Journal of Clinical Anesthesia (2009) 21, 585–594

Original contribution

Adverse events associated with intravenous regional

anesthesia (Bier block): a systematic review
of complications
Joanne Guay MD, FRCPC (Clinical Associate Professor)⁎
Department of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada H1T 2M4

Received 7 June 2008; revised 2 January 2009; accepted 20 January 2009

Keywords:
Abstract
Bier block;
Study Objective: To characterize the complications reported with intravenous regional anesthesia
Intravenous regional
(IVRA).
anesthesia;
Design: Literature search.
Regional anesthesia;
Setting: University-affiliated hospital.
Complications
Measurements: A search was done in the American National Library of Medicine's PUBMED,
EMBASE (1980-2007, wk 11), and Medline (from 1950) in March 2007. All complications associated
with IVRA were reviewed.
Main Results: The lowest dose of local anesthetic associated with a seizure was 1.4 mg/kg for lidocaine;
4 mg/kg for prilocaine, and 1.3 mg/kg for bupivacaine. Cardiac arrests and deaths were reported with
lidocaine and bupivacaine only. The lowest dose associated with a cardiac arrest was 2.5 mg/kg for
lidocaine and 1.6 mg/kg for bupivacaine. Local anesthetic toxicity occurring during tourniquet inflation
has been reported, with tourniquet pressure exceeding initial systolic arterial blood pressure by
150 mmHg. Seizures occurring after tourniquet deflation have been reported with a tourniquet time as
long as 60 minutes. Ten cases of compartment syndrome are reported.
Conclusion: Seizures have been reported with lidocaine at its lowest effective dose (1.5 mg/kg).
© 2009 Elsevier Inc. All rights reserved.

1. Introduction be cost-effective compared with general anesthesia and

Intravenous regional anesthesia (IVRA; Bier block)
remains a popular anesthetic technique amongst both
anesthesiologists and non-anesthesiologists for various
types of hand and forearm surgeries [1,2]. It is claimed to
Presented at the “XXVIII ESRA Annual Congress" Salzburg, Austria,
September 9-12, 2009.
⁎ Tel.: +1 514 252 3426; fax: +1 514 252 3542.
E-mail address: joanne.guay@umontreal.ca.
brachial plexus blocks for short ambulatory hand surgery
[3]. It also might allow for better fracture reduction than
hematoma block in forearm fractures (reduced risk of later
redislocation or need for rereduction) [2]. Since its introduc-
tion in 1908 by August Bier [4], IVRA has been associated
with serious complications and death [5]. When injuries
related to regional anesthesia were reviewed as part of the
ASA Closed Claims Project for the years 1980 to 1999, three
cases of death or brain damage associated with IVRA were
found [6]. The purpose of this review was to compile and
characterize the complications reported with IVRA.

0952-8180/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2009.01.015
586
2. Materials and methods
Cases were found from a literature search with the
following keywords: “Bier block”, “intravenous regional
anesthesia”, and “complications” in the American National
Library of Medicine's PUBMED, in EMBASE (1980-2007,
wk 11), and in Medline (from 1950) in March 2007. The
reference lists of all articles retrieved were also checked.
Only studies published in English were included in the study.
For central nervous system complications, only cases with
seizure and/or loss of consciousness or unusual reactions
were retained (cases of pre-seizure status or muscle twitching
without loss of consciousness were not included). For
hemodynamic complications, only those requiring an
intervention other than tourniquet reinflation or those
considered potentially life-threatening were included. Du-
plication of cases was avoided by checking the name of the
authors as well as location and date of occurrence of the
event. If patient weight information was unavailable, for
children (b 18 yrs), the average weight for age (according to
charts or formulae appropriate for the age group) was
applied. For adults (≥ 18 yrs), the mean weight of the
subgroup (women or men) was used.
3. Results
Partial or complete details were available for 64 cases
reported between 1964 and 2005: 40 adults (women = 19;
men = 17; unspecified = 4), 9 children, and 15 unspecified.
3.1. Major complications related to systemic local
anesthetic toxicity
Local anesthetic toxicity was the main problem for 39
patients (children = 8, adults = 24, unspecified = 7). Six
patients had an “unusual” reaction. Three patients either
talked excitably or incomprehensibly, or had unusual
behavior [7-9]. These patients were considered preictal.
One patient had a curare-like reaction (ptosis and partial loss
of muscle power) [9]. One patient had acute aphasia (loss of
speech) that lasted for 20 hours [10]. One patient had
temporary bilateral blindness [11] (Table 1).
Twenty-four seizures were reported (one listed in the
unusual reactions, two in the cardiac arrests, and one in the
deaths (Table 1) [9,11-26]. The seizures occurred while the
tourniquet was still inflated (n = 12; single cuff tourniquet =
5, double = 6, unspecified = one) or after tourniquet release
(n = 9; information not available = 3) which led to 7
respiratory arrests or respiratory compromise (requiring
positive pressure ventilation with or without tracheal
intubation) [12,20,22,24-26]. The lowest dose of local
anesthetic associated with a seizure was 1.4 mg/kg for
lidocaine, 4 mg/kg for prilocaine, and 1.3 mg/kg for
J. Guay
bupivacaine. Seizures occurring during tourniquet inflation
were reported with tourniquet pressure exceeding the initial
systolic arterial blood pressure (SBP) by 150 mmHg.
Seizures occurring after tourniquet deflation were reported
with tourniquet time as long as 60 minutes and with a delay
of up to 10 minutes after tourniquet deflation (Table 1).
Cardiac arrests and deaths were reported in 13 patients and
only with lidocaine and bupivacaine [24-31]. The lowest dose
associated with a cardiac arrest was 2.5 mg/kg for lidocaine
and 1.6 mg/kg for bupivacaine. The longest tourniquet time
associated with a lidocaine cardiac arrest occurring after
tourniquet release was 30 minutes (Table 1).
3.2. Major complications not related to systemic
local anesthetic toxicity
Two patients had nerve damage [32,33]. Ten patients
with compartment syndrome were reported. Inadvertent use
of hypertonic saline either used for dilution of the local
anesthetic or as a chaser (fluid injected after the local
anesthetic) was implicated in 5 of those cases [34-40]
(Table 2).
3.3. Minor complications
Five women had hand and/or forearm and/or arm
discoloration or widespread petechiae with IVRA (lido-
caine = one, bupivacaine = one, prilocaine = three; volume 5
to 40 mL) [41-44]. Three of the women were hypertensive.
The reaction was observed either during injection or
immediately after the surgery. Injection was said to be
painful in three patients. The arm recovered its normal color
within 8 days in one patient and the fate of the others is
unknown [41].
Eight patients had thrombophlebitis: 5 with chloropro-
caine (0.25 or 0.5%) (4 of which were not preservative-free)
and three with lidocaine containing chlor-cresol as a
preservative. The thrombophlebitis were located either at
the site of injection or close to the surgical site and were first
noted up to 6 days after the surgery [45-47].
4. Discussion
In a large prospective study of the complications of
regional anesthesia in France, the incidence of major
complications related to IVRA compared relatively well
with the one found for peripheral nerve blocks [48]. In this
study, the three seizures occurred after deflation of the
tourniquet. In each of these patients, tourniquet inflation after
injection of 30-45 mL of lidocaine 0.5%, exceeded
40 minutes. The present review shows that major complica-
tions related to local anesthetic toxicity may occur during
tourniquet inflation or after tourniquet deflation (Table 1).
Single cuff tourniquet, high tourniquet pressure (300 mmHg
 Bier block and complications
Table 1 Major complications related to local anesthetic toxicity reported with intravenous regional anesthesia
Age Gender Surgical Local Dose Comments Complications Duration of Outcome Reference
(yrs) limb anesthetic (mg/kg) complication
Unusual central nervous system changes
56 M Upper 0.75% Lidocaine 2.2 After tourniquet deflation. Tourniquet
Light-headedness and aphasia 20 hrs Normal [10]
time 20 min. Normal CT-scan. (loss of speech).
21 F Upper 2% Lidocaine 12 Within seconds after deflation. Tachycardia at 140 bpm, visual 15 min Normal [11]
Tourniquet time 45 min. Misreading changes (patient saw only red),
of the vial label. Inadvertent cuff loss of consciousness, seizure
deflation by operating room staff. for 30 sec, patient saw only white
before her eyes.
74 F Upper 1% Prilocaine 5 During tourniquet inflation, double Drowsy, light-headed, 5 min Normal [8]
cuffs at 250 mmHg (SBP 135 mmHg). incomprehensible speech and
Both cuffs inflated, a leak found in ventricular tachycardia at
the proximal cuff. Volume 0.5 mL/kg. 150 bpm.
15 M Upper 0.25% Bupivacaine 1.5 45 sec after tourniquet deflation. Irrational and excited talk N 45 min Normal [7]
Tourniquet time 40 min. accompanied by limb twitching.
N19 Upper 0.5% Bupivacaine (total dose 10 min after tourniquet deflation in Unusual behavior. [9]
b65 a 200 mg) one step. Tourniquet time 20 min.
Bupivacaine concentrations 8.3 and
4.1 μg/mL immediately and at 5 min
after deflation.
N19 Upper 0.5% Bupivacaine (total dose 10 min after tourniquet deflation in Curare-like reaction with ptosis 30 min Normal [9]
b65 a 200 mg) one step. Tourniquet time 20 min. and partial loss of muscle power.
Seizures
36 F Upper 0.5% Lidocaine 1.4 During tourniquet inflation, double Seizures Normal [12]
cuff (one inflated), injection into an
antecubital vein. Volume 0.3 mL/kg.
47 M Upper 1.5% Lidocaine 2.1 10 min after tourniquet deflation. Complex partial seizures Two hrs Normal [13]
Tourniquet time 60 min. On
nortriptyline therapy. The block
included 30 μg of clonidine.
Normal CT-scan.
7 F Upper Lidocaine 4.6 After tourniquet deflation. Seizures [14]
N18 M Upper 0.5% Lidocaine 6.3 Volume 1.3 mL/kg. Seizure [15]
b60
N18 M Upper 0.5 % Lidocaine 7.1 During tourniquet inflation. Single Seizure [15]
b60 cuff. Volume 1.4 mL/kg.
N18 M Upper 1% Lidocaine 7.3 During tourniquet inflation. Single Seizure Normal [15]
b60 cuff. Volume 0.7 mL/kg.
N18 M Upper 1% Lidocaine 7.6 10 minutes after tourniquet deflation. Seizure Normal [15]
b60
21 M Upper Lidocaine 11.4 Seizures [14]

587
(continued on next page)
 588
Table 1 (continued)
Age Gender Surgical Local Dose Comments Complications Duration of Outcome Reference
(yrs) limb anesthetic (mg/kg) complication
8 F Upper 0.25% Bupivacaine 1.3 During tourniquet inflation, single Seizures b 20 min Normal [16]
cuff at 180 mmHg, (SBP 120 mmHg),
distal injection. Volume 0.5 mL/kg.
56 F Upper 0.25% Bupivacaine 1.3 During tourniquet inflation, double Seizures Normal [16]
cuff at 300 mmHg (SBP 150 mmHg),
distal injection. Volume 0.7 mL/kg.
72 F Upper 0.25% Bupivacaine 1.4 During tourniquet inflation, double Seizure, hypertension. b 30 min Normal [17]
cuff, one cuff inflated at 250 mmHg
(SBP 140 mmHg), distal injection.
Volume 0.6 mL/kg.
a
Upper Bupivacaine (65 mg During tourniquet inflation of a single Seizure Normal [18]
total dose) cuff tourniquet at 250 mmHg on the
dial but with occlusion between the
cuff and the tube end.
N19 Upper 0.5% Bupivacaine (total dose 10 min after tourniquet deflation in Seizure [9]
b65 a 200 mg) one step. Tourniquet time 20 min.
Bupivacaine concentrations 7.1 and
3.2 μg/mL immediately and at 5 min
after deflation.
18 F Upper Bupivacaine During tourniquet inflation, injection Seizure [19]
in the median cubital vein.
13 M Lower 0.75% Lidocaine 20 One min after tourniquet deflation, Sleepiness, seizure, 50 min Normal [12]
tourniquet time 47 min post-injection. hypertension, coma.
47 M Lower Prilocaine 4 8 min after tourniquet deflation, Seizures, ventricular arrhythmias. 17 min Normal [20]
tourniquet time 50 min. Irritative
zone at site of old fracture on EEG.
16 M Lower 0.25% Bupivacaine 3 During tourniquet inflation of a Seizures and hypotension b5 min Normal [21]
double tourniquet (one cuff
inflated) on the thigh at
400 mmHg, distal
injection. Volume 1.2 mL/kg.
59 M Lower After tourniquet deflation, incision Seizure, loss of consciousness, 30 min Normal [22]
three min after injection and three respiratory arrest.
min operation time, one step release.
18 M Lidocaine 4.3 Seizure [14]
6 F 2% Lidocaine 8 After tourniquet deflation. Seizures and loss of consciousness. [23]
Cardiac arrest
41 M Upper 0.5% Lidocaine 2.5 68 sec after tourniquet deflation. Sinus bradycardia, asystole, One min Normal [27]
Tourniquet time 30 min. respiratory arrest, 23 sec CPR.

J. Guay
26 M Upper 0.5 % Lidocaine 2.8 Two min after tourniquet deflation. Sino-atrial block with cardiac arrest. Three sec Normal [28]
Tourniquet time 30 min.
 Bier block and complications
67 F Upper 0.25% Bupivacaine 1.6 During tourniquet inflation, single Severe headache, seizures, apnea, 30 min Normal [24]
cuff at 220 mmHg (SBP 160 mmHg), cardiac arrest for 0.5 min.
distal injection. Volume 0.6 mL/kg.
71 M Upper 0.25% Bupivacaine 1.7 During tourniquet inflation, double Bradycardia, loss of consciousness, 30 min Normal [25]
tourniquet at 300 mmHg (one cuff seizures, blood pressure not
7.5 cm wide inflated, (SBP 160 measurable, 15 min CPR, followed
mmHg), distal injection over 30 sec. by dopamine and
Volume 0.7 mL/kg. Chronic atrial nitroprusside infusions.
fibrillation treated with digoxin and
pindolol. Arterial bupivacaine
1.8 μg/mL at 10 min.
a
0.5% Bupivacaine+2% (Total doses of Sudden tourniquet deflation. [29]
Chloroprocaine 125 and 300 mg,
respectively).
Death
58 F Lower 1% Lidocaine 6.3 During tourniquet inflation. Two Seizures, pulseless and apneic, flat Death [26]
tourniquets on the calf at ECG alternating with ventricular
approximately 200 mU/mL, injection tachycardia. Prolonged unsuccessful
into the saphenous vein over a 4 min resuscitation.
period. Volume 0.6 mL/kg. Diabetic,
prior myocardial infarction, on
digoxin therapy.
11 M Bupivacaine Healthy, treated for a minor condition Death [30]
in an accident and emergency
department.
11 M Bupivacaine Healthy, treated for a minor condition Death [30]
in an accident and emergency
department.
Bupivacaine Healthy, treated for a minor condition Death [30]
in an accident and emergency
department.
Bupivacaine Healthy, treated for a minor condition Death [30]
in an accident and emergency
department.
Bupivacaine Healthy, treated for a minor condition Death [30]
in an accident and emergency
department.
Bupivacaine Death [31]
Bupivacaine Death [31]
SBP = systolic blood pressure; EEG = electroencephalography; CPR = cardopulmonary resuscitation; ECG = electrocardiography.
a
For these patients, weight was not available and could not be estimated (gender unspecified). The dose is then provided as an absolute dose instead of as a mg/kg dose.

589
 590
Table 2 Major complications not related to local anesthetic toxicity that were reported with intravenous anesthesia
Age Gender Surgical Local Dose Comments Complications Duration of Outcome Reference
(yrs) limb anesthetic (mg/kg) complication
Neurologic deficit
16 F Upper 0.5 % Lidocaine 3.1 Double tourniquet at Damage to radial, ulnar, Resolution of the Permanent slight [32]
250 mmHg (SBP 140 mmHg). median, and musculocutaneous sensory deficit at weakness of
Total tourniquet time 50 min. nerves localized at the upper one mo. the wrist.
arm, confirmed by EMG.
Sensory and motor deficit.
Upper 0.5% Prilocaine (total dose Tourniquet at least 100 mmHg Sensory radial nerve palsy. 6 hrs Normal [33]
200 mg) above SBP for 22 min.
Compartment syndrome
54 F Upper 0.5% Lidocaine 3.1 Inadvertent dilution with Severe swelling with skin Persistent median [34]
hypertonic saline of 1% bleb formation. Increase of nerve neuritis.
solution. Total tourniquet time preexisting carpal tunnel
85 min. Volume 0.6 mL/kg. syndrome. Carpal tunnel
release three mos later.
22 F Upper 0.5% Lidocaine 3.1 Inadvertent dilution with Moderate swelling. Normal [34]
hypertonic saline of 1%
solution. Total tourniquet
time 67 min. Volume
0.6 mL/kg.
37 F Upper Lidocaine Inadvertent dilution with Arm and forearm swelling 10 mos Stiffness and grip [34]
hypertonic saline. Total with bleb formation distal to strength 50% of her
tourniquet time 25 min. tourniquet with severe dominant hand.
Colles fracture. paresthesias. Required three
subsequent surgeries, including
early fasciotomy.
25 M Upper 0.5% Lidocaine 3.2 Inadvertent dilution with Forearm and hand swelling 5 mos Thumb adduction [35]
hypertonic saline 24%. with loss of sensory and contracture.
Volume 0.6 mL/kg motor function. Superficial
vein thrombosis. Fever,
leukocytosis, confusion, CK
elevation up to 1,144 mu/mL
during first week. Five

J. Guay
surgeries were required
including two fasciotomies.
 Bier block and complications
26 M Upper 0.5% Lidocaine 2.9 Inadvertent use of 20 mL Marked swelling distal to Slight residual [36]
hypertonic (23.4%) saline as a tourniquet plus motor deficit. weakness of wrist
chaser. Tourniquet at Early fasciotomy required. and hand at two
270 mmHg for 40 min. mos. Lost at follow
Volume 0.6 mL/kg. up.
Bennett's fracture.
57 M Upper Lidocaine 4.1 Multiple tourniquets (arm and Swelling of forearm Almost full [37]
forearm) at 260 mmHg for musculature with pallor and recovery.
107 min. No underlying sensory and motor deficit. CK
muscle abnormality at elevation up to 52,200 u//L.
muscle biopsy. Four surgeries required,
including early fasciotomy.
73 F Upper 0.5% Lidocaine 2.7 Multiple tourniquets (arm and Swelling of forearm to Normal [37]
forearm) at 250 mmHg for elbow with firm muscle. CK
64 min. Volume 0.5 mL/kg. elevation up to 2,020 u/L. Two
surgeries required, including
early fasciotomy.
25 F Upper Mepivacaine 3.1 Total tourniquet time 25 min. Swelling with sensory and Below elbow [38]
motor loss. Weak ulnar and amputation at day 8
absent radial pulse. Extensive
cutaneous vein thrombosis.
Fasciotomy and streptokinase
therapy leading to hemorrhage
and transfusion.
32 M Upper 0.5% Prilocaine 2.8 Double tourniquet at Swollen forearm with sensory Two wks Normal [39]
200 mmHg. Volume and motor loss. Loss of ulnar
0.6 mL/kg. Colles’ fracture. pulse. Fasciotomy required.
Forearm hematoma at
fracture site.
Lower 0.3% Lidocaine 3.3 Double tourniquet at Weakness of extensor hallucis Satisfactory [40]
500 mmHg at proximal thigh. longus requiring tendon
Volume 1.1 mL/kg. transfer at 6 mos.
SBP = systolic blood pressure; EMG = electromyography; CK = creatine kinase.

591
592
for an upper limb and 400 mmHg for a lower limb),
tourniquet pressure exceeding initial SBP by150 mmHg or
distal injection site cannot guarantee the absence of systemic
local anesthetic toxicity with an inflated tourniquet (Table 1).
Arterial blood pressure tends to rise during ischemia in
almost every subject (up to 46 mmHg above initial SBP),
thus seriously challenging the initial tourniquet-arterial
pressure gradient [17,25]. Accidental tourniquet deflation
or improper tourniquet inflation (device failure or human
error) is always possible (Table 1). A tourniquet time of
30 minutes does not always prevent systemic local anesthetic
toxicity after tourniquet deflation (Table 1).
In order to avoid any risk of local anesthetic toxicity
despite the possibility of a human error, the local
anesthetic dose injected has to be kept below its lower
limit of serious toxicity. Mid-forearm tourniquets and half
lidocaine doses (1.5 mg/kg) offer incomplete solutions.
The former does not cover all forearm surgeries and the
latter leads to poor results with completely displaced
fractures [49]. Three local anesthetics seem less toxic than
the others when accidentally injected intravascularly:
articaine, prilocaine, and chloroprocaine. The literature
contains no reports of seizure, cardiac arrest, or death for
articaine; no cardiac arrest or death for prilocaine (if
methemoglobinemia formation is avoided); and no death
for chloroprocaine. Because articaine is used almost
exclusively in dentistry, there may not be enough data
on large-dose administration to confirm or refute its safety
for IVRA. Extensive use of prilocaine 2.5 mg/kg is
reported for IVRA, and this dose is below the lowest dose
associated with seizures (4 mg/kg) [50]. If prilocaine is
avoided in children younger than 6 months of age, in
pregnant women, and in patients taking other oxidative
drugs, symptomatic methemoglobinemia seems unlikely
with a dose of 2.5 mg/kg [51]. There is only one case of
cardiac arrest following accidental intravascular injection
of chloroprocaine. A two month-old girl received up to 30
mg/kg of chloroprocaine (10 times the minimal dose
needed to perform IVRA) during an intended epidural
anesthesia (demonstrated by contrast dye injection the day
after) and suffered only a 30-second long wide QRS
complex bradycardia [52,53]. This case suggests that
chloroprocaine is safe for IVRA in normal patients.
Chloroprocaine is not recommended in patients with
deficient plasma cholinesterase activity [54].
Systemic local anesthetic toxicity may occur up to
30 minutes after tourniquet release [55]. Cyclic deflation in
order to decrease the incidence of systemic local anesthetic
toxicity was first proposed by Professor Bier himself [56].
The efficacy of this technique to decrease the maximal
arterial concentration and/or the incidence of symptomatic
patients is a controversial issue [57]. Maximal arterial
concentrations may occur as early as 30 seconds after
tourniquet deflation [58,59]. Cyclic deflation may delay the
occurrence of the maximal arterial concentration but does not
significantly affect its value [57]. If this technique is used, a
J. Guay
deflation time of 10 seconds followed by a reinflation time of
one minute has been proposed to decrease the risk of venous
limb congestion [57].
Other major complications reported with IVRA are nerve
injuries and compartment syndromes. Younger age, higher
tourniquet pressures (higher than 400 mmHg) and longer
tourniquet times (odds ratio = 2.8 per 30 min increase over
120 min) are all factors increasing the likelihood of a
tourniquet-induced neurological injury [60,61]. Reperfusion
intervals only modestly decrease the risk of nerve injury [60].
Therefore, a “continuous intravenous regional anesthesia”
cannot be recommended [62]. In the present review, 10 cases
of compartment syndrome were found. A medication error
(inadvertent use of hypertonic saline) was clearly identified
in 5 of the cases (Table 2). For two others, the use of multiple
tourniquets (arm and forearm in sequence) may have caused
extensive underlying myonecrosis. For one patient, possible
excessive tourniquet pressure (500 mmHg) cannot be
excluded. For another, significant hematoma formation at
the site of the bone fracture was found at the fasciotomy.
Because compartment syndrome is a known complication of
Colles' fractures, the exact contribution of the Bier block in
this specific case is difficult to determine [63]. For the last
case, although the picture is similar to the one reported for
inadvertent use of hypertonic saline— and a possible
medication error was suggested by the authors—, no clear
error was identified.
Intravenous regional anesthesia has also been associated
with minor complications such as widespread petechiae, skin
discoloration, thrombophlebitis, and urticaria. The incidence
of local reactions (from erythematous reaction to urticaria)
might be higher with articaine, chloroprocaine, and methyl-
paraben- containing solutions [47,64,65]. The incidence of
thrombophlebitis would, however, be increased only by the
addition of a preservative and not necessarily by the type of
local anesthetic used [45,66].
In conclusion, IVRA is associated with a low incidence of
complications and can therefore be considered a safe
anesthetic technique. Using a dose of local anesthetic less
than that known to induce a seizure or methemoglobinemia
might help in decreasing the occurrence of serious adverse
events associated with IVRA.
Acknowledgments
The author is grateful to the University of Montreal and
the Anesthesia Department of Maisonneuve-Rosemont
Hospital for granting access to the electronic data bases
and to all required references.
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