Review
Anaesthesia in craniosynostosis
Anestesia para craneosinostosis
Víctor Hugo González Cárdenasa,
, María Victoria Vanegas Martínezb, María Elvira Rojas Ruedac, Nelly Susana Guevarad, José Rolando Pradae, Pablo Baquerof
Corresponding author
a Physician and Surgeon – Anaesthetist – Clinical Epidemiologist, Hospital Infantil Universitario de San José (FUCS), FUCS Instructor, Research Coordinator, Anaesthesia Department and Leader in Anaesthesia Research – Deorum Opus Group, FUCS, Clinical Principal Professor – Universidad de la Sabana, Bogotá, Colombia
b Physician and Surgeon – Cardiovascular and Thoracic Anaesthetist – Specialist in Medical Education, Head of Medical Education, Coordinator of the Operative Unit and the Anaesthesiology Department at Hospital Infantil Universitario de San José, Associate Faculty, FUCS, Colombia
c Physician and Surgeon – Anaesthetist, Academic Coordinator of the Anaesthesia Department, Hospital Universitario de San José, Instructor, FUCS, Colombia
d Physician and Surgeon – Anaesthesia Resident, FUCS, Colombia
e Physician and Surgeon – Plastic Surgeon, Reconstructive Surgery Program for Craniofacial Abnormalities, Hospital Infantil Universitario de San José, Instructor FUCS, Colombia
f Physician and Surgeon – Neurosurgeon, Reconstructive Surgery Program for Craniofacial Abnormalities, Hospital Infantil Universitario de San José, Instructor FUCS, Colombia
Read
4865
Timeswas read the article
1271
Total PDF
3594
Total HTML
Share statistics
array:25 [ "pii" => "S2256208714000297" "issn" => "22562087" "doi" => "10.1016/j.rcae.2014.02.007" "estado" => "S300" "fechaPublicacion" => "2014-07-01" "aid" => "126" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "copyrightAnyo" => "2012" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "ssu" "cita" => "Rev Colomb Anestesiol. 2014;42:199-204" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2342 "formatos" => array:3 [ "EPUB" => 97 "HTML" => 1595 "PDF" => 650 ] ] "Traduccion" => array:1 [ "es" => array:20 [ "pii" => "S0120334714000288" "issn" => "01203347" "doi" => "10.1016/j.rca.2014.02.003" "estado" => "S300" "fechaPublicacion" => "2014-07-01" "aid" => "126" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/3.0/" "subdocumento" => "ssu" "cita" => "Rev Colomb Anestesiol. 2014;42:199-204" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7724 "formatos" => array:3 [ "EPUB" => 98 "HTML" => 6455 "PDF" => 1171 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Anestesia para craneosinostosis" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "199" "paginaFinal" => "204" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Anaesthesia in craniosynostosis" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Víctor Hugo González Cárdenas, María Victoria Vanegas Martínez, María Elvira Rojas Rueda, Nelly Susana Guevara, José Rolando Prada, Pablo Baquero" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Víctor Hugo" "apellidos" => "González Cárdenas" ] 1 => array:2 [ "nombre" => "María Victoria" "apellidos" => "Vanegas Martínez" ] 2 => array:2 [ "nombre" => "María Elvira" "apellidos" => "Rojas Rueda" ] 3 => array:2 [ "nombre" => "Nelly" "apellidos" => "Susana Guevara" ] 4 => array:2 [ "nombre" => "José Rolando" "apellidos" => "Prada" ] 5 => array:2 [ "nombre" => "Pablo" "apellidos" => "Baquero" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2256208714000297" "doi" => "10.1016/j.rcae.2014.02.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714000297?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0120334714000288?idApp=UINPBA00004N" "url" => "/01203347/0000004200000003/v2_201407240025/S0120334714000288/v2_201407240025/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S225620871400042X" "issn" => "22562087" "doi" => "10.1016/j.rcae.2014.04.004" "estado" => "S300" "fechaPublicacion" => "2014-07-01" "aid" => "131" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "ssu" "cita" => "Rev Colomb Anestesiol. 2014;42:205-13" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3789 "formatos" => array:3 [ "EPUB" => 90 "HTML" => 2930 "PDF" => 769 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Botulinum toxin for the treatment of chronic pain. Review of the evidence" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "205" "paginaFinal" => "213" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toxina botulínica para tratamiento del dolor crónico. Revisión de la evidencia" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2639 "Ancho" => 3162 "Tamanyo" => 418157 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Mechanism of action of botulinum toxin.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Roberto Carlo Rivera Día, Mario Andrés Arcila Lotero, María Victoria Avellaneda Suarez, Sara Echeverri Saldarriaga, Manuela Gómez Martínez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Roberto Carlo" "apellidos" => "Rivera Día" ] 1 => array:2 [ "nombre" => "Mario Andrés Arcila" "apellidos" => "Lotero" ] 2 => array:2 [ "nombre" => "María Victoria Avellaneda" "apellidos" => "Suarez" ] 3 => array:2 [ "nombre" => "Sara Echeverri" "apellidos" => "Saldarriaga" ] 4 => array:2 [ "nombre" => "Manuela Gómez" "apellidos" => "Martínez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0120334714000471" "doi" => "10.1016/j.rca.2014.03.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0120334714000471?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225620871400042X?idApp=UINPBA00004N" "url" => "/22562087/0000004200000003/v2_201407220045/S225620871400042X/v2_201407220045/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2256208714000273" "issn" => "22562087" "doi" => "10.1016/j.rcae.2014.02.005" "estado" => "S300" "fechaPublicacion" => "2014-07-01" "aid" => "123" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "ssu" "cita" => "Rev Colomb Anestesiol. 2014;42:192-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9718 "formatos" => array:3 [ "EPUB" => 102 "HTML" => 8857 "PDF" => 759 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Airway anatomy for the bronchoscopist: An anesthesia approach" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "192" "paginaFinal" => "198" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anatomía de la vía aérea para el broncoscopista. Una aproximación a la anestesia" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Developed by the authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1622 "Ancho" => 1562 "Tamanyo" => 112241 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Anatomical variation: tracheal bronchus. The right bronchus emerges superior to the bifurcation of the carina. Congenital anomaly present in 0.33% of the population.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Hans Fred García Araque, Oscar Valencia Orgaz, Ramón López Vicente, Sergio Esteban Gutiérrez Vidal" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Hans Fred" "apellidos" => "García Araque" ] 1 => array:2 [ "nombre" => "Oscar" "apellidos" => "Valencia Orgaz" ] 2 => array:2 [ "nombre" => "Ramón" "apellidos" => "López Vicente" ] 3 => array:2 [ "nombre" => "Sergio Esteban" "apellidos" => "Gutiérrez Vidal" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0120334714000252" "doi" => "10.1016/j.rca.2014.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0120334714000252?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714000273?idApp=UINPBA00004N" "url" => "/22562087/0000004200000003/v2_201407220045/S2256208714000273/v2_201407220045/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Anaesthesia in craniosynostosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "199" "paginaFinal" => "204" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Víctor Hugo González Cárdenas, María Victoria Vanegas Martínez, María Elvira Rojas Rueda, Nelly Susana Guevara, José Rolando Prada, Pablo Baquero" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Víctor Hugo" "apellidos" => "González Cárdenas" "email" => array:1 [ 0 => "vhgonzalez@fucsalud.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María Victoria" "apellidos" => "Vanegas Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "María Elvira" "apellidos" => "Rojas Rueda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Nelly Susana" "apellidos" => "Guevara" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "José Rolando" "apellidos" => "Prada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "Pablo" "apellidos" => "Baquero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Physician and Surgeon – Anaesthetist – Clinical Epidemiologist, Hospital Infantil Universitario de San José (FUCS), FUCS Instructor, Research Coordinator, Anaesthesia Department and Leader in Anaesthesia Research – Deorum Opus Group, FUCS, Clinical Principal Professor – Universidad de la Sabana, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Physician and Surgeon – Cardiovascular and Thoracic Anaesthetist – Specialist in Medical Education, Head of Medical Education, Coordinator of the Operative Unit and the Anaesthesiology Department at Hospital Infantil Universitario de San José, Associate Faculty, FUCS, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Physician and Surgeon – Anaesthetist, Academic Coordinator of the Anaesthesia Department, Hospital Universitario de San José, Instructor, FUCS, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Physician and Surgeon – Anaesthesia Resident, FUCS, Colombia" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Physician and Surgeon – Plastic Surgeon, Reconstructive Surgery Program for Craniofacial Abnormalities, Hospital Infantil Universitario de San José, Instructor FUCS, Colombia" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Physician and Surgeon – Neurosurgeon, Reconstructive Surgery Program for Craniofacial Abnormalities, Hospital Infantil Universitario de San José, Instructor FUCS, Colombia" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at</span>: Carrera 52, No. 67ª-71, Bogotá, Colombia." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anestesia para craneosinostosis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Craniosynostosis is known in the medical setting for its difficult treatment, usually requiring invasive procedures with a high impact on the patient's functional reserve and the economics of our healthcare system. In response to this situation, the surgical programme for craniofacial abnormalities at Hospital Infantil Universitario de San José was designed to give back to the child the expectation of functional performance and the ability to live in its social environment. The outcomes of the past years lead us to believe that this exercise might make the difference in terms of impact on quality of life when compared with treatments in other referral centres treating similar cases. This study describes the results for perioperative variables in patients intervened for craniosynostoses between January 1st 2008 and January 31st 2012 by the Anaesthesia Department at Hospital Infantil Universitario de San José, Bogota, Colombia.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This study was conducted with the approval of the Ethics and Research Committee of the Fundación Universitaria de Ciencias de la Salud (FUCS) Medical School, and required no informed consent because of its nature. Demographic, anaesthetic and critical data were described by gender. Means and standard deviations were estimated for continuous variables, and frequencies and percentages were estimated for nominal variables. Mean values for outcomes such as haemorrhage, transfusion, days on mechanical ventilation and length of stay in the ICU were compared, diverse variables were stratified and, finally, hypotheses for future work were postulated.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">p</span> value of <0.05 was used to designate statistically significant differences. A non-systematic review of the medical literature was conducted, and our data were discussed in relation with those found in the international literature. The STATA 10 statistical software package was used.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 41 patients were operated between January 1st 2008 and January 31st 2012. Three were excluded because of failure to meet the inclusion criteria, and no intra-operative anaesthesia data were obtained in three cases. The remaining 35 cases contributed 100% of the data (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The pre-anaesthesia airway assessment did not reveal a significant prevalence of difficult airway predictors. Only 17.6% of the patients in this cohort were classified as Cormack 3, 2.9% had difficult mouth opening, and only 5.2% were considered to have true difficult airways on intubation, despite the fact that 50% had a Mallampati score greater than, or equal to III (IV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8.3%).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Basic and invasive blood pressure monitoring was used in all cases, in 60% of the cases the lowest mean temperature was 35.09<span class="elsevierStyleHsp" style=""></span>°C (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.78), and central venous catheter monitoring and therapy were used in 94.7%.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The anaesthetics most commonly used for induction were sevoflurane (64.7%) and propofol (32.4%). Only in 71.4% was a specific analgesic used during the induction phase (remifentanil 88% of the time). Neuromuscular blockade was given in 91.2% of cases, with pancuronium and rocuronium being the most widely used (37.5% and 25%, respectively). For maintenance, the remifentanil/sevoflurane combination was chosen in 88.6% of cases, while sevoflurane was the inhaled drug most commonly used (94.3%).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Average blood loss during surgery was 35.6<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17.4), requiring transfusion of 27.9<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15.7) of PRBC in the operating room, and of 20.55<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12.21) of PRBC in the ICU. Moreover, an important difference was found in the volumes of other blood products transfused in the operating room and in the ICU (surgery 2.7% vs. ICU 36.8%, or 1 vs. 14 cases) (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). On arrival to the operating room, haemoglobin (Hb) was 13.27<span class="elsevierStyleHsp" style=""></span>g/dL (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.14), while on discharge Hb was 11.46<span class="elsevierStyleHsp" style=""></span>g/dL (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.04), with excess base (EB) of −8.55 (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.98) consistent with metabolic acidemia, despite the fact that the mean difference was only 1.69<span class="elsevierStyleHsp" style=""></span>g/dL between Hb on admission to the operating room and admission to the ICU.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Tranexamic acid was used in 44.7% of the cases, at a mean bolus dose of 14<span class="elsevierStyleHsp" style=""></span>mg/kg and a mean infusion dose of 1.1<span class="elsevierStyleHsp" style=""></span>mg/kg/h; only eight (8) patients received an additional bolus dose of desmopressin 0.36 mcg/kg. Of the 17 patients (44.7%) who received tranexamic acid, 41.2% received a single bolus, while 47.1% received a combined bolus and infusion dose.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Volemia was estimated in all patients according to age and weight as an indirect measurement of the effect of tranexamic acid, and blood loss goals of 25%, 33%, 40% and 50% were established. When describing bleeding volumes and comparing between those who received the drug and those who were not exposed, no significant differences were found between the patients who lost less than 40% and 50% of the estimated volemia ([9 vs. 4; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.105] for blood loss less than 40% and [9 vs. 9; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.746] for blood loss less than 50%). Also, no significant differences were found for blood losses less than 25% and 33% of the estimated blood volume.</p><p id="par0055" class="elsevierStylePara elsevierViewall">No reduction in blood loss was observed in the group receiving desmopressin. In contrast, the higher proportion of patients with bleeding below 50% of the estimated volemia were among those who were not exposed to the drug (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001). We do not describe differences for estimated losses less than 25%, 33% and 40% of the blood volume.</p><p id="par0060" class="elsevierStylePara elsevierViewall">When transfusion mean values were stratified at operating room with the use of tranexamic acid, averages varied from 24.48<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12.39) in patients exposed to 29.41<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14.49) in those who did not receive the drug, albeit with no significant differences (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.872). In the ICU, transfusion mean values showed marginal differences, not considered significant, for the use of PRBCs ([13.18<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6.99 vs. 26.07<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14.56] for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.058), but in no way does this mean that they should not be used and, on the contrary, it supports the decision of setting up experiments to evaluate this hypothesis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">When the effect of desmopressin was stratified, we did not find differences in PRBC transfusion averages in the operating room (29.17<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12.92 vs. 26.26, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13.85; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.949); but when PRBC transfusion volumes were stratified for the ICU, significant differences were found (15.82<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.01 vs. 22.81<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16.32; for a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.027), suggesting that desmopressin might reduce microvascular bleeding in the ICU and, consequently, the PRBC transfusion requirements, which we found not to be related to the transfusion of other blood products.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Of the patients, 13.5% required haemodynamic support in the operating room, with frequent use of norepinephrine (66.7%), while 42.1% received dopamine and/or norepinephrine (87.5%) during their stay in the ICU.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Operative time was 303.1<span class="elsevierStyleHsp" style=""></span>min (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>92) and was not associated with increased bleeding in the operating room or the ICU. Post-operative comorbidities occurred in 42.1% of patients, with disseminated intravascular coagulation (DIC) being the most frequent complication (35%), followed by post-extubation CROUP and acute renal failure (10.5%, each). The mean time on mechanical ventilation was 1.32 days (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.94). The mean length of stay in the ICU was 3.79 days (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.39) and none of the patients died during hospitalization.</p><p id="par0080" class="elsevierStylePara elsevierViewall">For this cohort, we did not observe a relationship between syndromic craniosynostosis and increased rates of bleeding, morbidity or mortality. In contrast, we describe a slight increase in the length of stay in the ICU (2.78, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.22 vs. 4.7, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.83; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.011) and the time on mechanical ventilation (0.39, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.03 vs. 2.15, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.21; with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004). When analysing the independent variables – number of sutures and complexity (advancement surgery vs. correction of several sutures and advancements) – no differences were found in terms of bleeding and/or transfusion outcomes, or in changes in surgical time.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The surgical procedures developed for correcting craniosynostosis are well known for the high volumes of blood loss and maximum risk of massive transfusions, as described by Koh and Soriano.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Patients are usually infants or school children, and have comorbidities associated with the use of drugs required for their adequate control and which impact the outcome of the surgical procedures.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In the world literature, difficult airways and haemorrhage control are cited as the main issues requiring anaesthesia intervention. In this study, although 17.6% of the patients were classified as Cormack 3 and 5.9% were considered to have a difficult airway, there were no complications at the time of intubation. We do not suggest the absence of a difficult airway in these patients; on the contrary, we would like to expand our protocols, which we hold with great respect at the Anaesthesiology Department, to include the potentially difficult airway in paediatric craniofacial dimorphism.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Intra-operative bleeding rates were consistent with the reports from other authors, but analysis of bleeding associated with different pro-coagulation strategies revealed some differences. For Goobie et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> (in an experiment using tranexamic acid in patients undergoing craniosynostosis correction), there was less haemorrhage in the tranexamic acid group (62<span class="elsevierStyleHsp" style=""></span>cc/kg, DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22) compared to placebo (101<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>63). In a similar study, Dadure et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> found the same bleeding rates for tranexamic acid (51.4<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28.3) compared with placebo (61.1<span class="elsevierStyleHsp" style=""></span>cc/kg, SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16.8); <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.25. However, they estimated an 85% reduction in intra-operative transfusion in the tranexamic acid group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02), related to a rigorous protocol with erythropoietin and iron supplementation.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The intra-operative transfused volume in this study was 27.9<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15.7), which correlates with transfusion requirements published in the world literature. For Goobie et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the mean transfusion value during surgery was 33<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13), and the PRBCs used postoperatively were 3<span class="elsevierStyleHsp" style=""></span>cc/kg (95% CI between 0 and 25), whereas Dadure et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> report an intra-operative transfused volume of 1.6<span class="elsevierStyleHsp" style=""></span>cc/kg in the tranexamic acid group vs. 11<span class="elsevierStyleHsp" style=""></span>cc/kg in the placebo group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01).</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the world literature, tranexamic acid is used in bolus (10–100<span class="elsevierStyleHsp" style=""></span>mg/kg) and infusion (1–10<span class="elsevierStyleHsp" style=""></span>mg/kg/h). In the case of our patients, a mean bolus dose of 14<span class="elsevierStyleHsp" style=""></span>mg/kg was used, occasionally associated with a 1<span class="elsevierStyleHsp" style=""></span>mg/kg/h infusion; however, this was not related with a lower bleeding volume or smaller amounts of PRBCs transfused intra-operatively or in the ICU. This analysis begs a question about the true efficacy of standard doses of tranexamic acid in preventing major bleeding and reducing the use of blood products, consistent with the report by Neilipovitz.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Dadure et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> used similar doses of tranexamic acid as those used in our group of patients (15<span class="elsevierStyleHsp" style=""></span>mg/kg followed by infusion at a rate of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/h), but combined with preoperative subcutaneous erythropoietin and iron supplementation, and observed no reduction in the rate of bleeding but a reduction in the transfusion volume, similar to that reported by Meneghini<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Fearon.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In an interesting reflection about the methods and results published by the authors mentioned above, Holcomb<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> discusses the accuracy and depth of their conclusion and advices physicians to base their judgement on solid evidence when it comes to starting these patients on this anti-fibrinolytic agent. Finding specific doses (bolus or infusion), developing protocols and forecasting transfusion goals based on the diversity of effects and with the guidance of modern simultaneous coagulation monitoring (in real time) might result in more accurate indications, follow-up and goals for tranexamic acid.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of desmopressin as an adjuvant or as a single therapy in this cohort of patients did not reduce bleeding volumes or the amount of PRBCs used in surgery. It is worth noting that transfused volumes of PRBCs observed in the ICU were significantly smaller (15.82 vs. 22.81; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.027), which suggests a potential benefit associated with their application in the operating room and leads us to recommend the experimental verification of these observations. It is clear that bleeding in the immediate and early post-operative period has different aetiologies, it varies depending on the age group, and it is more the result of an intrinsic coagulation defect than of a persistent vascular disruption in the paediatric patients, which might justify its potential efficacy in these patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Although the restrictive use of blood products has resulted in lower rates of complications when compared to their liberal use, it does not necessarily prevent associated morbidity, unlike what happens with the incidence of transfusion-related complications in adults (37:100,000 units of PRBCs).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Of significant importance is the study of alternatives such as normovolemic/hypervolemic haemodilution, deliberate hypotension, anti-fibrinolytics, blood cell savers, fibrinogen concentrate and autotransfusion, among other blood saving methods, which have not been studied or applied in this age group.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–15</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">This study outlines the anaesthesia model used at Hospital Infantil Universitario de San José for craniosynostosis, which includes intravenous and inhaled agents endorsed by the world literature for induction and maintenance, given their advantage of prompt and easy neurological assessment after surgery.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Its conclusions lead us to create a hypothesis regarding the preventive management of severe haemorrhage in the high-risk paediatric population.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The premise that tranexamic acid in a mean dose of 14<span class="elsevierStyleHsp" style=""></span>mg/kg may provide the same benefits as higher doses might not be true; for this retrospective cohort, bleeding and transfusion volumes at different points in time in relation to the administration of tranexamic acid were similar.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Although massive transfusions contributed to the improvement of perfusion indices and the optimization of haemoglobin levels, they did not prevent DIC or diminish metabolic acidosis, just as was reported by Choi.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Only one of our patients received fresh frozen plasma (FFP) during surgery, similar to what was reported by Kerner,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> who published that the use of FFP during surgery did not reduce blood loss volumes, transfusion requirements, or the length of stay in the ICU. In our research, the high rate of DIC associated with aggressive PRBC transfusion, fluid resuscitation with crystalloids free from significant metabolic acidosis, and the presence of mild hypothermia point to the need of reconsidering the early administration of FPP and PLA guided by modern coagulation monitoring (thromboelastography), as well as timely replacement of serum ionic calcium.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In accordance with worldwide publications, the strategy to approach the airway in patients with facial abnormalities must be based on meticulous pre-operative planning. For Beer and Bingham,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> the key to success is to identify the site of the abnormality, the degree of mouth opening and neck mobility, and control of all those factors that may exacerbate intracranial pressure and/or decompensate pathological cardiac conditions; these authors also consider that the invasive technique to approach the airway must be tailored individually.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In our study, cases were rarely associated with a difficult intubation or perioperative respiratory complications. These findings were similar to those of Barnett, Moloney and Bingham<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> who found a low rate of complications in Apert's syndrome (4.5%). Unlike reported difficulty in approaching the airway of patients with mid-facial hypoplasia due to irregular inter-maxillary proportions and reduced temporomandibular mobility,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in our cohort only a minority of patients (17.6%) were Cormack grade III and only 5.26% had a difficult airway. This may be related to the use of modern advanced management techniques (video laryngoscopy and fibreoptic intubation).</p><p id="par0150" class="elsevierStylePara elsevierViewall">Air embolism is quite frequent during craniectomy in patients with craniosynostosis, with an incidence ranging between 36% and 82.6%.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21–23</span></a> In this cohort, there was no study or diagnosis of this condition, which is a weakness when it comes to analyze the reason for haemodynamic support in the ICU.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Just as reported in the world literature, the syndromic aetiology of craniosynostosis, the comorbidities, the drugs used up to the moment of surgery, the number of sutures, and the complexity were not correlated with the increased volume of bleeding, blood product transfusion or morbidity. Only a slight increase in mechanical ventilation and length of stay in the ICU was found to correlate with the syndromic aetiology.</p><p id="par0160" class="elsevierStylePara elsevierViewall">In this cohort, the anaesthetic medium apparently did not modify bleeding, transfusion, time on mechanical ventilation, fast-tracking strategy or the length of stay in the UCI.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall">Our observations regarding haemorrhage and needs for transfusion lead us to suspect that tranexamic acid (at a mean dose of 14<span class="elsevierStyleHsp" style=""></span>mg/kg) in children taken to carniosynostosis correction might not prevent massive bleeding or reduce the volume of PRBC transfusion, the days on mechanical ventilation or the length of stay in the ICU; we suggest that its use must be subject to the availability of the best evidence on paediatric doses, administration regimen and coagulation monitoring.</p><p id="par0170" class="elsevierStylePara elsevierViewall">We suggest that invasive monitoring, adequate airway management planning and early restrictive transfusion based on cell perfusion and coagulation goals are the pillars for the anaesthetic management. We believe that these may have contributed to reducing the frequency of adverse events and mortality in this cohort, compared with what has been reported in the world literature.</p><p id="par0175" class="elsevierStylePara elsevierViewall">We strongly recommend conducting randomized clinical trials to determine the effectiveness of different doses of anti-fibrinolytics in preventing severe bleeding and high transfusion volumes, as well as research on alternatives to transfusion and blood saving in paediatric patients taken to surgery with a high risk of bleeding. Likewise, we recognize the need for clinical practice guidelines for this anaesthetic challenge.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleGrantSponsor" id="gs0005">Research Division, Fundación Universitaria de Ciencias de la Salud – Bogotá, Colombia</span>.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres354048" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec335387" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres354047" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec335386" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack87367" "titulo" => "Acknowledgments" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-04-30" "fechaAceptado" => "2012-09-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec335387" "palabras" => array:5 [ 0 => "Craniosynostoses" 1 => "Anesthesia" 2 => "Tranexamic Acid" 3 => "Airway Management" 4 => "Anestesiology" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec335386" "palabras" => array:5 [ 0 => "Craneosinostosis" 1 => "Anestesia" 2 => "Ácido tranexámico" 3 => "Manejo de la Vía Aérea" 4 => "Anestesiología" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Craniosynostosis is a congenital disorder requiring extensive reconstructive surgery that entails a high probability of severe bleeding, massive transfusion and difficult airway management. Considering that the anaesthetic management for this procedure has special requirements and priority targets, presenting the experience of the anaesthesiology department working under the programme for surgery of craniofacial abnormalities is of the greatest importance.</p> <span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describe the behaviour of anaesthetic variables during the perioperative period in patients taken to craniosynostosis correction at Hospital Infantil Universitario de San José.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational cohort study in patients taken to surgery between January 1st 2008 and January 31st 2012. Data were collected from electronic clinical records and anaesthesia records.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The most relevant data were haemorrhage and transfusion. Blood loss was 35.6<span class="elsevierStyleHsp" style=""></span>cc/kg (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17.4), considered as severe haemorrhage. Patients receiving tranexamic acid did not show lower intra-operative levels of blood loss or packed red blood cell (PRBC) transfusions, shorter mechanical ventilation or ICU (intensive care unit) length of stay. We observed a smaller number of PRBC transfusions in patients in the ICU who received desmopressin.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We suggest that neither tranexamic acid (14<span class="elsevierStyleHsp" style=""></span>mg/kg) nor desmopressin (0.36<span class="elsevierStyleHsp" style=""></span>mg/kg) in this cohort correlated with reduced haemorrhage or smaller volumes of intra-operative PRBCs. We only describe a smaller volume of transfused PRBCs in the ICU associated with the use of desmopressin.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La craneosinostosis es un trastorno congénito que requiere intensas cirugías reconstructivas que implican alta probabilidad de hemorragia severa, transfusión masiva y difícil abordaje de la vía aérea. Debido a que el manejo anestésico previsto para este procedimiento presenta particularidades y metas de prioritario alcance, la presentación de la experiencia del departamento de anestesiología en el programa de cirugía de anomalías craneofaciales toma gran importancia.</p> <span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir el comportamiento de variables anestésicas en el perioperatorio de pacientes llevados a corrección de craneosinostosis en el Hospital Infantil Universitario de San José.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional de cohorte retrospectiva en pacientes intervenidos entre el1 de enero de 2008 y el 31 de enero del 2012. Se realizó extracción de datos de historias clínicas electrónicas y registros anestésicos.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los datos de mayor relevancia fueron la hemorragia y la transfusión. La hemorragia quirúrgica fue de 35,6 cc/kg (DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17,4), lo cual consideramos como hemorragia severa; allí los casos que utilizaron ácido tranexámico no presentaron inferiores volúmenes hemorrágicos o transfusionales de glóbulos rojos empaquetados (GRE) intraoperatorios, menor tiempo de ventilación mecánica o estancia en la unidad de cuidados intensivos (UCI). Observamos menor cantidad de GRE transfundidos en la UCI en los casos que recibieron desmopresina.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sugerimos que probablemente el ácido tranexámico (14<span class="elsevierStyleHsp" style=""></span>mg/kg) y la desmopresina (0,36 mg/kg) en esta cohorte no se relacionaron con disminución de la hemorragia, ni menor cantidad de GRE transfundidos durante el intraoperatorio; solo describimos menor cantidad de GRE transfundidos en la UCI asociados al empleo de desmopresina.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Cárdenas VH, Vanegas Martínez MV, Rojas Rueda ME, Guevara Nelly S, Prada JR, Baquero P. Anestesia para Craneosinostosis. Rev Colomb Anestesiol. 2014;42:199–204.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Male %: % of men; comorbidities: conditions present in the patients before surgery.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Frequency or mean (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Percentage or standard deviation \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age (months)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Weight (kg)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Gender (male %)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.89% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Syndrome</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.63% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Apert \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crouzon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sutures (>1)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76.31% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.47% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Broncho-obstructive syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hydrocephalus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab528996.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Demographic data.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">PRBC: packed red blood cells; ICU: intensive care unit; SD: standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">With tranexamic acid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Without tranexamic acid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Haemorrhage (cc/kg)</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intra-operative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.606 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">PRBC transfusion (cc/kg)</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intra-operative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.872 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post-operative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.058 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Mechanical ventilation (days)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">ICU (days)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.777 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab528997.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Blood losses, PRBC transfusion, days on mechanical ventilation and length of stay in the ICU.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of pediatric patients with craneosynostosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Kho" 1 => "H. Gries" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2007.05.008" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2007" "volumen" => "25" "paginaInicial" => "465" "paginaFinal" => "481" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17884704" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric neuroanesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Soriano" 1 => "E. Eldredge" 2 => "M. Rockoff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nic.2007.03.010" "Revista" => array:6 [ "tituloSerie" => "Neuroimaging Clin N Am" "fecha" => "2007" "volumen" => "17" "paginaInicial" => "259" "paginaFinal" => "267" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17645975" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: a retrospective analysis of 95 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Goyal" 1 => "A. Chaturvedi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0028-3886.91358" "Revista" => array:6 [ "tituloSerie" => "Neurol India" "fecha" => "2011" "volumen" => "59" "paginaInicial" => "823" "paginaFinal" => "828" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22234192" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy of tranexamic acid in pediatric craniosynostosis surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Goobie" 1 => "P. Meier" 2 => "L. Pereira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e318201cf92" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2011" "volumen" => "114" "paginaInicial" => "1" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21139497" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Dadure" 1 => "M. Sauter" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e318210f9e3" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2011" "volumen" => "114" "paginaInicial" => "856" "paginaFinal" => "861" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21358317" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized trial of tranexamic acid to reduce blood transfusion for scoliosis surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.T. Neilipovitz" 1 => "K. Murto" 2 => "L. Hall" 3 => "N.J. Barrowman" 4 => "W.M. Splinter" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2001" "volumen" => "93" "paginaInicial" => "82" "paginaFinal" => "87" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11429344" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythropoietin therapy and acute preoperative normovolaemic haemodilution in infants undergoing craniosynostosis surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Meneghini" 1 => "N. Zadra" 2 => "V. Aneloni" 3 => "S. Metrangolo" 4 => "R. Faggin" 5 => "F. Giusti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Paediatr Anesth" "fecha" => "2003" "volumen" => "13" "paginaInicial" => "392" "paginaFinal" => "396" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of recombinant erythropoietin in the reduction of blood transfusion rates in craniosynostosis repair in infants and children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Fearon" 1 => "J. Weinthal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2002" "volumen" => "109" "paginaInicial" => "2190" "paginaFinal" => "2196" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12045535" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tranexamic acid in elective craniosynostosis surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Holcomb" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e3182110083" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2011" "volumen" => "114" "paginaInicial" => "737" "paginaFinal" => "738" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21358316" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Principles of hemostasis in children: models and maduration – review article" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.A. Guzzetta" 1 => "B.E. Miller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Anesth" "fecha" => "2011" "volumen" => "21" "paginaInicial" => "3" "paginaFinal" => "9" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood transfusion risks and alternative strategies in pediatric patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Lavoie" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Anesth" "fecha" => "2011" "volumen" => "21" "paginaInicial" => "14" "paginaFinal" => "24" "itemHostRev" => array:3 [ "pii" => "S0210480611000702" "estado" => "S300" "issn" => "02104806" ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood conservation strategies in pediatric anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Verma" 1 => "M. Eisses" 2 => "M. Richards" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2009.05.002" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2009" "volumen" => "27" "paginaInicial" => "337" "paginaFinal" => "351" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19703680" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative blood salvage during surgical correction of craniosynostosis in infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Dahmani" 1 => "G. Orliaguet" 2 => "P. Meyer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2000" "volumen" => "85" "paginaInicial" => "550" "paginaFinal" => "555" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11064613" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fibinogen in craneosynostosis surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. Thosrten" 1 => "F. Dietmar" 2 => "V. Corinna" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ane.0b013e318163fb26" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2008" "volumen" => "106" "paginaInicial" => "725" "paginaFinal" => "731" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18292409" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood loss, replacement, and associated morbidity in infants and children undergoing craniofacial surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Stricker" 1 => "T. Shaw" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Anesth" "fecha" => "2010" "volumen" => "20" "paginaInicial" => "150" "paginaFinal" => "159" "itemHostRev" => array:3 [ "pii" => "S0210480613000119" "estado" => "S300" "issn" => "02104806" ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sevoflurane–remifentanil vs isoflurane–remifentanil for the surgical correction of craniosynostosis in infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Pietrini" 1 => "F. Ciano" 2 => "E. Forte" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Anesth" "fecha" => "2005" "volumen" => "15" "paginaInicial" => "653" "paginaFinal" => "662" "itemHostRev" => array:3 [ "pii" => "S0302283808007781" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metabolic changes during major craniofacial surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Choi" 1 => "N. Ahmad" 2 => "D. De Beer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Anesth" "fecha" => "2010" "volumen" => "20" "paginaInicial" => "851" "paginaFinal" => "855" "itemHostRev" => array:3 [ "pii" => "S0210480611001732" "estado" => "S300" "issn" => "02104806" ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A clinical pilot study of fresh frozen plasma versus human albumin in paediatric craneofacial repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Kerner" 1 => "A. Machotta" 2 => "S. Kerner" 3 => "H. Haberl" 4 => "H. Riess" 5 => "B. Hildebrandt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Int Med Res" "fecha" => "2008" "volumen" => "36" "paginaInicial" => "171" "paginaFinal" => "177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18304417" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0210480612000691" "estado" => "S300" "issn" => "02104806" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The child with facial abnormalities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. De Beer" 1 => "R. Bingham" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Curr Opin Anesthesiol" "fecha" => "2011" "volumen" => "24" "paginaInicial" => "282" "paginaFinal" => "288" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative complications in children with Apert syndrome: a review of 509 anesthetics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Barnett" 1 => "C. Moloney" 2 => "R. Bingham" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Anesth" "fecha" => "2011" "volumen" => "21" "paginaInicial" => "72" "paginaFinal" => "77" "itemHostRev" => array:3 [ "pii" => "S0022534711002254" "estado" => "S300" "issn" => "00225347" ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of venous air embolism during craniectomy for craneosynostosis repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Faberowski" 1 => "S. Black" 2 => "P. Mickle" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Anesthesiology" "fecha" => "2000" "volumen" => "92" "paginaInicial" => "20" "paginaFinal" => "23" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10638894" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0210480611003196" "estado" => "S300" "issn" => "02104806" ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Venous embolism during craniectomy in supine infants" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.M. Harris" 1 => "T.A. Yemen" 2 => "A. Davidson" 3 => "M.A. Strafford" 4 => "R.W. Rowe" 5 => "S.P. Sanders" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "1987" "volumen" => "67" "paginaInicial" => "816" "paginaFinal" => "819" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3674488" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Venous air embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Albin" 1 => "J. Souders" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Complications in anesthesia" "paginaInicial" => "704" "paginaFinal" => "707" "edicion" => "2nd ed." "serieFecha" => "2007" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack87367" "titulo" => "Acknowledgments" "texto" => "<p id="par0190" class="elsevierStylePara elsevierViewall">To Fundación Universitaria de Ciencias de la Salud, Hospital Infantil Universitario de San José and its Departments of Anaesthesiology, Plastic Surgery, Neurosurgery, and the Reconstructive Surgery Program for Craniofacial Abnormalities (CSAP).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22562087/0000004200000003/v2_201407220045/S2256208714000297/v2_201407220045/en/main.assets" "Apartado" => array:4 [ "identificador" => "34050" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Review articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22562087/0000004200000003/v2_201407220045/S2256208714000297/v2_201407220045/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714000297?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 2 | 13 |
| 2024 October | 52 | 12 | 64 |
| 2024 September | 58 | 9 | 67 |
| 2024 August | 41 | 10 | 51 |
| 2024 July | 51 | 9 | 60 |
| 2024 June | 41 | 5 | 46 |
| 2024 May | 34 | 10 | 44 |
| 2024 April | 60 | 29 | 89 |
| 2024 March | 41 | 18 | 59 |
| 2024 February | 54 | 6 | 60 |
| 2024 January | 31 | 10 | 41 |
| 2023 December | 25 | 7 | 32 |
| 2023 November | 38 | 7 | 45 |
| 2023 October | 42 | 15 | 57 |
| 2023 September | 35 | 19 | 54 |
| 2023 August | 45 | 12 | 57 |
| 2023 July | 58 | 7 | 65 |
| 2023 June | 47 | 2 | 49 |
| 2023 May | 64 | 7 | 71 |
| 2023 April | 61 | 5 | 66 |
| 2023 March | 52 | 5 | 57 |
| 2023 February | 51 | 9 | 60 |
| 2023 January | 34 | 6 | 40 |
| 2022 December | 30 | 7 | 37 |
| 2022 November | 30 | 12 | 42 |
| 2022 October | 19 | 6 | 25 |
| 2022 September | 40 | 29 | 69 |
| 2022 August | 26 | 26 | 52 |
| 2022 July | 31 | 8 | 39 |
| 2022 June | 26 | 12 | 38 |
| 2022 May | 20 | 13 | 33 |
| 2022 April | 20 | 9 | 29 |
| 2022 March | 40 | 19 | 59 |
| 2022 February | 73 | 10 | 83 |
| 2022 January | 85 | 16 | 101 |
| 2021 December | 27 | 10 | 37 |
| 2021 November | 26 | 12 | 38 |
| 2021 October | 48 | 22 | 70 |
| 2021 September | 29 | 10 | 39 |
| 2021 August | 41 | 14 | 55 |
| 2021 July | 18 | 9 | 27 |
| 2021 June | 18 | 12 | 30 |
| 2021 May | 20 | 11 | 31 |
| 2021 April | 68 | 26 | 94 |
| 2021 March | 41 | 8 | 49 |
| 2021 February | 7 | 9 | 16 |
| 2021 January | 25 | 14 | 39 |
| 2020 December | 20 | 8 | 28 |
| 2020 November | 34 | 10 | 44 |
| 2020 October | 10 | 7 | 17 |
| 2020 September | 19 | 13 | 32 |
| 2020 August | 13 | 10 | 23 |
| 2020 July | 16 | 7 | 23 |
| 2020 June | 6 | 3 | 9 |
| 2020 May | 14 | 6 | 20 |
| 2020 April | 10 | 5 | 15 |
| 2020 March | 15 | 6 | 21 |
| 2020 February | 19 | 4 | 23 |
| 2020 January | 15 | 8 | 23 |
| 2019 December | 14 | 10 | 24 |
| 2019 November | 8 | 4 | 12 |
| 2019 October | 10 | 2 | 12 |
| 2019 September | 8 | 3 | 11 |
| 2019 August | 3 | 0 | 3 |
| 2019 July | 4 | 7 | 11 |
| 2019 June | 2 | 5 | 7 |
| 2019 May | 1 | 7 | 8 |
| 2018 September | 1 | 0 | 1 |
| 2018 August | 0 | 5 | 5 |
| 2018 July | 0 | 2 | 2 |
| 2018 June | 1 | 0 | 1 |
| 2018 May | 17 | 6 | 23 |
| 2018 April | 42 | 8 | 50 |
| 2018 March | 32 | 11 | 43 |
| 2018 February | 21 | 12 | 33 |
| 2018 January | 31 | 13 | 44 |
| 2017 December | 37 | 9 | 46 |
| 2017 November | 17 | 8 | 25 |
| 2017 October | 24 | 14 | 38 |
| 2017 September | 44 | 14 | 58 |
| 2017 August | 45 | 17 | 62 |
| 2017 July | 48 | 13 | 61 |
| 2017 June | 51 | 17 | 68 |
| 2017 May | 50 | 10 | 60 |
| 2017 April | 56 | 15 | 71 |
| 2017 March | 29 | 49 | 78 |
| 2017 February | 24 | 13 | 37 |
| 2017 January | 18 | 7 | 25 |
| 2016 December | 41 | 17 | 58 |
| 2016 November | 32 | 8 | 40 |
| 2016 October | 40 | 17 | 57 |
| 2016 September | 38 | 3 | 41 |
| 2016 August | 60 | 18 | 78 |
| 2016 July | 29 | 10 | 39 |
| 2016 June | 0 | 7 | 7 |
| 2016 May | 2 | 19 | 21 |
| 2016 April | 0 | 18 | 18 |
| 2016 March | 6 | 23 | 29 |
| 2016 February | 0 | 18 | 18 |
| 2015 December | 16 | 0 | 16 |
| 2015 November | 32 | 16 | 48 |
| 2015 October | 49 | 10 | 59 |
| 2015 September | 40 | 6 | 46 |
| 2015 August | 39 | 7 | 46 |
| 2015 July | 39 | 6 | 45 |
| 2015 June | 34 | 7 | 41 |
| 2015 May | 46 | 11 | 57 |
| 2015 April | 30 | 4 | 34 |
| 2015 March | 42 | 14 | 56 |
| 2015 February | 42 | 9 | 51 |
| 2015 January | 58 | 10 | 68 |
| 2014 December | 34 | 19 | 53 |
| 2014 November | 23 | 12 | 35 |
| 2014 October | 31 | 23 | 54 |
| 2014 September | 39 | 19 | 58 |
| 2014 August | 32 | 11 | 43 |
| 2014 July | 57 | 16 | 73 |
Show all