status. J Trauma. 2011;71(3):565–70.PubMed Plurad DS, Talving P, Lam L, Inaba K, Green D, Demetriades D. Early vasopressor use in critical injury is associated with mortality independent from volume status. J Trauma. 2011;71(3):565–70.PubMed
17.
Zurück zum Zitat Sperry JL, Minei JP, Frankel HL, West MA, Harbrecht BG, Moore EE, et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008;64(1):9–14.PubMed Sperry JL, Minei JP, Frankel HL, West MA, Harbrecht BG, Moore EE, et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008;64(1):9–14.PubMed
18.
Zurück zum Zitat Cohn SM, McCarthy J, Stewart RM, Jonas RB, Dent DL, Michalek JE. Impact of low-dose vasopressin on trauma outcome: prospective randomized study. World J Surg. 2011;35(2):430–9.PubMed Cohn SM, McCarthy J, Stewart RM, Jonas RB, Dent DL, Michalek JE. Impact of low-dose vasopressin on trauma outcome: prospective randomized study. World J Surg. 2011;35(2):430–9.PubMed
19.
Zurück zum Zitat Beloncle F, Meziani F, Lerolle N, Radermacher P, Asfar P. Does vasopressor therapy have an indication in hemorrhagic shock? Ann Intensive Care. 2013;3(1):13.PubMedPubMedCentral Beloncle F, Meziani F, Lerolle N, Radermacher P, Asfar P. Does vasopressor therapy have an indication in hemorrhagic shock? Ann Intensive Care. 2013;3(1):13.PubMedPubMedCentral
20.
Zurück zum Zitat Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Hamann C, et al. Small volume resuscitation: a randomized controlled trial with either norepinephrine or vasopressin during severe hemorrhage. J Trauma. 2007;62(3):640–6.PubMed Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Hamann C, et al. Small volume resuscitation: a randomized controlled trial with either norepinephrine or vasopressin during severe hemorrhage. J Trauma. 2007;62(3):640–6.PubMed
21.
Zurück zum Zitat D’Alessandro A, Moore HB, Moore EE, Wither M, Nemkov T, Gonzalez E, et al. Early hemorrhage triggers metabolic responses that build up during prolonged shock. Am J Physiol Regul Integr Comp Physiol. 2015;308(12):R1034–44.PubMedPubMedCentral D’Alessandro A, Moore HB, Moore EE, Wither M, Nemkov T, Gonzalez E, et al. Early hemorrhage triggers metabolic responses that build up during prolonged shock. Am J Physiol Regul Integr Comp Physiol. 2015;308(12):R1034–44.PubMedPubMedCentral
22.
Zurück zum Zitat Peltz ED, D’Alessandro A, Moore EE, Chin T, Silliman CC, Sauaia A, et al. Pathologic metabolism: an exploratory study of the plasma metabolome of critical injury. J Trauma Acute Care Surg. 2015;78(4):742–51.PubMedPubMedCentral Peltz ED, D’Alessandro A, Moore EE, Chin T, Silliman CC, Sauaia A, et al. Pathologic metabolism: an exploratory study of the plasma metabolome of critical injury. J Trauma Acute Care Surg. 2015;78(4):742–51.PubMedPubMedCentral
23.
Zurück zum Zitat Clendenen N, Nunns GR, Moore EE, Reisz JA, Gonzalez E, Peltz E, et al. Hemorrhagic shock and tissue injury drive distinct plasma metabolome derangements in swine. J Trauma Acute Care Surg. 2017;83(4):635–42.PubMedPubMedCentral Clendenen N, Nunns GR, Moore EE, Reisz JA, Gonzalez E, Peltz E, et al. Hemorrhagic shock and tissue injury drive distinct plasma metabolome derangements in swine. J Trauma Acute Care Surg. 2017;83(4):635–42.PubMedPubMedCentral
24.
Zurück zum Zitat Vogt N, Herden C, Roeb E, Roderfeld M, Eschbach D, Steinfeldt T, et al. Cerebral alterations following experimental multiple trauma and hemorrhagic shock. Shock. 2018;49(2):164–73.PubMed Vogt N, Herden C, Roeb E, Roderfeld M, Eschbach D, Steinfeldt T, et al. Cerebral alterations following experimental multiple trauma and hemorrhagic shock. Shock. 2018;49(2):164–73.PubMed
25.
Zurück zum Zitat Ida KK, Otsuki DA, Sasaki AT, Borges ES, Castro LU, Sanches TR, et al. Effects of terlipressin as early treatment for protection of brain in a model of haemorrhagic shock. Crit Care. 2015;19:107.PubMedPubMedCentral Ida KK, Otsuki DA, Sasaki AT, Borges ES, Castro LU, Sanches TR, et al. Effects of terlipressin as early treatment for protection of brain in a model of haemorrhagic shock. Crit Care. 2015;19:107.PubMedPubMedCentral
26.
Zurück zum Zitat Cavus E, Meybohm P, Dörges V, Stadlbauer KH, Wenzel V, Weiss H, et al. Regional and local brain oxygenation during hemorrhagic shock: a prospective experimental study on the effects of small-volume resuscitation with norepinephrine. J Trauma. 2008;64(3):641–8 (discussion 648-9).PubMed Cavus E, Meybohm P, Dörges V, Stadlbauer KH, Wenzel V, Weiss H, et al. Regional and local brain oxygenation during hemorrhagic shock: a prospective experimental study on the effects of small-volume resuscitation with norepinephrine. J Trauma. 2008;64(3):641–8 (discussion 648-9).PubMed
27.
Zurück zum Zitat Sarrafzadeh AS, Haux D, Lüdemann L, Amthauer H, Plotkin M, Küchler I, et al. Cerebral ischemia in aneurysmal subarachnoid hemorrhage: a correlative microdialysis-PETstudy. Stroke. 2004;35(3):638–43.PubMed Sarrafzadeh AS, Haux D, Lüdemann L, Amthauer H, Plotkin M, Küchler I, et al. Cerebral ischemia in aneurysmal subarachnoid hemorrhage: a correlative microdialysis-PETstudy. Stroke. 2004;35(3):638–43.PubMed
28.
Zurück zum Zitat Meybohm P, Cavus E, Bein B, Steinfath M, Brand PA, Scholz J, et al. Cerebral metabolism assessed with microdialysis in uncontrolled hemorrhagic shock after penetrating liver trauma. Anesth Analg. 2006;103(4):948–54.PubMed Meybohm P, Cavus E, Bein B, Steinfath M, Brand PA, Scholz J, et al. Cerebral metabolism assessed with microdialysis in uncontrolled hemorrhagic shock after penetrating liver trauma. Anesth Analg. 2006;103(4):948–54.PubMed
29.
Zurück zum Zitat Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Scholz J, et al. Neurochemical monitoring using intracerebral microdialysis during systemic haemorrhage. Acta Neurochir (Wien). 2007;149(7):691–8.PubMed Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Scholz J, et al. Neurochemical monitoring using intracerebral microdialysis during systemic haemorrhage. Acta Neurochir (Wien). 2007;149(7):691–8.PubMed
30.
Zurück zum Zitat Larentzakis A, Toutouzas KG, Papalois A, Lapidakis G, Doulgerakis S, Doulami G, et al. Porcine model of hemorrhagic shock with microdialysis monitoring. J Surg Res. 2013;179(1):e177–82.PubMed Larentzakis A, Toutouzas KG, Papalois A, Lapidakis G, Doulgerakis S, Doulami G, et al. Porcine model of hemorrhagic shock with microdialysis monitoring. J Surg Res. 2013;179(1):e177–82.PubMed
31.
Zurück zum Zitat Berkowitz ID, Gervais H, Schleien CL, Koehler RC, Dean JM, Traystman RJ. Epinephrine dosage effects on cerebral and myocardial blood flow in an infant swine model of cardiopulmonary resuscitation. Anesthesiology. 1991;75(6):1041–50.PubMed Berkowitz ID, Gervais H, Schleien CL, Koehler RC, Dean JM, Traystman RJ. Epinephrine dosage effects on cerebral and myocardial blood flow in an infant swine model of cardiopulmonary resuscitation. Anesthesiology. 1991;75(6):1041–50.PubMed
33.
Zurück zum Zitat Luchette FA, Jenkins WA, Friend LA, Su C, Fischer JE, James JH. Hypoxia is not the sole cause of lactate production during shock. J Trauma. 2002;52(3):415–9.PubMed Luchette FA, Jenkins WA, Friend LA, Su C, Fischer JE, James JH. Hypoxia is not the sole cause of lactate production during shock. J Trauma. 2002;52(3):415–9.PubMed
34.
Zurück zum Zitat Levy B, Mansart A, Bollaert PE, Franck P, Mallie JP. Effects of epinephrine and norepinephrine on hemodynamics, oxidative metabolism, and organ energetics in endotoxemic rats. Intensive Care Med. 2003;29(2):292–300.PubMed Levy B, Mansart A, Bollaert PE, Franck P, Mallie JP. Effects of epinephrine and norepinephrine on hemodynamics, oxidative metabolism, and organ energetics in endotoxemic rats. Intensive Care Med. 2003;29(2):292–300.PubMed
35.
Zurück zum Zitat Di Giantomasso D, Bellomo R, May CN. The haemodynamic and metabolic effects of epinephrine in experimental hyperdynamic septic shock. Intensive Care Med. 2005;31:454–62.PubMed Di Giantomasso D, Bellomo R, May CN. The haemodynamic and metabolic effects of epinephrine in experimental hyperdynamic septic shock. Intensive Care Med. 2005;31:454–62.PubMed
36.
Zurück zum Zitat Hutchinson PJ, Jalloh I, Helmy A, Carpenter KL, Rostami E, Bellander BM, et al. Consensus statement from the 2014 International Microdialysis Forum. Intensive Care Med. 2015;41(9):1517–28.PubMedPubMedCentral Hutchinson PJ, Jalloh I, Helmy A, Carpenter KL, Rostami E, Bellander BM, et al. Consensus statement from the 2014 International Microdialysis Forum. Intensive Care Med. 2015;41(9):1517–28.PubMedPubMedCentral
37.
Zurück zum Zitat Hillered L, Valtysson J, Enblad P, Persson L. Interstitial glycerol as a marker for membrane phospholipid degradation in the acutely injured human brain. J Neurol Neurosurg Psychiatry. 1998;64(4):486–91.PubMedPubMedCentral Hillered L, Valtysson J, Enblad P, Persson L. Interstitial glycerol as a marker for membrane phospholipid degradation in the acutely injured human brain. J Neurol Neurosurg Psychiatry. 1998;64(4):486–91.PubMedPubMedCentral
38.
Zurück zum Zitat Nielsen TH, Olsen NV, Toft P, Nordstrom CH. Cerebral energy metabolism during mitochondrial dysfunction induced by cyanide in piglets. Acta Anaesthesiol Scand. 2013;57(6):793–801.PubMed Nielsen TH, Olsen NV, Toft P, Nordstrom CH. Cerebral energy metabolism during mitochondrial dysfunction induced by cyanide in piglets. Acta Anaesthesiol Scand. 2013;57(6):793–801.PubMed
39.
Zurück zum Zitat Johnston AJ, Gupta AK. Advanced monitoring in the neurology intensive care unit: microdialysis. Curr Opin Crit Care. 2002;8(2):121–7.PubMed Johnston AJ, Gupta AK. Advanced monitoring in the neurology intensive care unit: microdialysis. Curr Opin Crit Care. 2002;8(2):121–7.PubMed
40.
Zurück zum Zitat Tisdall MM, Smith M. Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006;97(1):18–25.PubMed Tisdall MM, Smith M. Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006;97(1):18–25.PubMed
41.
Zurück zum Zitat Kett-White R, Hutchinson PJ, Al-Rawi PG, Gupta AK, Pickard JD, Kirkpatrick PJ. Adverse cerebral events detected after subarachnoid hemorrhage using brain oxygen and microdialysis probes. Neurosurgery. 2002;50(6):1213–21.PubMed Kett-White R, Hutchinson PJ, Al-Rawi PG, Gupta AK, Pickard JD, Kirkpatrick PJ. Adverse cerebral events detected after subarachnoid hemorrhage using brain oxygen and microdialysis probes. Neurosurgery. 2002;50(6):1213–21.PubMed
42.
Zurück zum Zitat Chamoun R, Suki D, Gopinath SP, Goodman JC, Robertson C. Role of extracellular glutamate measured by cerebral microdialysis in severe traumatic brain injury. J Neurosurg. 2010;113(3):564–70.PubMedPubMedCentral Chamoun R, Suki D, Gopinath SP, Goodman JC, Robertson C. Role of extracellular glutamate measured by cerebral microdialysis in severe traumatic brain injury. J Neurosurg. 2010;113(3):564–70.PubMedPubMedCentral
43.
Zurück zum Zitat Millet L, Barbe P, Lafontan M, Berlan M, Galitzky J. Catecholamine effects on lipolysis and blood flow in human abdominal and femoral adipose tissue. J Appl Physiol. 1998;85(1):181–8.PubMed Millet L, Barbe P, Lafontan M, Berlan M, Galitzky J. Catecholamine effects on lipolysis and blood flow in human abdominal and femoral adipose tissue. J Appl Physiol. 1998;85(1):181–8.PubMed
44.
Zurück zum Zitat Wenzel V, Lindner KH, Krismer AC, Miller EA, Voelckel WG, Lingnau W. Repeated administration of vasopressin but not epinephrine maintains coronary perfusion pressure after early and late administration during prolonged cardiopulmonary resuscitation in pigs. Circulation. 1999;99(10):1379–84.PubMed Wenzel V, Lindner KH, Krismer AC, Miller EA, Voelckel WG, Lingnau W. Repeated administration of vasopressin but not epinephrine maintains coronary perfusion pressure after early and late administration during prolonged cardiopulmonary resuscitation in pigs. Circulation. 1999;99(10):1379–84.PubMed
Metadaten
Titel
Cerebral effects of resuscitation with either epinephrine or vasopressin in an animal model of hemorrhagic shock
verfasst von
Jan Küchler
Stephan Klaus
Ludger Bahlmann
Nils Onken
Alexander Keck
Emma Smith
Jan Gliemroth
Claudia Ditz
Publikationsdatum
24.05.2019
Verlag
Springer Berlin Heidelberg
Erschienen in
European Journal of Trauma and Emergency Surgery / Ausgabe 6/2020
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-019-01158-6

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