Predictors for extubation failure in COVID-19 patients using a machine learning approach

Critical Care, vol. 25, pp. 448

Abstract

INTRODUCTION: Determining the optimal timing for extubation can be challenging in the intensive care. In this study, we aim to identify predictors for extubation failure in critically ill patients with COVID-19. METHODS: We used highly granular data from 3464 adult critically ill COVID patients in the multicenter Dutch Data Warehouse, including demographics, clinical observations, medications, fluid balance, laboratory values, vital signs, and data from life support devices. All intubated patients with at least one extubation attempt were eligible for analysis. Transferred patients, patients admitted for less than 24 h, and patients still admitted at the time of data extraction were excluded. Potential predictors were selected by a team of intensive care physicians. The primary and secondary outcomes were extubation without reintubation or death within the next 7 days and within 48 h, respectively. We trained and validated multiple machine learning algorithms using fivefold nested cross-validation. Predictor importance was estimated using Shapley additive explanations, while cutoff values for the relative probability of failed extubation were estimated through partial dependence plots. RESULTS: A total of 883 patients were included in the model derivation. The reintubation rate was 13.4% within 48 h and 18.9% at day 7, with a mortality rate of 0.6% and 1.0% respectively. The grandient-boost model performed best (area under the curve of 0.70) and was used to calculate predictor importance. Ventilatory characteristics and settings were the most important predictors. More specifically, a controlled mode duration longer than 4 days, a last fraction of inspired oxygen higher than 35%, a mean tidal volume per kg ideal body weight above 8 ml/kg in the day before extubation, and a shorter duration in assisted mode (< 2 days) compared to their median values. Additionally, a higher C-reactive protein and leukocyte count, a lower thrombocyte count, a lower Glasgow coma scale and a lower body mass index compared to their medians were associated with extubation failure. CONCLUSION: The most important predictors for extubation failure in critically ill COVID-19 patients include ventilatory settings, inflammatory parameters, neurological status, and body mass index. These predictors should therefore be routinely captured in electronic health records.

Authors 97

1. Lucas M. Fleuren corresponding

   Amsterdam University Medical Centers · Vrije Universiteit Amsterdam

   Affiliation as printed

   Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands. l.fleuren@amsterdamumc.nl

   Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands

2. Tariq A. Dam

   Amsterdam University Medical Centers · Vrije Universiteit Amsterdam

   Affiliation as printed

   Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands

3. Michele Tonutti
   Affiliation as printed

   , Pacmed, Amsterdam, The Netherlands

   Pacmed, Amsterdam, The Netherlands

4. Daan P. de Bruin
   Affiliation as printed

   , Pacmed, Amsterdam, The Netherlands

   Pacmed, Amsterdam, The Netherlands

5. Robbert C. A. Lalisang
   Affiliation as printed

   , Pacmed, Amsterdam, The Netherlands

   Pacmed, Amsterdam, The Netherlands

6. Diederik A M P J Gommers

   Erasmus MC

   Affiliation as printed

   Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands

7. Olaf L. Cremer

   University Medical Center Utrecht

   Affiliation as printed

   Department of Intensive Care, UMC Utrecht, Utrecht, The Netherlands

8. Rob J. Bosman

   OLVG

   Affiliation as printed

   ICU, OLVG, Amsterdam, The Netherlands

9. Sander Rigter

   St. Antonius Ziekenhuis

   Affiliation as printed

   Department of Anesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands

10. Evert‐Jan Wils

    Sint Franciscus Gasthuis · Franciscus Vlietland

    Affiliation as printed

    Department of Intensive Care, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands

11. Tim Frenzel

    Radboud University Medical Center

    Affiliation as printed

    Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands

12. Dave Anton Dongelmans

    Amsterdam University Medical Centers

    Affiliation as printed

    Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, The Netherlands

13. Remko de Jong
    Affiliation as printed

    Intensive Care, Bovenij Ziekenhuis, Amsterdam, The Netherlands

14. Marco Peters

    Canisius-Wilhelmina Ziekenhuis

    Affiliation as printed

    Intensive Care, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands

15. Marlijn J. A. Kamps

    Catharina Ziekenhuis

    Affiliation as printed

    Intensive Care, Catharina Ziekenhuis Eindhoven, Eindhoven, The Netherlands

16. Dharmanand Ramnarain

    Elisabeth-TweeSteden Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, ETZ Tilburg, Tilburg, The Netherlands

17. Ralph O. Nowitzky

    Haga Hospital

    Affiliation as printed

    Intensive Care, HagaZiekenhuis, Den Haag, The Netherlands

18. Fleur G. C. A. Nooteboom

    Laurentius Ziekenhuis

    Affiliation as printed

    Intensive Care, Laurentius Ziekenhuis, Roermond, The Netherlands

19. Wouter de Ruijter

    Noordwest Ziekenhuisgroep

    Affiliation as printed

    Department of Intensive Care Medicine, Northwest Clinics, Alkmaar, The Netherlands

20. Louise C. Urlings‐Strop

    Reinier de Graaf Hospital

    Affiliation as printed

    Intensive Care, Reinier de Graaf Gasthuis, Delft, The Netherlands

21. Ellen G. M. Smit

    Spaarne Ziekenhuis · Spaarne Gasthuis

    Affiliation as printed

    Intensive Care, Spaarne Gasthuis, Haarlem en Hoofddorp, The Netherlands

22. D. Jannet Mehagnoul‐Schipper

    VieCuri Medisch Centrum

    Affiliation as printed

    Intensive Care, VieCuri Medisch Centrum, Venlo, The Netherlands

23. Tom P.J. Dormans

    Zuyderland Medisch Centrum

    Affiliation as printed

    Intensive Care, Zuyderland MC, Heerlen, The Netherlands

24. Cornelis P. C. de Jager

    Jeroen Bosch Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands

25. Stefaan H. A. Hendriks

    Albert Schweitzer Ziekenhuis

    Affiliation as printed

    Intensive Care, Albert Schweitzerziekenhuis, Dordrecht, The Netherlands

26. Sefanja Achterberg

    Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    ICU, Haaglanden Medisch Centrum, Den Haag, The Netherlands

27. Evelien A. N. Oostdijk

    Maasstad Ziekenhuis

    Affiliation as printed

    ICU, Maasstad Ziekenhuis Rotterdam, Rotterdam, The Netherlands

28. Auke C. Reidinga

    Martini Ziekenhuis

    Affiliation as printed

    ICU, SEH, BWC, Martiniziekenhuis, Groningen, The Netherlands

29. Barbara Festen‐Spanjer

    Ziekenhuis Gelderse Vallei

    Affiliation as printed

    Intensive Care, Ziekenhuis Gelderse Vallei, Ede, The Netherlands

30. Gert B. Brunnekreef

    Ziekenhuis Groep Twente

    Affiliation as printed

    Department of Intensive Care, Ziekenhuisgroep Twente, Almelo, The Netherlands

31. Alexander Daniel Cornet

    Medisch Spectrum Twente

    Affiliation as printed

    Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands

32. Walter van den Tempel

    Ikazia Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Ikazia Ziekenhuis Rotterdam, Rotterdam, The Netherlands

33. Age D. Boelens

    Antonius Ziekenhuis

    Affiliation as printed

    Antonius Ziekenhuis Sneek, Sneek, The Netherlands

34. Judith Lens

    IJsselland Ziekenhuis

    Affiliation as printed

    ICU, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands

35. Harald J. Faber
    Affiliation as printed

    ICU, WZA, Assen, The Netherlands

36. A. Karakus

    Diakonessenhuis hospital

    Affiliation as printed

    Department of Intensive Care, Diakonessenhuis Hospital, Utrecht, The Netherlands

37. Robert Entjes

    Admiraal De Ruyter Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Adrz, Goes, The Netherlands

38. Thijs C. D. Rettig

    Amphia Ziekenhuis

    Affiliation as printed

    Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Ziekenhuis, Breda, The Netherlands

39. M. Sesmu Arbous Aachen Department of Intensive Care

    Leiden University Medical Center

    Affiliation as printed

    Department of Intensive Care, LUMC, Leiden, The Netherlands

40. Sebastiaan J. J. Vonk
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

41. Mattia Fornasa
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

42. Tomas Machado
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

43. Taco Houwert
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

44. Hidde Hovenkamp
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

45. Roberto Noorduijn Londono
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

46. Davide Quintarelli
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

47. Martijn G. Scholtemeijer
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

48. Aletta A. de Beer
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

49. Giovanni Cinà
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

50. Adam Kantorik
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

51. Tom de Ruijter
    Affiliation as printed

    BigData Republic, Nieuwegein, The Netherlands

52. Willem Ernst Herter
    Affiliation as printed

    , Pacmed, Amsterdam, The Netherlands

    Pacmed, Amsterdam, The Netherlands

53. Martijn Beudel

    Amsterdam University Medical Centers · University of Amsterdam

    Affiliation as printed

    Department of Neurology, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands

54. Armand R. J. Girbes

    Amsterdam University Medical Centers · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands

55. Mark Hoogendoorn

    Vrije Universiteit Amsterdam

    Affiliation as printed

    Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands

56. Patrick J. Thoral

    Amsterdam University Medical Centers · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands

57. Paul Elbers

    Amsterdam University Medical Centers · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands

58. Julia Koeter

    Canisius-Wilhelmina Ziekenhuis · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    Intensive Care, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands

    Business Intelligence, Haaglanden MC, Den Haag, The Netherlands

59. Roger van Rietschote

    Amsterdam University Medical Centers · Stichting Haaglanden Medisch Centrum · University of Amsterdam

    Affiliation as printed

    Business Intelligence, Haaglanden MC, Den Haag, The Netherlands

    Department of Intensive Care Medicine, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands

60. Merijn Constantijn Reuland

    Amsterdam University Medical Centers · University of Amsterdam

    Affiliation as printed

    Department of Intensive Care Medicine, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands

    Department of Intensive Care, BovenIJ Ziekenhuis, Amsterdam, The Netherlands

61. Laura van Manen

    Catharina Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, BovenIJ Ziekenhuis, Amsterdam, The Netherlands

    Department of Anesthesiology, Pain Management and Intensive Care, Catharina Ziekenhuis Eindhoven, Eindhoven, The Netherlands

62. Leon J. Montenij

    Catharina Ziekenhuis · Erasmus MC

    Affiliation as printed

    Department of Anesthesiology, Pain Management and Intensive Care, Catharina Ziekenhuis Eindhoven, Eindhoven, The Netherlands

    Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands

63. Jasper van Bommel

    Erasmus MC · Elisabeth-TweeSteden Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands

    Department of Intensive Care, ETZ Tilburg, Tilburg, The Netherlands

64. Roy van den Berg

    Haga Hospital · Elisabeth-TweeSteden Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, ETZ Tilburg, Tilburg, The Netherlands

    Department of ICMT, Haga Ziekenhuis, Den Haag, The Netherlands

65. Ellen van Geest

    Haga Hospital · Laurentius Ziekenhuis

    Affiliation as printed

    Department of ICMT, Haga Ziekenhuis, Den Haag, The Netherlands

    Intensive Care, Laurentius Ziekenhuis, Roermond, The Netherlands

66. Anisa Hana

    OLVG · Laurentius Ziekenhuis

    Affiliation as printed

    Intensive Care, Laurentius Ziekenhuis, Roermond, The Netherlands

    ICU, OLVG, Amsterdam, The Netherlands

67. Bas van den Bogaard

    Radboud University Medical Center · OLVG

    Affiliation as printed

    ICU, OLVG, Amsterdam, The Netherlands

    Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands

68. Peter Pickkers

    Radboud University Medical Center · Reinier de Graaf Hospital

    Affiliation as printed

    Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands

    Intensive Care, Reinier de Graaf Gasthuis, Delft, The Netherlands

69. Pim van der Heiden

    Reinier de Graaf Hospital · Spaarne Ziekenhuis · Spaarne Gasthuis

    Affiliation as printed

    Intensive Care, Reinier de Graaf Gasthuis, Delft, The Netherlands

    Intensive Care, Spaarne Gasthuis, Haarlem en Hoofddorp, The Netherlands

70. Claudia van Gemeren

    Spaarne Ziekenhuis · St. Antonius Ziekenhuis · Spaarne Gasthuis

    Affiliation as printed

    Intensive Care, Spaarne Gasthuis, Haarlem en Hoofddorp, The Netherlands

    Department of Internal Medicine and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands

71. Arend Jan Meinders

    Sint Franciscus Gasthuis · St. Antonius Ziekenhuis · Franciscus Vlietland

    Affiliation as printed

    Department of Internal Medicine and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands

    Department of Intensive Care, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands

72. Martha de Bruin

    University Medical Center Utrecht · Sint Franciscus Gasthuis · Franciscus Vlietland

    Affiliation as printed

    Department of Intensive Care, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands

    Department of Intensive Care, UMC Utrecht, Utrecht, The Netherlands

73. Emma Rademaker

    University Medical Center Utrecht · VieCuri Medisch Centrum

    Affiliation as printed

    Department of Intensive Care, UMC Utrecht, Utrecht, The Netherlands

    Department of Clinical Epidemiology, VieCuri Medisch Centrum, Venlo, The Netherlands

74. Frits van Osch

    VieCuri Medisch Centrum · Zuyderland Medisch Centrum

    Affiliation as printed

    Department of Clinical Epidemiology, VieCuri Medisch Centrum, Venlo, The Netherlands

    Department of Pulmonology, Zuyderland MC, Heerlen, The Netherlands

75. Martijn D. de Kruif

    Albert Schweitzer Ziekenhuis · Zuyderland Medisch Centrum

    Affiliation as printed

    Department of Pulmonology, Zuyderland MC, Heerlen, The Netherlands

    Intensive Care, Albert Schweitzerziekenhuis, Dordrecht, The Netherlands

76. Nicolas F. Schroten

    Albert Schweitzer Ziekenhuis · Antonius Ziekenhuis

    Affiliation as printed

    Intensive Care, Albert Schweitzerziekenhuis, Dordrecht, The Netherlands

    Antonius Ziekenhuis Sneek, Sneek, The Netherlands

77. Klaas Sierk Arnold

    Diakonessenhuis hospital · Antonius Ziekenhuis

    Affiliation as printed

    Antonius Ziekenhuis Sneek, Sneek, The Netherlands

    Department of Intensive Care, Diakonessenhuis Hospital, Utrecht, The Netherlands

78. Jan Willem Fijen

    Diakonessenhuis hospital · IJsselland Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Diakonessenhuis Hospital, Utrecht, The Netherlands

    ICU, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands

79. Jacomar J. M. van Koesveld

    IJsselland Ziekenhuis · Jeroen Bosch Ziekenhuis

    Affiliation as printed

    ICU, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands

    Department of Intensive Care, Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands

80. Koen S. Simons

    Maasstad Ziekenhuis · Jeroen Bosch Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands

    ICU, Maasstad Ziekenhuis, Rotterdam, The Netherlands

81. Joost A. M. Labout

    Maasstad Ziekenhuis · Martini Ziekenhuis

    Affiliation as printed

    ICU, Maasstad Ziekenhuis, Rotterdam, The Netherlands

    Martiniziekenhuis, Groningen, The Netherlands

82. Bart van de Gaauw

    Medisch Centrum Leeuwarden · Martini Ziekenhuis

    Affiliation as printed

    Martiniziekenhuis, Groningen, The Netherlands

    Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands

83. Michael A. Kuiper

    Medisch Spectrum Twente · Medisch Centrum Leeuwarden

    Affiliation as printed

    Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands

    Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands

84. Albertus Beishuizen

    Medisch Spectrum Twente · Slingeland Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands

    Department of Information Technology, Slingeland Ziekenhuis, Doetinchem, The Netherlands

85. Dennis Geutjes

    Slingeland Ziekenhuis

    Affiliation as printed

    Department of Information Technology, Slingeland Ziekenhuis, Doetinchem, The Netherlands

    ICU, WZA, Assen, The Netherlands

86. Johan Lutisan

    Ziekenhuis Groep Twente

    Affiliation as printed

    ICU, WZA, Assen, The Netherlands

    Department of Intensive Care, Ziekenhuisgroep Twente, Almelo, The Netherlands

87. Bart P. X. Grady

    Ziekenhuis Groep Twente · Admiraal De Ruyter Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Ziekenhuisgroep Twente, Almelo, The Netherlands

    Intensive Care, Adrz, Goes, The Netherlands

88. Remko van den Akker

    Amphia Ziekenhuis · Admiraal De Ruyter Ziekenhuis

    Affiliation as printed

    Intensive Care, Adrz, Goes, The Netherlands

    Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Ziekenhuis, Breda, The Netherlands

89. Tom A. Rijpstra

    Noordwest Ziekenhuisgroep · Amphia Ziekenhuis

    Affiliation as printed

    Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Ziekenhuis, Breda, The Netherlands

    Department of Pulmonology, Northwest Clinics, Alkmaar, The Netherlands

90. Wim G. Boersma

    Noordwest Ziekenhuisgroep

    Affiliation as printed

    Department of Pulmonology, Northwest Clinics, Alkmaar, The Netherlands

    Department of Intensive Care Medicine, Hospital St Jansdal, Harderwijk, The Netherlands

91. Daniël Pretorius

    Streekziekenhuis Koningin Beatrix

    Affiliation as printed

    Department of Intensive Care Medicine, Hospital St Jansdal, Harderwijk, The Netherlands

    Department of Intensive Care, Streekziekenhuis Koningin Beatrix, Winterswijk, The Netherlands

92. Menno Beukema

    Streekziekenhuis Koningin Beatrix · Bravis Ziekenhuis

    Affiliation as printed

    Department of Intensive Care, Streekziekenhuis Koningin Beatrix, Winterswijk, The Netherlands

    Intensive Care, Bravis Ziekenhuis, Bergen Op Zoom en Roosendaal, The Netherlands

93. Bram Simons

    Flevoziekenhuis · Bravis Ziekenhuis

    Affiliation as printed

    Intensive Care, Bravis Ziekenhuis, Bergen Op Zoom en Roosendaal, The Netherlands

    ICU, Flevoziekenhuis, Almere, The Netherlands

94. A. A. Rijkeboer

    Maastricht University Medical Centre · Maastricht University · Flevoziekenhuis

    Affiliation as printed

    ICU, Flevoziekenhuis, Almere, The Netherlands

    MUMC+, University Maastricht, Maastricht, The Netherlands

95. Marcel J H Ariës

    Maastricht University Medical Centre · Maastricht University · Treant Zorggroep

    Affiliation as printed

    MUMC+, University Maastricht, Maastricht, The Netherlands

    Intensive Care, Treant Zorggroep, Emmen, The Netherlands

96. Niels C. Gritters van den Oever

    Treant Zorggroep · Tjongerschans

    Affiliation as printed

    Intensive Care, Treant Zorggroep, Emmen, The Netherlands

    Department of Intensive Care Medicine, Afdeling Intensive Care, Ziekenhuis Tjongerschans, Heerenveen, The Netherlands

97. Martijn van Tellingen

    Ziekenhuis Bethesda · Tjongerschans

    Affiliation as printed

    Department of Intensive Care Medicine, Afdeling Intensive Care, Ziekenhuis Tjongerschans, Heerenveen, The Netherlands

    Department of Intensive Care Medicine, Het Van Weel-Bethesda Ziekenhuis, Dirksland, The Netherlands