Scientific and Technological Research
Remifentanil vs. epidural analgesia for the management of acute pain associated with labour. Systematic review and meta-analysis
Remifentanilo vs. analgesia epidural para el manejo del dolor agudo relacionado con el trabajo de parto. Revisión sistemática y meta-análisis
Víctor Hugo González Cárdenasa,
, Fredy Danilo Munar Gonzálezb, Wilson Javier Gómez Barajasc, Angélica María Cardonad, Byron Rafael Roseroe, Álvaro José Manriquef
Corresponding author
vhagonzalez@fucsalud.edu.co
vhgc79@gmail.com
Corresponding author at: Cra. 52 No. 67A-71, Oficina de Anestesiología, Hospital Infantil Universitario de San José, Bogotá, Colombia.
vhgc79@gmail.com
Corresponding author at: Cra. 52 No. 67A-71, Oficina de Anestesiología, Hospital Infantil Universitario de San José, Bogotá, Colombia.
a Anaesthetist Physician, Clinical Epidemiologist and Masters in Anaesthesia and Regional Analgesia; Leader of the Deorum Opus Research Group at Hospital Infantil Universitario de San José and Fundación Universitaria de Ciencias de la Salud (FUCS); Anaesthetist, Anaesthesia Department, Hospital Infantil Universitario de San José; FUCS Instructor; Clinical Faculty, Universidad de la Sabana – Anaesthesia Residence Program, Bogotá, Colombia; Ganador segundo puesto en el Concurso Luis Cerezo del XXX Congreso Colombiano de Anestesiología y I Global TIVA - Cartagena de Indias, Colombia, 2013
b Anaesthetist Physician, Anaesthesia Department, Hospital Infantil Universitario de San José; FUCS Instructor, Bogotá, Colombia
c Anaesthetist Physician, Anaesthesia Department, Hospital Infantil Universitario de San José; FUCS Instructor; Clinical Faculty, Universidad de la Sabana – Anaesthesia Residence Program, Bogotá, Colombia
d Physician, Anaesthesia Resident, FUCS Residence Program (currently anesthesiologist at Hospital Infantil Universitario de San José), Bogotá, Colombia
e Physician, Anaesthesia Resident, FUCS Residence Program (currently anesthesiologist at Hospital Universitario de San José), Bogotá, Colombia
f Physician, Anaesthesia Resident, FUCS Residence Program, Bogotá, Colombia
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Revisión sistemática y meta-análisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 680 "Ancho" => 3222 "Tamanyo" => 194366 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in studies with low bias risk at first hour.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lumbar epidural analgesia is considered the gold standard in the treatment of labour-associated pain due to its effectiveness and low frequency of adverse effects.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> However, its use is restricted in patients with absolute contraindications and in those who refuse to receive it because of its invasive nature and its potential complications.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> Consequently, various authors have written about the need for an equivalent option for patients who cannot benefit from its application.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The use of opioids intravenously or in regional techniques during labour is quite controversial because, on the one hand, they induce respiratory depression in the mother and, on the other hand, because of potential respiratory, cardiovascular and tissue perfusion complications in the newborn.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> Over the past decade, the massive use of the potent opioid remifentanil in anaesthesia<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> has given rise to multiple reviews and editorials highlighting the strong profile of this drug for the control of pain during labour.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, due to the low epidemiological power of this work, no recommendation has been structured. In 2008, after the publication by Volmanen et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> a whole new experimental stage was set in motion for assessing the efficacy of remifentanil and its equivalence with epidural analgesia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The goal of this study is to establish the equivalence in terms of efficacy and safety of intravenous remifentanil compared to epidural analgesia for the treatment of acute pain in labour, and to suggest a recommendation in this regard. The method to achieve this objective was a systematic review and meta-analysis. The question proposed to achieve this objective was: <span class="elsevierStyleItalic">Is remifentanil as effective and safe as epidural analgesia for labour-associated pain?</span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Analytical study with a systematic review design and meta-analysis of randomized clinical trials controlled with epidural analgesia, conducted in accordance with the Cochrane collaboration methodology<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and pursuant to the recommendations of the PRISMA Declaration.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The evaluation was performed using the R-Amstar tool.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Selection criteria</span><p id="par0025" class="elsevierStylePara elsevierViewall">Studies: Randomized clinical trials controlled with epidural analgesia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients included: Women in labour with an indication for obstetric analgesia.</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Interventions:</span><p id="par0040" class="elsevierStylePara elsevierViewall">Two groups were defined as follows:</p><p id="par0045" class="elsevierStylePara elsevierViewall">Remifentanil group: Patients assigned to analgesic intervention with intravenous remifentanil, irrespective of the specific technique used (patient controlled analgesia – PCA – or infusion, or combined PCA and infusion).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Epidural group: Patients assigned to analgesic intervention with epidural analgesia, irrespective of the specific technique used (patient controlled epidural analgesia – PCEA – or infusion, or combined PCEA and infusion).</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Outcomes:</span><p id="par0060" class="elsevierStylePara elsevierViewall">Pain: Assessment of pain intensity using the visual analogue scale (VAS) from 0 to 10, summarized as means and standard deviations according to each study, and developed in accordance with the protocol.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Other outcomes assessed in accordance with the definition in each study:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Conditions: foetal bradycardia, respiratory depression, caesarean section, instrumented delivery, nausea.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Behaviours: sedation, Apgar test and umbilical artery pH.</p></li></ul></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study identification:</span><p id="par0085" class="elsevierStylePara elsevierViewall">The search was conducted in the following sources:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Primary: PubMed, Embase, Lilacs, Cochrane, Ebsco.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Secondary: ACP Journal Club, NHS Centre for Reviews and Dissemination; National Library of Medicine Health Service Research, Scirus.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Dissertations and grey literature: SIGLEá, NTIS, Pascal and Cinhal, New York Academy of Sciences Grey Sources, Clinical Medicine Netprints, Collection Index to Theses, Canada Portal Networked Digital Library of Theses and Dissertations, Australian Digital Theses Program ProQuest, NHMRC Science.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Search of papers registered and in development on the World Health Organization platform (<a id="intr0005" class="elsevierStyleInterRef" href="http://www.who.int/trialsearch">www.who.int/trialsearch</a>).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Based on the articles found during the systematic review, the search was completed using a snowball strategy and manual online search of bibliographic references included in each article. Search strategies were used for each of the cited databases, developed from the one generated for Medline – PubMed <span class="elsevierStyleItalic">(“remifentanil” [Supplementary Concept] or “remifentanil” [All Fields]) and (“labour” [All Fields] or “work” [MeSH Terms] or “work” [All Fields] or “labor” [All Fields] or “labor, obstetric” [MeSH Terms] or “labor” [All Fields]) and (“obstetric” [All Fields]) or “obstetric labor” [All Fields]) and (Clinical Trial [ptyp] or Randomized Controlled Trial [ptyp]</span>).</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">– No date or language restrictions were applied.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Data collection and analysis</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Study identification and selection</span><p id="par0120" class="elsevierStylePara elsevierViewall">Each title was evaluated by the reviewer group and classified as relevant, irrelevant or uncertain. Every title classified as relevant or uncertain triggered abstract evaluation. Once relevance was confirmed, the full article was reviewed. Later, a group of three reviewers, each of them working independently, selected all the articles that met the expected criteria. Extraction and analysis of each study were free from masking, and discrepancies were settled through common agreement.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Data extraction and management</span><p id="par0125" class="elsevierStylePara elsevierViewall">Three investigators, working separately, extracted the data included as protocol variables, as well as the methodology used in every study in particular. Data were recorded in a specific Excel format and the statistical Kappa was calculated in order to evaluate inter-rater agreement.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Discrepancies were solved through data review to reach common agreement. Data entry in RevMan 5.1 was done by one of the authors (VHGC), and no masking techniques were used.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Systematic review quality evaluation</span><p id="par0130" class="elsevierStylePara elsevierViewall">The R-Amstar tool was implemented to evaluate the quality of the systematic review and support the confidence or wisdom of the recommendations derived from it. The tool was applied by two expert reviewers, one of them external to the study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Evaluation of bias risk</span><p id="par0135" class="elsevierStylePara elsevierViewall">A group of three investigators, working separately, evaluated the risk of bias using a specific form, in accordance with the Cochrane criteria. The evaluation included: hypothesis, masking, randomization strategy, follow-up losses or dropouts, analysis, and sample size calculation.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In each case, scores were obtained according to the compliance percentage of the items evaluated in each of the strategies used for rating the quality of the clinical trial. The evaluation was done on the basis of the data published electronically in each case.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Treatment effect measurement</span><p id="par0145" class="elsevierStylePara elsevierViewall">For continuous outcomes (visual analogue scale scores) the mean difference between the groups assessed was used; odds ratios (OR) were calculated for nominal dichotomous outcomes; and 95% confidence intervals (95% CI) were used for estimates.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Approach to unknown (publication) or lost data</span><p id="par0150" class="elsevierStylePara elsevierViewall">When necessary, an attempt was made to contact the authors of the studies included in order to retrieve lost data. When this was not possible, they were calculated (in this particular case, standard deviation calculation from quartiles) and analyzed by sensitivity and study subgroup. If, despite this, it was still not possible to obtain lost data, the analysis was done using only the available data.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Heterogeneity evaluation</span><p id="par0155" class="elsevierStylePara elsevierViewall">The evaluation was done using the methodological heterogeneity and/or clinical heterogeneity and/or graphic heterogeneity (forest plot), aside from the Cochrane I2 and Q statistics (Ji2).</p><p id="par0160" class="elsevierStylePara elsevierViewall">Statistical heterogeneity was defined as the finding of a Cochrane Q (Ji2) of less than 0.1 or I2 greater than 50%.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Publication bias evaluation</span><p id="par0165" class="elsevierStylePara elsevierViewall">It was based on a dual strategy involving the specific assessment of the study methodologies and/or the funnel plot analysis.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Summary of the data</span><p id="par0170" class="elsevierStylePara elsevierViewall">The free Cochrane Collaboration Review Manager (REvMan 5.1) was used. The quantitative analysis of the data was done per protocol. Difference means were used for continuous outcomes and their 95% CI was estimated; ORs were calculated for dichotomous data with their 95% CI, based on a random effects model for collective estimates.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Subgroup analysis</span><p id="par0175" class="elsevierStylePara elsevierViewall">It was performed for all outcomes, differentiated by type of intervention (remifentanil group and epidural group) and by the risk of bias of the studies included in the analysis.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Sensitivity analysis</span><p id="par0180" class="elsevierStylePara elsevierViewall">Sensitivity analyses focused on investigating the cause of the heterogeneity and the potential effect of the bias on the results.</p></span></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Results</span><p id="par0185" class="elsevierStylePara elsevierViewall">This systematic review was conducted of the world literature published until February 29, 2012, with a strategy open to the evaluation of experimental evidence capable of providing scientific support to propose recommendations on the use of remifentanil for the management of labour-associated pain.</p><p id="par0190" class="elsevierStylePara elsevierViewall">By February 29, 2012, there were four active studies on remifentanil in the central clinical trial registry<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>; two of them assessed effectiveness, equivalence, and safety of the use of remifentanil vs. epidural analgesia for labour-associated pain, but they were not available at that time. (These are studies NCT00801047 and EUCTR2007-000808-32-NL.)</p><p id="par0195" class="elsevierStylePara elsevierViewall">After selecting the articles for analysis<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,20–22</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), those that were included were listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>; overall, 116 were excluded and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists those that were not included in the analysis, corresponding to the Pubmed and Lilacs databases.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,23–46</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">Two of the four studies included (inter-rater selection agreement, Kappa<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1) (50%) were classified as “low bias risk” (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 3</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">For <span class="elsevierStyleItalic">equivalence</span> evaluation, time analyses were performed in the studies evaluated of the intensity of pain in relation to baseline prior to the initiation of the specific analgesic therapy (remifentanil or epidural) in the two intervention groups (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig3"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">When the data of the four studies were analyzed at time point 0, important heterogeneity was found (I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>72% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01). In the subgroup analysis, no heterogeneity was found for the studies with low bias probability (I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.3). When only the data of the studies with a high bias risk were considered, heterogeneity was observed (I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.05). None of the measurements showed statistical differences when comparing baseline pain levels (time 0), according to the <span class="elsevierStyleItalic">p</span> values for all the studies included, irrespective of the bias risk (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.19), studies with low bias risk (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.84), or studies with high bias risk (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.25).</p><p id="par0215" class="elsevierStylePara elsevierViewall">For pain measurements at 1, 2 and 3<span class="elsevierStyleHsp" style=""></span>h (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4–7</a>) heterogeneity was found when all the studies included in the analysis were examined (1<span class="elsevierStyleHsp" style=""></span>h: I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>75% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.008; 2<span class="elsevierStyleHsp" style=""></span>h: I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>89% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002; 3<span class="elsevierStyleHsp" style=""></span>h: I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>61%, but Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.11<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>disagreement against heterogeneity). In the subgroup analysis for the first hour, including only the studies with a low bias risk, no heterogeneity was observed (I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.75); there was an important difference in pain intensity between the two groups (mean difference<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.11; 95% CI 1.75 and 2.45 with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001 in favour of epidural analgesia).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig5"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">Absence of heterogeneity at the end of labour was confirmed (I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.44). When the differences in pain intensity were analyzed with both therapies at the time of delivery, no statistically significant differences were found (mean difference<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.04; 95% CI −0.85 and 0.77, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.92) (see <a class="elsevierStyleCrossRef" href="#fig0045">Fig. 8</a>).</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">When the independent heterogeneity results were evaluated, an important statistical difference was apparent for the first 3<span class="elsevierStyleHsp" style=""></span>h in favour of the use of epidural analgesia (mean difference at first hour: 1.9 (95% CI 1.5 and 2.22 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001); 2<span class="elsevierStyleHsp" style=""></span>h: 3.63 (95% CI 2.64 and 4.63 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001); 3<span class="elsevierStyleHsp" style=""></span>h: 2.57 (95% CI 1.17 and 2.45 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0003).</p><p id="par0230" class="elsevierStylePara elsevierViewall">In assessing the efficacy of the treatment, pain intensity was analyzed at different points in time, using the pain level before the intervention (baseline) as control. Heterogeneity was confirmed when it was evaluated at different time points (remifentanil group for first hour: I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>97% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001; 3<span class="elsevierStyleHsp" style=""></span>h 3: I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>93% and Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001; final time point: I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>96%, but Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001) (<a class="elsevierStyleCrossRefs" href="#fig9">Figs. 9–11</a>). With the subgroup analysis in the first hour for low bias risk studies, heterogeneity was also found (I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>93%, but Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001) (<a class="elsevierStyleCrossRef" href="#fig12">Fig. 12</a>). Based on summary measurements of the four studies, despite the finding of heterogeneity, it is suggested that significant contrast was observed for mean pain differences, as follows: first hour: −0.9 (95% CI −1.07 and −0.72 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001); 3<span class="elsevierStyleHsp" style=""></span>h: −3.26 (95% CI −4.01 and −2.51 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001) and final time point −3.47 (95% CI −4.29 and −2.65 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.00001).</p><elsevierMultimedia ident="fig9"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><elsevierMultimedia ident="fig0055"></elsevierMultimedia><elsevierMultimedia ident="fig12"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">In evaluating the incidence of adverse events associated with both interventions, we were able to isolate the investigation regarding outcomes of important medical interest. They were divided into those that compromise the newborn and those that compromise the woman in labour.</p><p id="par0240" class="elsevierStylePara elsevierViewall">The maternal outcomes studied were: respiratory depression, sedation, nausea, instrumented delivery and caesarean section. The outcomes for the newborn were foetal bradycardia, Apgar and umbilical artery pH.</p><p id="par0245" class="elsevierStylePara elsevierViewall">Neither of the groups showed abnormalities in foetal heart rate, Apgar score or umbilical artery pH. In some cases, the assessment of adverse events was discussed in the results and analysis section, as found within the normal range and with no differences between the two intervention groups. Those conclusions were based on the individual consideration of each article and not on a meta-analysis value as a result of this review.</p><p id="par0250" class="elsevierStylePara elsevierViewall">The mothers did not present important levels of respiratory depression or sedation; three of the four studies mentioned the number of mothers who experienced nausea, and the meta-analysis of the data (Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.51 and I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0%) showed a higher incidence in the remifentanil group (21 vs. 9, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02) (<a class="elsevierStyleCrossRef" href="#fig0065">Fig. 13</a>).</p><elsevierMultimedia ident="fig0065"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">The analysis of the incidence of instrumented delivery, taking into consideration a borderline heterogeneity (Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.08 and I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>61%), found a similar trend (8 vs. 5, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.46). The subgroup analysis, excluding the study by Douma<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> (due to a higher incidence in the epidural group) confirmed a not higher incidence of instrumentation in the remifentanil group, based on and OR of 5.43 (95% CI 0.89 and 33.16, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.07) and absence of heterogeneity (Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.69 and I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0%). Those data were considered borderline and clinical analysis data (<a class="elsevierStyleCrossRefs" href="#fig0070">Figs. 14 and 15</a>).</p><elsevierMultimedia ident="fig0070"></elsevierMultimedia><elsevierMultimedia ident="fig0075"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Regarding the incidence of caesarean section, following the heterogeneity analysis (Q<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.94 and I2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0%), no statistical difference was observed between the two groups (7 vs. 6, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.79) (<a class="elsevierStyleCrossRef" href="#fig0080">Fig. 16</a>).</p><elsevierMultimedia ident="fig0080"></elsevierMultimedia><p id="par0265" class="elsevierStylePara elsevierViewall">Regarding satisfaction assessment, Douma<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> does not show statistically significant differences between the comparison groups and when he evaluated 20 patients using a scale from 0 to 10 (where 0 is highly dissatisfied and 10 is highly satisfied), he found important values in hours 1, 2, 3 and in the final time point (remifentanil group: 8.6, 7.4, 7.3 and 8.0; epidural group: 8.3, 8.6, 7.3 and 8.3). In the study by Volmanen,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> satisfaction was based on a pain relief score from 0 to 4, were 0 was “no improvement” and 4 was “total improvement”. In that article, published values were 2.5 (2.2–2.9) vs. 2.8 (2.3–3.5) between the remifentanil group and the epidural group, with no statistically significant differences (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.11); scores of 2 and 3 were considered Moderate to Good pain relief. It is worth noting that neither intervention was rated as “complete improvement”. For El-Kerdawy, patient-rated satisfaction was 2.8 (±1) for the epidural group and 3.1 (±0.9) for remifentanil, with no statistically significant differences. In this study, satisfaction was assessed using a 1–4 scale that was described as ranging from poor to excellent, and a conclusion from the observations may be that both remifentanil as well as epidural analgesia correlated with good patient satisfaction with both treatments. This item was not assessed by Sołek-Pastuszka.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The probability of publication bias was evaluated for pain data points reported at different time points and it was found that there was low probability of bias derived from graphic symmetry in all items; bias probability for data reported at 2<span class="elsevierStyleHsp" style=""></span>h is uncertain (<a class="elsevierStyleCrossRef" href="#fig0085">Fig. 17</a>). Likewise, the funnel plot was used to evaluate the probability of publication bias for the incidence of nausea, instrumented delivery and caesarean section, with the conclusion that there was low probability in the data shown in each study due to their symmetry (<a class="elsevierStyleCrossRefs" href="#fig0085">Figs. 17 and 18</a>).</p><elsevierMultimedia ident="fig0085"></elsevierMultimedia><elsevierMultimedia ident="fig0105"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">The R-Amstar was implemented by two reviewers working separately. A mean score of 41 was observed out of a total of 44, representing compliance with the Amstar standards of 93.18%, which categorizes this systematic review in the A ranking with high degree of confidence and clinical relevance for its recommendations.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Discussion</span><p id="par0280" class="elsevierStylePara elsevierViewall">The use of remifentanil resulted in significant pain reduction in each study. When the data were grouped together, it was impossible to arrive at a statistical conclusion about a summary number due to heterogeneity. Nonetheless, we found clinical pain reduction (3–4 points on the VAS) at different times in relation to time 0 of the intervention. Although prescription of control or placebo is ideal for this hypothesis, it is not ethical to withhold obstetric analgesia and, for that reason, the closest effectiveness measure was to study response to pain before and after the intervention.</p><p id="par0285" class="elsevierStylePara elsevierViewall">When comparing remifentanil and epidural analgesia in terms of effectiveness, we suggest non-equivalence. We found marked effectiveness for epidural analgesia, although the analysis is limited by the heterogeneity of the data at certain times.</p><p id="par0290" class="elsevierStylePara elsevierViewall">When remifentanil doses (0.2–0.9<span class="elsevierStyleHsp" style=""></span>mcg/kg per PCA dose) were analyzed by sensitivity, no dose-efficacy correlation was shown that could modify the analgesic effect or the adverse events. Other studies that have analyzed the issue have demonstrated it with different doses (0.2–0.93<span class="elsevierStyleHsp" style=""></span>mcg/kg/min) and similar analgesic efficacy.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,31,33,34,37–39</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Remifentanil and epidural analgesia were equivalent at the end of delivery. This hypothesis may be based on incomplete epidural analgesic coverage due to the anatomy or the duration of the effect of the single dose used in some of the studies.</p><p id="par0300" class="elsevierStylePara elsevierViewall">In the study by López-Millán et al.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> patients felt “satisfied” or “very satisfied” with the use of PCA with remifentanil; in this review, each study, using different scales, found an important correlation between remifentanil and good satisfaction, equivalent to that reported for epidural analgesia.</p><p id="par0305" class="elsevierStylePara elsevierViewall">In terms of safety, we only found statistical differences for nausea, allowing us to conclude that remifentanil acts as a risk factor for nausea during labour. When analysing instrumented delivery, we concluded that the incidence in the remifentanil group was similar to that in the epidural group. We believe that the number of patients to treat must be larger in order to make a strong determination regarding remifentanil and this adverse event. We consider that the incidence and risk of caesarean section are similar as with epidural analgesia.</p><p id="par0310" class="elsevierStylePara elsevierViewall">Neonatal respiratory depression is low when remifentanil is used during phase one of labour; in fact, Ross et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> showed a rapid washout in neonates undergoing elective surgery or diagnostic procedures, and several articles have reported increased neonatal bradycardia with remifentanil,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,49,50</span></a> but none of them report an association with important compromise of umbilical artery pH or abnormal APGAR test.</p><p id="par0315" class="elsevierStylePara elsevierViewall">For this study, the probability of maternal or foetal complications is similar for patients treated with remifentanil or with epidural analgesia, which is consistent with what is published by Aristizábal and Londoño.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Support for the management of non-surgical acute pain,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> opens the way for an alternative to conventional management of obstetric analgesia in our country. The idea of promoting its use with PCA when patients have contraindications for standard management suggests the need for clinical research in order to identify safe and effective doses. Our study contributes promising findings to the scientific community. Based on sound anaesthetic judgement, they point to the choice of an option that may be effective and safe during labour. We suggest that randomized controlled trials are needed, as well as the development of a sequential study of clinical trials in accordance with the recommendations from the group of Wetterslev et al.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusion</span><p id="par0325" class="elsevierStylePara elsevierViewall">Based on the results of this study, remifentanil for obstetric analgesia could be effective in the treatment of labour-associated pain, leading to a reduction of up to 5 points in the VAS in different trials and at specific time points. However, non-heterogeneous randomized controlled clinical trials are needed in order to confirm this hypothesis.</p><p id="par0330" class="elsevierStylePara elsevierViewall">Remifentanil vs. epidural analgesia did not show equivalence on the basis of the statistical/or clinical analyses, although treatment efficacy was not discarded. In terms of safety, remifentanil showed the same therapeutic margin as epidural analgesia for the main expected maternal and foetal adverse events; the only measurement that showed increased incidence and risk was nausea. In view of this finding, if this option is considered for analgesia in labour, we recommend the application of the World Health Organization standards for prophylaxis and treatment of opioid-related nausea, as well as close mandatory monitoring in order to ensure best results.</p><p id="par0335" class="elsevierStylePara elsevierViewall">We believe that satisfaction must be assessed using a universally adapted scale to avoid sensitivity-based analytical approaches, thus avoiding subjective challenges of an objective measurement that may polarize the use of remifentanil in labour.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Ethical disclosures</span><p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects.</span> The authors declare that no experiments were performed on humans or animals for this study.</p><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Confidentiality of data.</span> The authors declare that no patient data appear in this article.</p><p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent.</span> The authors declare that no patient data appear in this article.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Funding</span><p id="par0340" class="elsevierStylePara elsevierViewall">Research Division and Fundación Universitaria de Ciencias de la Salud (FUCS) Medical School.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Conflicts of interest</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres371174" "titulo" => array:6 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objective" 3 => "Methods" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec350341" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres371175" "titulo" => array:6 [ 0 => "Resumen" 1 => "Introducción" 2 => "Objetivo" 3 => "Métodos" 4 => "Resultados" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec350342" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Selection criteria" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Interventions:" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Outcomes:" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Study identification:" ] 4 => array:3 [ "identificador" => "sec0020" "titulo" => "Data collection and analysis" "secciones" => array:11 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Study identification and selection" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Data extraction and management" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Systematic review quality evaluation" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Evaluation of bias risk" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Treatment effect measurement" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Approach to unknown (publication) or lost data" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Heterogeneity evaluation" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Publication bias evaluation" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Summary of the data" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Subgroup analysis" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Sensitivity analysis" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0080" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0085" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0120" "titulo" => "Ethical disclosures" ] 10 => array:2 [ "identificador" => "sec0095" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack93465" "titulo" => "Acknowledgments" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-08-12" "fechaAceptado" => "2014-05-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec350341" "palabras" => array:5 [ 0 => "Labor, obstetric" 1 => "Anesthesia, conduction" 2 => "Meta-analysis" 3 => "Acute pain" 4 => "Analgesics, opioid" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec350342" "palabras" => array:5 [ 0 => "Trabajo de Parto" 1 => "Anestesia de Conducción" 2 => "Meta-análisis" 3 => "Dolor agudo" 4 => "Analgésicos opioides" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Remifentanil has an attractive pharmacological profile for use in obstetric analgesia as a technique for mass application, with similar benefits and satisfaction as epidural analgesia.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the efficacy, equivalence and safety of remifentanil vs. epidural analgesia in obstetrics.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Systematic review and meta-analysis of clinical trials using the Cochrane methodology.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">No equivalence was found in relation to epidural analgesia; however, efficacy was found in the remifentanil group at different time points during the evaluation. The incidence of adverse effects was similar in the two groups, except for nausea.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Remifentanil is not equivalent to epidural analgesia but could certainly decrease the intensity of pain.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">El remifentanilo presenta un perfil farmacológico atractivo para definirse como analgesia obstétrica, dada la necesidad de una técnica de empleo masivo, con similares beneficios y satisfacción que la analgesia epidural.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">Evaluar la eficacia, la equivalencia y la seguridad del remifentanilo vs. Analgesia epidural en analgesia obstétrica.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Métodos</span><p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">Revisión sistemática y meta-análisis de experimentos clínicos siguiendo la metodología Cochrane.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0175" class="elsevierStyleSimplePara elsevierViewall">No hallamos equivalencia con respecto a analgesia epidural, pero sí eficacia en el grupo de remifentanilo a diferentes horas de evaluación. La incidencia de efectos adversos fue similar en ambos grupos, salvo para las náuseas.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0180" class="elsevierStyleSimplePara elsevierViewall">El remifentanilo puede no ser equivalente a la analgesia epidural, pero podría disminuir la intensidad del dolor consonante con los niveles de satisfacción de cada artículo.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Cárdenas VH, González FDM, Barajas WJG, Cardona AM, Rosero BR, Manrique AJ. Remifentanil vs. analgesia Epidural para manejo del dolor agudo relacionado con el trabajo de parto. Revisión sistemática y meta-análisis. Rev Colomb Anestesiol. 2014;42:281–294.</p>" ] ] "multimedia" => array:21 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1896 "Ancho" => 2106 "Tamanyo" => 135730 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Selection process for the articles include (listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>); excluded studies, from the Pubmed and Lilacs databases, are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 713 "Ancho" => 3250 "Tamanyo" => 175875 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in all the studies at time point 0.</p>" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 672 "Ancho" => 3251 "Tamanyo" => 187418 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in studies with low bias risk at time point 0 (only the studies by Douma and Volmanen were included in the analysis).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 757 "Ancho" => 3251 "Tamanyo" => 175188 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in all studies at first hour.</p>" ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 680 "Ancho" => 3222 "Tamanyo" => 194366 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in studies with low bias risk at first hour.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 619 "Ancho" => 3224 "Tamanyo" => 142705 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in all studies at 2<span class="elsevierStyleHsp" style=""></span>h.</p>" ] ] 6 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 628 "Ancho" => 3224 "Tamanyo" => 139011 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in all studies at 3<span class="elsevierStyleHsp" style=""></span>h.</p>" ] ] 7 => array:8 [ "identificador" => "fig0045" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 619 "Ancho" => 3224 "Tamanyo" => 139778 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil vs. epidural groups in all studies at final time point (delivery).</p>" ] ] 8 => array:8 [ "identificador" => "fig9" "etiqueta" => "Fig. 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 750 "Ancho" => 3222 "Tamanyo" => 164966 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0185" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil group – analgesic effect comparison between the first hour and time point 0.</p>" ] ] 9 => array:8 [ "identificador" => "fig0050" "etiqueta" => "Fig. 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 754 "Ancho" => 3222 "Tamanyo" => 166945 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil group – analgesic effect comparison between hour 3 and time point 0.</p>" ] ] 10 => array:8 [ "identificador" => "fig0055" "etiqueta" => "Fig. 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 624 "Ancho" => 3223 "Tamanyo" => 146614 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil group – analgesic effect comparison between time point 0 and final time point (delivery).</p>" ] ] 11 => array:8 [ "identificador" => "fig12" "etiqueta" => "Fig. 12" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr12.jpeg" "Alto" => 861 "Ancho" => 3223 "Tamanyo" => 196784 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Pain intensity, remifentanil group – (subgroup of low bias risk studies: Douma and Volmanen) – analgesic effect comparison between the first hour and time point 0.</p>" ] ] 12 => array:8 [ "identificador" => "fig0065" "etiqueta" => "Fig. 13" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr13.jpeg" "Alto" => 858 "Ancho" => 3214 "Tamanyo" => 144683 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Risk of nausea – comparison between the remifentanil and epidural groups.</p>" ] ] 13 => array:8 [ "identificador" => "fig0070" "etiqueta" => "Fig. 14" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr14.jpeg" "Alto" => 856 "Ancho" => 3214 "Tamanyo" => 144391 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Risk of instrumented delivery – comparison between the remifentanil and epidural groups.</p>" ] ] 14 => array:8 [ "identificador" => "fig0075" "etiqueta" => "Fig. 15" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr15.jpeg" "Alto" => 913 "Ancho" => 3249 "Tamanyo" => 161038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Risk of instrumented delivery – comparison between the remifentanil and epidural groups (subgroup of studies biased in favour of remifentanil).</p>" ] ] 15 => array:8 [ "identificador" => "fig0080" "etiqueta" => "Fig. 16" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr16.jpeg" "Alto" => 878 "Ancho" => 3250 "Tamanyo" => 152098 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Risk of caesarean section – comparison between the remifentanil and epidural groups.</p>" ] ] 16 => array:8 [ "identificador" => "fig0085" "etiqueta" => "Fig. 17" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr17.jpeg" "Alto" => 4033 "Ancho" => 3168 "Tamanyo" => 285736 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Funnel plot for pain at: A. time point 0 (baseline); B. 1<span class="elsevierStyleHsp" style=""></span>h; C. 2<span class="elsevierStyleHsp" style=""></span>h; D. 3<span class="elsevierStyleHsp" style=""></span>h; E. final time point.</p>" ] ] 17 => array:8 [ "identificador" => "fig0105" "etiqueta" => "Fig. 18" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr18.jpeg" "Alto" => 2703 "Ancho" => 3244 "Tamanyo" => 204363 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Funnel plot for incidence and risk of: A. nausea; B. instrumented delivery; and C. caesarean section.</p>" ] ] 18 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "tabla" => array:1 [ "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">Study \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">Year \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">N</span> \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">Intervention remifentanil \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">N</span> \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">Intervention epidural \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 population \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">Outcome \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">Reference \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">Volmanen et al. \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">2007 \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 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCA Shot 0.1<span class="elsevierStyleHsp" style=""></span>mcg/kg, ineffectual:Increase 0.1 – 0.2 – 0.33 – 0.5 – 0.7 – 0.9<span class="elsevierStyleHsp" style=""></span>mcg/kg \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">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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Levobupivacaine 10<span class="elsevierStyleHsp" style=""></span>cc bolus 0.625%<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Fentanyl 2<span class="elsevierStyleHsp" style=""></span>mcg/cc, infusion at 10<span class="elsevierStyleHsp" style=""></span>cc/h Levobupivacaine 0.625%<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Fentanyl 2<span class="elsevierStyleHsp" style=""></span>mcg/cc \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><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">Pain according to baseline VAS every 10<span class="elsevierStyleHsp" style=""></span>min until the first hour \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0070">14</a> \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">Sołek-Pastuszka et al. \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">2009 \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 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCA Shot 0.2<span class="elsevierStyleHsp" style=""></span>mcg/kg, ineffectual: Increase of 0.2 every 10<span class="elsevierStyleHsp" style=""></span>min up to 0.8<span class="elsevierStyleHsp" style=""></span>mcg/kg \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 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.125% Bupivacaine 10<span class="elsevierStyleHsp" style=""></span>cc bolus<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Fentanyl 0.1<span class="elsevierStyleHsp" style=""></span>mg, infusion at 1<span class="elsevierStyleHsp" style=""></span>cc/h 0.125% Bupivacaine, PCEA 4<span class="elsevierStyleHsp" style=""></span>cc 15<span class="elsevierStyleHsp" style=""></span>min interval, ineffectual 0.25% bupivacaine 5<span class="elsevierStyleHsp" style=""></span>cc (all mixes with epinephrine) \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 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain according to baseline Visual Analogue Scale (VAS) and every hour until delivery \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0100">20</a> \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">El-Kerdawy and Farouk \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">2010 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial bolus, 0.5<span class="elsevierStyleHsp" style=""></span>mcg/kg in 20<span class="elsevierStyleHsp" style=""></span>s, PCA shot 0.25<span class="elsevierStyleHsp" style=""></span>mcg/kg, 5<span class="elsevierStyleHsp" style=""></span>min interval, Max 3<span class="elsevierStyleHsp" style=""></span>mg c/4<span class="elsevierStyleHsp" style=""></span>h, infusion, 0.05<span class="elsevierStyleHsp" style=""></span>mcg/kg/min \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25% bupivacaine bolus 10–15<span class="elsevierStyleHsp" style=""></span>cc<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Fentanyl 1<span class="elsevierStyleHsp" style=""></span>mcg/cc, infusion 10–12<span class="elsevierStyleHsp" style=""></span>cc/h 0.125%<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mcg/cc \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">30 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain according to baseline VAS in the first hour and at the time of delivery \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0105">21</a> \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">Douma et al. \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">2011 \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">10 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial bolus 40<span class="elsevierStyleHsp" style=""></span>mcg, PCA Shot 40<span class="elsevierStyleHsp" style=""></span>mcg, 2<span class="elsevierStyleHsp" style=""></span>min interval, max 1200<span class="elsevierStyleHsp" style=""></span>mcg \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">10 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2% Ropivacaine bolus 12.5<span class="elsevierStyleHsp" style=""></span>cc, infusion at 10<span class="elsevierStyleHsp" style=""></span>cc/h 0.1% Ropivacaine<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Sufentanil 0.5<span class="elsevierStyleHsp" style=""></span>mcg/cc \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain according to Visual Analogue Scale (VAS) and every hour until hour 3 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0110">22</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab560272.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Studies included.</p>" ] ] 19 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "tabla" => array:1 [ "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">Study \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">Reason for exclusion \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">Bibliographic reference \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="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">PUBMED</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">Ng et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention (Pethidine) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0115">23</a> \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">Natalini et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention (Other outcomes) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0120">24</a> \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">Volmanen et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0125">25</a> \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">Douma et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Different interventions \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0130">26</a> \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">Evron et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0135">27</a> \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">Gospic et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant due to topic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0140">28</a> \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">Balcioglu et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0145">29</a> \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">Balki et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0150">30</a> \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">Volikas et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0155">31</a> \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">Mesolella et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant due to topic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0160">32</a> \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">Volmanen et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention (Nitrous oxide) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0165">33</a> \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">Evron et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention (Meperidine) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0170">34</a> \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">Blair et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0065">13</a> \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">Pleym et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant due to topic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0175">35</a> \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">Volikas and Male \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention (Pethidine) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0180">36</a> \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">Thurlow et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention (Pethidine) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0185">37</a> \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">Volmanen et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and Design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0190">38</a> \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">Blair et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and Design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0195">39</a> \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">Pittarello et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant due to topic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0200">40</a> \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">Roelants et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0205">41</a> \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">Olufolabi et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention and design \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0210">42</a> \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 " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">LILACS</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">Soares et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant (Review) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0215">43</a> \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">Aristizábal and Londoño \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant (Design) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0220">44</a> \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">Costa et al. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant due to topic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0225">45</a> \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">Vale et el. \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irrelevant due to topic \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0230">46</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab560273.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">Excluded studies (PUBMED and LILACS).</p>" ] ] 20 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "tabla" => array:1 [ "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">Study \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">COCHRANE \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">BIAS RISK \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">VOLMANEN – 2007<span class="elsevierStyleSup">(14)</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">++++++/++++++ (100%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LOW \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">SOLEK – 2009<span class="elsevierStyleSup">(19)</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+++/++++++ (50%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HIGH \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">EL KERDAWY 2010<span class="elsevierStyleSup">(20)</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+++/++++++ (50%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HIGH \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">DOUMA – 2011<span class="elsevierStyleSup">(21)</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+++++/++++++ (84%) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LOW \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab560274.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar1185" class="elsevierStyleSimplePara elsevierViewall">Risk of Bias evaluated according to the Cochrane checklist for bias evaluation in Clinical Trials (Inter-rater agreement for Cochrane Criteria: Kappa=0.92).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:52 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Levobupivacaine for epidural analgesia in labor: the sparing effect of epidural fentanyl" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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Duran R. – Hospital Universitario de la Samaritana Research Centre); and our families (CSAP).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22562087/0000004200000004/v1_201409200219/S2256208714000716/v1_201409200219/en/main.assets" "Apartado" => array:4 [ "identificador" => "951" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific and Technological Research" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22562087/0000004200000004/v1_201409200219/S2256208714000716/v1_201409200219/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714000716?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 33 | 1 | 34 |
| 2024 September | 26 | 4 | 30 |
| 2024 August | 18 | 4 | 22 |
| 2024 July | 28 | 1 | 29 |
| 2024 June | 13 | 5 | 18 |
| 2024 May | 12 | 2 | 14 |
| 2024 April | 18 | 4 | 22 |
| 2024 March | 48 | 5 | 53 |
| 2024 February | 38 | 7 | 45 |
| 2024 January | 17 | 6 | 23 |
| 2023 December | 23 | 12 | 35 |
| 2023 November | 36 | 11 | 47 |
| 2023 October | 41 | 10 | 51 |
| 2023 September | 27 | 4 | 31 |
| 2023 August | 26 | 7 | 33 |
| 2023 July | 15 | 2 | 17 |
| 2023 June | 17 | 3 | 20 |
| 2023 May | 25 | 5 | 30 |
| 2023 April | 17 | 4 | 21 |
| 2023 March | 21 | 5 | 26 |
| 2023 February | 21 | 4 | 25 |
| 2023 January | 14 | 5 | 19 |
| 2022 December | 11 | 2 | 13 |
| 2022 November | 23 | 5 | 28 |
| 2022 October | 23 | 7 | 30 |
| 2022 September | 23 | 8 | 31 |
| 2022 August | 18 | 5 | 23 |
| 2022 July | 23 | 9 | 32 |
| 2022 June | 17 | 4 | 21 |
| 2022 May | 22 | 4 | 26 |
| 2022 April | 18 | 16 | 34 |
| 2022 March | 9 | 8 | 17 |
| 2022 February | 11 | 3 | 14 |
| 2022 January | 15 | 4 | 19 |
| 2021 December | 10 | 9 | 19 |
| 2021 November | 12 | 4 | 16 |
| 2021 October | 6 | 10 | 16 |
| 2021 September | 8 | 11 | 19 |
| 2021 August | 12 | 6 | 18 |
| 2021 July | 5 | 4 | 9 |
| 2021 June | 5 | 4 | 9 |
| 2021 May | 6 | 5 | 11 |
| 2021 April | 51 | 21 | 72 |
| 2021 March | 9 | 5 | 14 |
| 2021 February | 5 | 9 | 14 |
| 2021 January | 5 | 6 | 11 |
| 2020 December | 9 | 4 | 13 |
| 2020 November | 12 | 2 | 14 |
| 2020 October | 3 | 5 | 8 |
| 2020 September | 4 | 8 | 12 |
| 2020 August | 16 | 9 | 25 |
| 2020 July | 11 | 7 | 18 |
| 2020 June | 9 | 1 | 10 |
| 2020 May | 10 | 6 | 16 |
| 2020 April | 4 | 3 | 7 |
| 2020 March | 4 | 1 | 5 |
| 2020 February | 8 | 3 | 11 |
| 2020 January | 6 | 2 | 8 |
| 2019 December | 5 | 5 | 10 |
| 2019 November | 2 | 1 | 3 |
| 2019 October | 1 | 1 | 2 |
| 2019 September | 2 | 4 | 6 |
| 2019 August | 1 | 3 | 4 |
| 2019 July | 1 | 9 | 10 |
| 2019 June | 0 | 3 | 3 |
| 2019 May | 2 | 13 | 15 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 3 | 1 | 4 |
| 2018 May | 102 | 6 | 108 |
| 2018 April | 80 | 6 | 86 |
| 2018 March | 174 | 9 | 183 |
| 2018 February | 86 | 6 | 92 |
| 2018 January | 159 | 3 | 162 |
| 2017 December | 77 | 4 | 81 |
| 2017 November | 24 | 6 | 30 |
| 2017 October | 27 | 10 | 37 |
| 2017 September | 41 | 9 | 50 |
| 2017 August | 62 | 5 | 67 |
| 2017 July | 58 | 5 | 63 |
| 2017 June | 59 | 10 | 69 |
| 2017 May | 57 | 6 | 63 |
| 2017 April | 63 | 9 | 72 |
| 2017 March | 44 | 14 | 58 |
| 2017 February | 22 | 2 | 24 |
| 2017 January | 22 | 9 | 31 |
| 2016 December | 40 | 14 | 54 |
| 2016 November | 38 | 11 | 49 |
| 2016 October | 41 | 6 | 47 |
| 2016 September | 44 | 6 | 50 |
| 2016 August | 58 | 11 | 69 |
| 2016 July | 34 | 11 | 45 |
| 2016 May | 2 | 21 | 23 |
| 2016 March | 4 | 18 | 22 |
| 2016 February | 3 | 0 | 3 |
| 2016 January | 4 | 0 | 4 |
| 2015 December | 13 | 8 | 21 |
| 2015 November | 52 | 14 | 66 |
| 2015 October | 91 | 16 | 107 |
| 2015 September | 65 | 9 | 74 |
| 2015 August | 59 | 10 | 69 |
| 2015 July | 89 | 5 | 94 |
| 2015 June | 62 | 3 | 65 |
| 2015 May | 64 | 10 | 74 |
| 2015 April | 47 | 5 | 52 |
| 2015 March | 55 | 13 | 68 |
| 2015 February | 57 | 6 | 63 |
| 2015 January | 79 | 11 | 90 |
| 2014 December | 83 | 14 | 97 |
| 2014 November | 37 | 9 | 46 |
| 2014 October | 107 | 17 | 124 |
| 2014 September | 17 | 8 | 25 |
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