Liquid handling, lidocaine and epinephrine in liposuction. The properly form

array:24 ["pii" => "S225620871400114X" "issn" => "22562087" "doi" => "10.1016/j.rcae.2014.10.003" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "173" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "copyrightAnyo" => "2014" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "ssu" "cita" => "Rev Colomb Anestesiol. 2015;43:95-100" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2687 "formatos" => array:3 [ "EPUB" => 79 "HTML" => 2157 "PDF" => 451 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0120334714001324" "issn" => "01203347" "doi" => "10.1016/j.rca.2014.09.007" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "173" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "documento" => "article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/3.0/" "subdocumento" => "ssu" "cita" => "Rev Colomb Anestesiol. 2015;43:95-100" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 30789 "formatos" => array:3 [ "EPUB" => 90 "HTML" => 27874 "PDF" => 2825 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "REVISIÓN" "titulo" => "Manejo de líquidos, lidocaína y epinefrina en liposucción. La forma correcta" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "95" "paginaFinal" => "100" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Liquid handling, lidocaine and epinephrine in liposuction. The properly form" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2473 "Ancho" => 1670 "Tamanyo" => 507862 ] ] "descripcion" => array:1 [ "es" => "Rescate y resucitación con lípidos al 20% ante una intoxicación con anestésicos locales que lleve a parada cardiaca. Tomado de la página www.lipidrescue.org y avalado por la Sociedad Americana de Anestesia Regional y la Sociedad Americana de Cirugía Plástica." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jorge Enrique Bayter Marin" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Jorge Enrique" "apellidos" => "Bayter Marin" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S225620871400114X" "doi" => "10.1016/j.rcae.2014.10.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225620871400114X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0120334714001324?idApp=UINPBA00004N" "url" => "/01203347/0000004300000001/v2_201706012200/S0120334714001324/v2_201706012200/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2256208714001187" "issn" => "22562087" "doi" => "10.1016/j.rcae.2014.10.006" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "176" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Colomb Anestesiol. 2015;43:101-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2897 "formatos" => array:3 [ "EPUB" => 90 "HTML" => 2340 "PDF" => 467 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "Essay" "titulo" => "Intrathecal opioids and respiratory depression: Is it myth in obstetrics?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "101" "paginaFinal" => "103" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Opioides intratecales y depresión respiratoria: ¿un mito en obstetricia?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro José Herrera Gómez, Juan Federico Garzón" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Pedro José Herrera" "apellidos" => "Gómez" ] 1 => array:2 [ "nombre" => "Juan Federico" "apellidos" => "Garzón" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S012033471400135X" "doi" => "10.1016/j.rca.2014.09.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S012033471400135X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714001187?idApp=UINPBA00004N" "url" => "/22562087/0000004300000001/v1_201501210932/S2256208714001187/v1_201501210932/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2256208714000741" "issn" => "22562087" "doi" => "10.1016/j.rcae.2014.06.004" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "149" "copyright" => "Sociedad Colombiana de Anestesiología y Reanimación" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Colomb Anestesiol. 2015;43:87-94" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2362 "formatos" => array:3 [ "EPUB" => 89 "HTML" => 1729 "PDF" => 544 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Scientific and Technological Research" "titulo" => "Cost/effectiveness evaluation of three fixed combinations of acetaminophen and opioids in the management of acute pain in Colombia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "94" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de costo/efectividad de tres combinaciones fijas de acetaminofén y opiáceos para el manejo del dolor agudo en Colombia" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2170 "Ancho" => 1625 "Tamanyo" => 214300 ] ] "descripcion" => array:1 [ "en" => "A) Codeine/Acet vs. hydrocodone/Acet. B) Codeine/Acet vs. tramadol/Acet." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rafael Alfonso Cristancho, Andres I. Vecino, Juan Diego Misas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Rafael Alfonso" "apellidos" => "Cristancho" ] 1 => array:2 [ "nombre" => "Andres I." "apellidos" => "Vecino" ] 2 => array:2 [ "nombre" => "Juan Diego" "apellidos" => "Misas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S012033471400080X" "doi" => "10.1016/j.rca.2014.05.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S012033471400080X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714000741?idApp=UINPBA00004N" "url" => "/22562087/0000004300000001/v1_201501210932/S2256208714000741/v1_201501210932/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Liquid handling, lidocaine and epinephrine in liposuction. The properly form" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "95" "paginaFinal" => "100" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Jorge Enrique Bayter Marin" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Jorge Enrique Bayter" "apellidos" => "Marin" "email" => array:1 [ 0 => "jokibay@yahoo.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "MD, Anesthesiologist and Intensivist, Medical Director Clínica El Pinar, Bucaramanga, Colombia. Anesthesia for Plastic Surgery Coordinating Committee, Sociedad Colombiana de Antesiología y Reanimación (S.C.A.R.E.), Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo de líquidos, lidocaína y epinefrina en liposucción. La forma correcta" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2445 "Ancho" => 2177 "Tamanyo" => 556123 ] ] "descripcion" => array:1 [ "en" => "Rescue and resuscitation with 20% lipid, before a local anesthetic intoxication leading to heart arrest. Taken from the page www.lipidrescue.org and endorsed by the American Society of Regional Anesthesia and the American Society of Plastic Surgeons." ] ] ] "textoCompleto" => "IntroductionLiposuction is the most common cosmetic surgery procedure performed in the United States<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and also in Colombia. Advances in the techniques for infiltration, designed to allow placement of epinephrine in a solution, thus reducing bleeding during lipoaspiration, have enabled removal in large volumes during liposuction. This induces significant changes in fluid behaviour inside the compartment, with the risk of pulmonary oedema and heart failure.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Added to the invention by Klein in 1987 of a tumescent solution that included 500–1000mg of lidocaine plus 1mg of epinephrine for every 1000cc of NSS<a class="elsevierStyleCrossRef" href="#bib0015">3</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and which is widely used today for subcutaneous infiltration, the risk of lidocaine toxicity is a reality and the second cause of death in plastic surgery according to the American Society of Plastic Surgeons (ASPS).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The biggest problem with these new infiltration techniques, in particular the super wet and the tumescent techniques is associated with the large infiltration volumes, at infiltration/aspiration ratios ranging from 1:1 in the super wet technique up to 2–3:1 in the tumescent technique.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> This means that in a 3-litre liposuction, subcutaneous fluid infiltration may amount to 3–9 litres, and this fluid volume requires special consideration from the point of view of anaesthesia.MethodsNon-systematic review of the literature using the PubMed and Medline databases, introducing key words in English like Fluid Management, Liposuction, pulmonary oedema, larger infiltration, Aspiration volumes. All the articles were read and other articles of the selected references regarding the topic were also queried. Overall, 151 references were selected using this methodology.ReviewThe use of large infiltration volumes in the tumescent solutions increases the difficulty of anaesthetic management in liposuction significantly. The risk of hypervolemia, pulmonary oedema, epinephrine-related cardiovascular effects, and lidocaine toxicity is always present.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>The purpose of using infiltration solutions with 1mg of epinephrine in 1000cc of Hartman's or NSS is to reduce bleeding into the lipoaspirate down to less than 5% of the extracted volume.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> This results in the ability to perform large-volume liposuction, with the ensuing complications. Some studies conducted by Burk and Vasconez<a class="elsevierStyleCrossRef" href="#bib0035">7</a> have shown the use of up to 10mg of epinephrine at concentrations of 1:1,000,000 in healthy patients, with no deleterious effects from toxicity such as tachycardia and hypertension, although these megadoses may lead to fatal consequences in patients with underlying cardiac disease in whom no workup has been done.The second problem, when Klein solutions are used, is the infiltration of high doses of lidocaine (500–1000mg of 1% lidocaine for every 1000cc of NSS). There are multiple studies in the world literature conducted in plastic surgery patients that show that very high doses of lidocaine (up to 35–55mg/kg) could be safe<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> considering that the infiltration is applied to scarcely vascularized adipose tissue and, moreover, considering the additional vasoconstriction derived from the use of epinephrine in the dilution. These studies have shown a margin of safety in thousands of liposuction procedures performed, with no risk of toxic levels despite the high doses of infiltrated lidocaine.As far as anaesthesia is concerned, the FDA only accepts maximum doses of 7–10mg/kg. The ASPS has reported that lidocaine toxicity may be an important cause of death in plastic surgery and might account for some intra- and post-operative deaths resulting from cardiac arrest in conditions of normal oxygen saturation. However, this is very difficult to demonstrate because of the difficulty in measuring post-mortem serum levels, something that is usually done late or not done at all. It is worth noting that the use of high lidocaine doses has enabled dermatologists and surgeons to perform liposuction in their offices using local anaesthesia without the support of an anaesthetist, with the sole purpose of lowering the costs associated with the use of the operating room and the support of the anaesthetist. For this reason, our recommendation, when large quantities of lidocaine are used for infiltration, is that an anaesthetist must be present in the room and must be prepared to manage lidocaine toxicity-related cardiac arrest. Additionally, 20% lipids must be available in the room as the only effective measure to revert cardiac arrest while waiting for resuscitation. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, shows the protocol for the management of local anaesthetic toxicity-related cardiac arrest, endorsed by the American Society of Regional Anaesthesia and the American Society of Plastic Surgeons, and published in <a href="http://www.lipidrescue.org/">www.lipidrescue.org</a> together with the supporting literature.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The third issue relates to the large volumes of infiltrated fluids and volume overloading: in a 4-litre liposuction, subcutaneous fluid infiltration may be as high as 12 litres.In 1998, the University of Texas Southwestern Medical Centre defined that a large-volume liposuction is the removal of more than 4000cc of fat, while a small-volume liposuction corresponds to the removal of less than 4000cc. The same study determined that the volume of fluids delivered is equal to the volume of infiltration fluids given by the plastic surgeon plus the volume of intravenous fluids given by the anaesthetist. When added together and then divided by the liposuction volume, the ratio should not be greater than 2 for liposuctions under 4L (or 8 litres of fluids administered when intravenous and infiltration fluids are added together, in a 4-litre liposuction), or greater than 1.4 for liposuctions of more than 4 litres. In this study of 53 patients there were no cases of complications or fluid overload, and diuresis was maintained at a level higher than 1cc/k/h. In a later study by Rohrich in 89 patients,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> it was shown, in essence, that the use of this same formula for liposuction does not result in complications.In plastic surgery, pulmonary oedema is the third cause of death, resulting mainly from human error associated with the lack of knowledge of the basic physiological principles of infiltration, the lack of protocols, and poor communication between the surgeon and the anaesthetist. In a study conducted in The Netherlands in 50% of the hospitals between 1995 and 1997, it was found that 2–4% of all anaesthesia-related deaths were due to poor fluid management and pulmonary oedema, and medical error was demonstrated in 85% of these fatal cases.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>The main physiological consideration is that most of the infiltrated fluids go into the general circulation and only 22–29% is recovered with lipoaspiration.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> This means that up to 70% of infiltration fluids, lidocaine and epinephrine go into the intravascular space. Later studies have shown that 1 litre of subcutaneous infiltration is fully resorbed if not removed within 163min, and that 70% of the lidocaine and epinephrine is totally resorbed, with maximum peaks at 12 and 5h.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>In a study of 5 healthy ASA 1 women<a class="elsevierStyleCrossRef" href="#bib0070">14</a> undergoing large-volume liposuction, a Swan-Ganz catheter was used for 24-h monitoring in the ICU, with continuous measurement of the haemodynamic parameters in order to assess the effects of the infiltration and the high adrenaline doses. It was determined that cardiac index, heart rate and mean pulmonary artery pressure increased by more than 45%, while central venous pressure increased from 4 to 14cm H2O 8h into the postoperative period.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Moreover, the same study showed that all patients were hypothermic during surgery with recorded temperatures under 35.5°C.High doses of epinephrine are used routinely in liposuction, with all the haemodynamic implications. Epinephrine reaches maximum concentration levels 3–5h after subcutaneous administration. After infiltrating 7mg of adrenaline, serum levels reach 323pg/ml, very similar to the levels found in aortic clamping or coronary bypass,<a class="elsevierStyleCrossRefs" href="#bib0075">15,7</a> which are 3 or 4 times as high as baseline levels. In fact, there are anecdotal reports on epinephrine-related complications in patients with previously undiagnosed coronary heart disease; this is due to the low rate of its systemic absorption in fat and to its vasoconstriction effect, and the potential protective anti-arrhythmic effect of lidocaine.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The presence of lidocaine in the infiltration may lead to serious and even fatal complications. Neurological symptoms appear when levels are above 5¿g/cc, and there is cardiovascular collapse with levels higher than 10¿g/cc.<a class="elsevierStyleCrossRef" href="#bib0090">16</a> Apparently, many studies have shown a certain margin of safety with subcutaneous lidocaine infiltration, even in doses as high as 55mg/kg, due to the low vascularity of fat and the vasoconstrictor effect of adrenaline.<a class="elsevierStyleCrossRefs" href="#bib0095">17–19</a> The problem is that its release from fat is also slow, and it has been shown that maximum levels are reached within 8–12h after the infiltration<a class="elsevierStyleCrossRef" href="#bib0115">20</a> when the patient is already at home, creating an additional risk. It is also important to take into consideration differential absorption rates, given that when the face is infiltrated, maximum concentrations are reached after 5h, but when the abdomen and the thighs are infiltrated, they peak at 12h, and at some point there may be a summation effect.<a class="elsevierStyleCrossRef" href="#bib0100">18</a> Lidocaine metabolism may worsen the situation in cases of toxicity. Lidocaine is cleared mainly through liver metabolism (95%) while only 5% is cleared through the urine.<a class="elsevierStyleCrossRef" href="#bib0125">21</a> It is deacetylated to monoethyliglycinexylidine (MEGX) which is then deacetylated to glycinexylidine (GX). The two enzymes responsible for this action are CYP3A4 and CYP1A2 which belong to the cytochrome P450 family of isoenzymes.<a class="elsevierStyleCrossRefs" href="#bib0125">21,22</a> These isoenzymes may be inhibited by various commonly used drugs, including ciprofloxacin, cimetidine, erythromycin, amiodarone, ketoconazole, fluconazole and even propofol;<a class="elsevierStyleCrossRefs" href="#bib0125">21,22</a> or the metabolism may be altered by drugs that compete for the same enzyme, as is the case of midazolam and fentanyl, which are also metabolized by CYP3A4.<a class="elsevierStyleCrossRefs" href="#bib0125">21,22</a> This is very important because these drugs not only may alter the metabolism but also may mask the initial signs of intoxication, leading to serious neurological or cardiovascular symptoms. Although these subcutaneous megadoses of 35–50mg/kg of lidocaine may seem suboptimal, intraoperative deaths have been reported due to heart block in conditions of normal oxygen saturation. In those cases, the autopsy does not find any abnormality,<a class="elsevierStyleCrossRef" href="#bib0135">23</a> and lidocaine levels may appear normal; however post-mortem stability of lidocaine has not been demonstrated so far. In a census carried out among all the members of the American Society of Plastic Surgeons in 2000, mortality from liposuction was shown to be 1 out of every 5000 procedures. The primary cause of death was PTE, but it was also found that most deaths occurred on the first postoperative night, so lidocaine toxicity and residual anaesthetic effects are not ruled out as an important cause of mortality.Although PTE is the main cause of death, there are stringent, well developed protocols for prophylaxis that may lower the incidence of DVT and PTE by 85%, and of fatal PTE by 95%. The problem with fluid management in liposuction is that with the new super wet and tumescent infiltration techniques, fluid overload is a potential risk and there is no consensus regarding its management to this date. There are only a few empirical division formulae for fluid delivery versus infiltration fluids to guide the management of fluid therapy.<a class="elsevierStyleCrossRefs" href="#bib0140">24–26</a> Using these formulae, fluid delivery in a liposuction under 4 litres must follow a ratio of 2 between infiltrated plus intravenous fluids divided by the aspirate, and a ratio of 1.4 in a liposuction of more than 4 litres.<a class="elsevierStyleCrossRefs" href="#bib0140">24–26</a> Despite these formulae, fluid overload continues to be a problem, and there are reports of deaths in liposuction when they are applied. Intravenous fluids are being used less in liposuction, and although the standard is not to use the tumescent technique (3:1) but the super wet technique (1:1), this has contributed to a lowering of fluid delivery down to a ratio of 1.2 between fluids delivered (intravenous plus infiltration) and fat removed, according to Rohrich.<a class="elsevierStyleCrossRef" href="#bib0140">24</a> Recently, a study was conducted with 30 patients undergoing large volume liposuctions of more than 6 litres in which half of the patients received fluids according to Rohrich, i.e. a 1.2 ratio (for a 6-litre liposuction they could receive only a maximum of 7200cc of infiltrated plus intravenous fluids) and the other half of the patients received fluids on the basis of systolic volume variation using the arterial line thermodilution technique (LIDCO).<a class="elsevierStyleCrossRef" href="#bib0155">27</a> This study showed that, in large-volume liposuction where infiltration was greater than 1:1, intravenous fluids were used only for maintenance −500 to 600cc over the 5h of surgery – and an excellent stroke volume was achieved, with diuresis remaining always above 1.2cc/k/h.<a class="elsevierStyleCrossRefs" href="#bib0155">27–29</a> Studies show that intravenous fluid quantities must be as low as possible when super wet techniques are used<a class="elsevierStyleCrossRefs" href="#bib0170">30,31</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), and there are some that have even proposed abolishing intravenous fluids.<a class="elsevierStyleCrossRef" href="#bib0180">32</a> In conclusion, when liposuction is performed as a single procedure, conservative management of intravenous fluids is required, considering that infiltration fluids go into the central circulation. Consequently, the recommendation is to use only maintenance fluids.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>As stated above, fluid management also involves managing infiltration, lidocaine and epinephrine levels, and hypothermia.<a class="elsevierStyleCrossRef" href="#bib0185">33</a> Together, these factors are responsible for numerous reports of deaths due to myocardial infarction, pulmonary oedema and lidocaine toxicity.<a class="elsevierStyleCrossRefs" href="#bib0185">33–43</a>.Although it is not within the scope of this paper, it needs to be mentioned that the subcutaneous infusion of these large volumes of infiltration fluids at ambient temperature means that temperature in all patients remains under 36°C. Consequently, we are required to take the necessary steps to avoid hypothermia, considering that it may lead to problems such as bleeding, AMI and seromas.<a class="elsevierStyleCrossRefs" href="#bib0240">44–47</a>ConclusionsCorrect fluid and infiltration management, together with the steps for preventing DVT and PTE, is the most important measure to reduce complications and deaths in plastic surgery. Regarding fluid management in liposuction, when super wet or tumescent techniques are used, the worldwide recommendation is to use a minimum amount of intravenous fluids, that is, only maintenance fluids, because the infiltrated volume is sufficient (1.2 maximum ratio between fluid delivery and fat removal).As for the dose of epinephrine in the infiltration, it should not be higher than 6mg or 1kg/kg, as long as the patient does not have an underlying cardiovascular disease.As for lidocaine, although the FDA recommends a maximum of 7–10mg/kg, there are multiple studies showing that higher doses (35mg/kg) are relatively safe. Consequently, in cases of infiltration with large volumes of lidocaine, our recommendation is that the procedure must be performed under the constant supervision of an anaesthetist who must be prepared to manage lidocaine toxicity-related cardiac arrest. Moreover, 20% lipids must be available in the room as the sole effective measure to revert cardiac arrest while waiting for resuscitation.FinancingNo.Conflicts of interestThe author is coordinator of the Committee on Anesthesia for Plastic Surgery, Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres412682" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objectives" 3 => "Methods" 4 => "Results and conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec388406" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres412681" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Objetivos" 3 => "Métodos" 4 => "Resultados y conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec388407" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Review" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Financing" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-28" "fechaAceptado" => "2014-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec388406" "palabras" => array:5 [ 0 => "Lipectomy" 1 => "Pulmonary edema" 2 => "Anesthetics, local" 3 => "Toxicity" 4 => "Surgery, plastic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec388407" "palabras" => array:5 [ 0 => "Lipiectomía" 1 => "Edema Pulmonar" 2 => "Anestésicos locales" 3 => "Toxicidad" 4 => "Cirugía plástica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionFluid mismanagement in liposuction leads to pulmonary edema in a previously healthy individual. Pulmonary edema is considered the third cause of death in plastic surgery after PTE and lidocaine toxicity. The most important risk factor leading to this outcome is inadequate knowledge of fluid management and poor communication between the surgeon and the anaesthetist. ObjectivesTo review the causes leading up to pulmonary edema in liposuction and the valid options for correct fluid management. MethodsNon-systematic review of the literature in PubMed and Medline. Results and conclusionsCorrect fluid management in liposuction is based on a close communication between the surgeon and the anaesthetist in order to keep track of the total amount of subcutaneous fluid infiltration plus fluids delivered intravenously, always bearing in mind that infiltration fluids go to the central circulation." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl mal manejo de líquidos en liposucción, conlleva a edema pulmonar en un paciente previamente sano. El edema pulmonar se considera la tercera causa de muerte en cirugía plástica después del TEP y la Intoxicación por lidocaína. El principal factor de riesgo que conlleva a este desenlace es el desconocimiento en el manejo de líquidos y la mala comunicación entre el cirujano y el anestesiólogo. ObjetivosRevisar las causas que llevan a edema pulmonar en liposucción y las opciones validas de manejo correcto de líquidos. MétodosSe realizó una revisión de la literatura no sistemática en las bases de datos PubMed y Medline. Resultados y conclusionesEl correcto manejo de líquidos en liposucción se basa en una estrecha comunicación entre el cirujano y el anestesiólogo para sumar los líquidos infiltrados a nivel subcutáneo y los colocados por vía venosa, siempre teniendo en cuenta que los líquidos de la infiltración pasan a la circulación central." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Marin JEB. Manejo de líquidos, lidocaína y epinefrina en liposucción. La forma correcta. Rev Colomb Anestesiol. 2015;43:95–100." ] ] "multimedia" => array:3 [ 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" => 760 "Ancho" => 2389 "Tamanyo" => 115900 ] ] "descripcion" => array:1 [ "en" => "Klein's solution composition and advantages for bleeding in liposuction." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2445 "Ancho" => 2177 "Tamanyo" => 556123 ] ] "descripcion" => array:1 [ "en" => "Rescue and resuscitation with 20% lipid, before a local anesthetic intoxication leading to heart arrest. Taken from the page www.lipidrescue.org and endorsed by the American Society of Regional Anesthesia and the American Society of Plastic Surgeons." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: 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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group A: Fluids based on systolic volume \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group B: Formula-guided fluids \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Infiltration fluids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7400cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6700cc \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lipoaspirate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8500cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8100cc \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IV fluids administered \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">560cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2400cc \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">INF+IV fluids/aspirate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IO maintenance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">120±18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">122±16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diuresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>1cc/k/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>1cc/k/h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab642078.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison between formula-guided and systolic volume-guided intravenous fluid administration using the LIDCO method in large-volume liposuction." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:47 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of subcutaneous infiltration in suction-assisted lipoplasty: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.J. Rohrich" 1 => "S.J. Beran" 2 => "P.B. Fodor" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1996" "volumen" => "9" "paginaInicial" => "514" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors contributing to adverse effects of the tumescent technique (surgical strategies)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F.M. Grazer" 1 => "F.L. Meister" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Aesthetic Surg J" "fecha" => "1997" "volumen" => "7" "paginaInicial" => "411" "paginaFinal" => "416" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The tumescent technique for liposuction surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.A. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Cosmetic Surg" "fecha" => "1987" "volumen" => "4" "paginaInicial" => "263" "paginaFinal" => "266" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.A. Trott" 1 => "S.J. Beran" 2 => "R.J. Rohrich" 3 => "J.M. Kenkel" 4 => "W.P. Adams" 5 => "K.W. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1998" "volumen" => "102" "paginaInicial" => "2220" "paginaFinal" => "2225" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9811024" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lidocaine and epinephrine levels in tumescent technique liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.W. Burk" 1 => "G. Guzman-Stein" 2 => "L.O. Vasconez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1996" "volumen" => "97" "paginaInicial" => "1379" "paginaFinal" => "1385" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8643720" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumescent technique for local anesthesia improves safety in large-volume liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.A. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1993" "volumen" => "92" "paginaInicial" => "1085" "paginaFinal" => "1090" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8234507" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lidocaine and epinephrine levels in tumescent technique liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.W. Burk" 1 => "G. Guzman-Stein" 2 => "L.O. Vasconez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1996" "volumen" => "97" "paginaInicial" => "1379" "paginaFinal" => "1384" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8643720" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumescent technique for regional anesthesia permits lidocaine doses of 35mg/kg for liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.A. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Dermatol Surg Oncol" "fecha" => "1990" "volumen" => "16" "paginaInicial" => "248" "paginaFinal" => "252" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2179348" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumescent anesthesia with a lidocaine dose of 55mg/kg is safe for liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Ostad" 1 => "N. Kageyama" 2 => "R. Moy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "1996" "volumen" => "22" "paginaInicial" => "921" "paginaFinal" => "928" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9063507" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fluid resuscitation in liposuction: a retrospective review of 89 consecutive patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.J. Rohrich" 1 => "E. Jason" 2 => "Leedy" 3 => "J.R. Swamy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.prs.0000201477.30002.ce" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2006" "volumen" => "117" "paginaInicial" => "431" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16462322" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mortality associated with anaesthesia: a qualitative analysis to identify risk factors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.S. Arbous" 1 => "D.E. Grobbee" 2 => "J.W. van Kleef" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2001" "volumen" => "56" "paginaInicial" => "1141" "paginaFinal" => "1153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11736769" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood loss during liposuction using the tumescent technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Samdal" 1 => "P.F. Amland" 2 => "J.F. Bugge" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Aesthetic Plast Surg" "fecha" => "1994" "volumen" => "18" "paginaInicial" => "157" "paginaFinal" => "162" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8017219" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumescent liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.H. Pitman" 1 => "J.S. Aker" 2 => "Z.D. Tripp" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Plast Surg" "fecha" => "1996" "volumen" => "23" "paginaInicial" => "633" "paginaFinal" => "638" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8906394" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemodynamic physiology and thermoregulation in liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.M. Kenkel" 1 => "A.H. Lipschitz" 2 => "M. Luby" 3 => "I. Kallmeyer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2004" "volumen" => "114" "paginaInicial" => "503" "paginaFinal" => "513" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15277823" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmacokinetics and safety of epinephrine use in liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.A. Brown" 1 => "A.H. Lipschitz" 2 => "J.M. Kenkel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2004" "volumen" => "114" "paginaInicial" => "756" "paginaFinal" => "765" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15318058" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0090" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rapid absorption of tumescent lidocaine above the clavicles: a prospective clinical study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.P. Rubin" 1 => "X. Zhongcong" 2 => "Ch. Davidson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2005" "volumen" => "115" "paginaInicial" => "1744" "paginaFinal" => "1751" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15861085" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0095" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.A. Feisher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Anesthesia" "paginaInicial" => "893" "paginaFinal" => "920" "serieFecha" => "2005" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0100" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reduction of lipoplasty risks and mortality: an ASAPS survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.E. Hughes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ann Plast Surg" "fecha" => "2001" "volumen" => "21" "paginaInicial" => "120" "paginaFinal" => "127" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0105" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lidocaine levels during the first two hours of infiltration of dilute anesthetic solution for tumescent liposuction: rapid versus slow delivery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.J. Butterwick" 1 => "M.P. Goldman" 2 => "S. Sriprachya-Anunt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "1999" "volumen" => "25" "paginaInicial" => "681" "paginaFinal" => "685" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10491056" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0115" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Liver enzyme induction and inhibition: implications for anaesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.P. Sweeney" 1 => "J. Bromilow" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2005.04462.x" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2006" "volumen" => "61" "paginaInicial" => "159" "paginaFinal" => "177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16430569" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0125" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deaths related to liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.B. Rao" 1 => "S.F. Ely" 2 => "R.S. Hoffman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199905133401904" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1999" "volumen" => "340" "paginaInicial" => "1471" "paginaFinal" => "1475" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10320385" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0130" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An update on the role of subcutaneous infiltration in suction-assisted lipoplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.J. Rohrich" 1 => "J.M. Kenkel" 2 => "J.E. Janis" 3 => "S.J. Beran" 4 => "P.B. Fodor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.PRS.0000039396.69495.C5" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2003" "volumen" => "111" "paginaInicial" => "926" "paginaFinal" => "927" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12560722" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0135" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fluid resuscitation in liposuction: a prospective analysis of infiltrate total-aspirate ratios lower than used for the super wet technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.R. Basile" 1 => "F. Fernandes" 2 => "V.V. Basile" 3 => "F.V. Basile" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00266-006-0118-4" "Revista" => array:6 [ "tituloSerie" => "Aesthetic Plast Surg" "fecha" => "2006" "volumen" => "30" "paginaInicial" => "659" "paginaFinal" => "665" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17093883" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0140" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.A. Trott" 1 => "S.J. Beran" 2 => "R.J. Rohrich" 3 => "J.M. Kenkel" 4 => "W.P. Adams Jr." 5 => "K.W. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1998" "volumen" => "102" "paginaInicial" => "2220" "paginaFinal" => "2229" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9811024" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0145" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stroke volume variation as a guide for fluid resuscitation in patients undergoing large-volume liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.K. Jain" 1 => "A.M. Khan" 2 => "M.M. Asma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2012" "volumen" => "130" "paginaInicial" => "462" "paginaFinal" => "469" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0150" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimizing fluid therapy in mechanically ventilated patients after cardiac surgery by on-line monitoring of left ventricular stroke volume variations: a comparison to aortic systolic pressure variations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.A. Reuter" 1 => "T.W. Felbinger" 2 => "E. Kilger" 3 => "C. Schmidt" 4 => "P. Lamm" 5 => "A.E. Goetz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2002" "volumen" => "88" "paginaInicial" => "124" "paginaFinal" => "126" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11881866" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0155" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.A. Reuter" 1 => "A. Kirchner" 2 => "T.W. Felbinger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000059442.37548.E1" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2003" "volumen" => "31" "paginaInicial" => "1399" "paginaFinal" => "1404" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12771609" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0160" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of cosmetic liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.H. de Jong" 1 => "F.M. Grazer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2011" "volumen" => "107" "paginaInicial" => "1039" "paginaFinal" => "1044" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11252101" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0165" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumescent liposuction: a surgeon's perspective" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.H. Pitman" 1 => "J.S. Aker" 2 => "Z.D. Tripp" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Plast Surg" "fecha" => "1996" "volumen" => "23" "paginaInicial" => "633" "paginaFinal" => "641" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8906394" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0170" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Larger infiltration/aspiration volumes, plasma/subcutaneous fluid lidocaine levels and quantitative abdominal tissue accommodation after water-assisted liposuction (WAL): comparative safety and efficacy to traditional liposuction (TL) in advanced techniques in liposuction and fat transfer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.H. Sasaki" 1 => "A. Tevez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "11th ed." "fecha" => "2011" "paginaInicial" => "81" "paginaFinal" => "94" ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0175" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatal outcomes from liposuction: census survey of cosmetic surgeons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F.M. Grazer" 1 => "R.H. de Jong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2000" "volumen" => "105" "paginaInicial" => "436" "paginaFinal" => "442" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10627013" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0180" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatal and near fatal complications of liposuction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.J. Barillo" 1 => "L.C. Cancio" 2 => "S.H. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "South Med J" "fecha" => "1998" "volumen" => "91" "paginaInicial" => "487" "paginaFinal" => "494" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9598863" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0185" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Suction-assisted lipoplasty: complications and fatal outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Gorney" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:3 [ "titulo" => "Presented at the annual meeting of the American Society of Plastic and Reconstructive Surgeons" "conferencia" => "Boston, MA, October" "serieFecha" => "1998" ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0190" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lipoplasty complications and their prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.G. Gingrass" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Plast Surg" "fecha" => "1999" "volumen" => "26" "paginaInicial" => "341" "paginaFinal" => "349" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10549434" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0195" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumescent liposuction alert: deaths from lidocaine cardiotoxicity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.H. de Jong" 1 => "F.M. Grazer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Forensic Med Pathol" "fecha" => "1999" "volumen" => "20" "paginaInicial" => "100" "paginaFinal" => "107" ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0200" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deaths associated with liposuction: case reports and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.S. Platt" 1 => "L.J. Kohler" 2 => "R. Ruiz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Forensic Sci" "fecha" => "2002" "volumen" => "47" "paginaInicial" => "205" "paginaFinal" => "209" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12064654" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0205" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Procedural Statistics Report. Arlington Heights Ill" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "American Society of Plastic Surgeons" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2001" "editorial" => "American Society of Plastic Surgeons" ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0210" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The tumescent technique: anesthesia and modified liposuction technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.A. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatol Clin" "fecha" => "1990" "volumen" => "8" "paginaInicial" => "425" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2199105" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0215" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blood loss during liposuction using the tumescent technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Samdal" 1 => "P.F. Amland" 2 => "J.F. Bugge" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Aesthetic Plast Surg" "fecha" => "1994" "volumen" => "18" "paginaInicial" => "157" "paginaFinal" => "163" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8017219" "web" => "Medline" ] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0220" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.J. Lillis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Dermatol Surg Oncol" "fecha" => "1988" "volumen" => "14" "paginaInicial" => "1145" "paginaFinal" => "1152" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3170931" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0225" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient safety in office-based surgery facilities: 1. Procedures in the office-based surgery setting" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.E. Iverson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.PRS.0000025306.15589.FA" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2002" "volumen" => "110" "paginaInicial" => "1337" "paginaFinal" => "1345" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12360080" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0230" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative heat balance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.I. Sessler" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2000" "volumen" => "92" "paginaInicial" => "578" "paginaFinal" => "584" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10691247" "web" => "Medline" ] ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0235" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictive variables of hypothermia in the early phase of general anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.Y. Yamakage" 1 => "Y. Kamada" 2 => "Y. Homma" 3 => "N. Tsujiguchi" 4 => "A. Namiki" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2000" "volumen" => "90" "paginaInicial" => "456" "paginaFinal" => "463" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10648339" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0240" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postanesthetic shivering: epidemiology, pathophysiology, and approaches to prevention and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Alfonsi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Drugs" "fecha" => "2001" "volumen" => "61" "paginaInicial" => "2193" "paginaFinal" => "2199" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11772130" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0245" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relation between oxygen consumption and cardiac output during inhalation anesthesia under the influence of catecholamines: a study in dogs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T.W. Scheeren" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-2000-306" "Revista" => array:6 [ "tituloSerie" => "Anasthesiol Intensivmed Notfallmed Schmerzther" "fecha" => "2000" "volumen" => "35" "paginaInicial" => "214" "paginaFinal" => "222" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10830073" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0250" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catecholamines, sympathomimetic drugs and adrenergic receptors antagonists" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B.B. Hoffman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "The pharmacological basis of therapeutics" "paginaInicial" => "215" "paginaFinal" => "268" "edicion" => "10th ed." "serieFecha" => "2001" ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0255" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effects of dopamine and epinephrine on hemodynamics and oxygen metabolism in hypoxic anesthetized piglets" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.Y. Cheung" 1 => "K.J. Barrington" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care" "fecha" => "2001" "volumen" => "5" "paginaInicial" => "158" "paginaFinal" => "165" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11353933" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22562087/0000004300000001/v1_201501210932/S225620871400114X/v1_201501210932/en/main.assets" "Apartado" => array:4 [ "identificador" => "34050" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Review articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22562087/0000004300000001/v1_201501210932/S225620871400114X/v1_201501210932/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225620871400114X?idApp=UINPBA00004N"]

Statistics

Review

Manejo de líquidos, lidocaína y epinefrina en liposucción. La forma correcta

Jorge Enrique Bayter Marin

MD, Anesthesiologist and Intensivist, Medical Director Clínica El Pinar, Bucaramanga, Colombia. Anesthesia for Plastic Surgery Coordinating Committee, Sociedad Colombiana de Antesiología y Reanimación (S.C.A.R.E.), Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)

Read

7341

Times
was read the article

1031

Total PDF

6310

Total HTML

Share statistics

 array:24 [
  "pii" => "S225620871400114X"
  "issn" => "22562087"
  "doi" => "10.1016/j.rcae.2014.10.003"
  "estado" => "S300"
  "fechaPublicacion" => "2015-01-01"
  "aid" => "173"
  "copyright" => "Sociedad Colombiana de Anestesiolog&#237;a y Reanimaci&#243;n"
  "copyrightAnyo" => "2014"
  "documento" => "article"
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "ssu"
  "cita" => "Rev Colomb Anestesiol. 2015;43:95-100"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 2687
    "formatos" => array:3 [
      "EPUB" => 79
      "HTML" => 2157
      "PDF" => 451
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0120334714001324"
      "issn" => "01203347"
      "doi" => "10.1016/j.rca.2014.09.007"
      "estado" => "S300"
      "fechaPublicacion" => "2015-01-01"
      "aid" => "173"
      "copyright" => "Sociedad Colombiana de Anestesiolog&#237;a y Reanimaci&#243;n"
      "documento" => "article"
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/3.0/"
      "subdocumento" => "ssu"
      "cita" => "Rev Colomb Anestesiol. 2015;43:95-100"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 30789
        "formatos" => array:3 [
          "EPUB" => 90
          "HTML" => 27874
          "PDF" => 2825
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">REVISI&#211;N</span>"
        "titulo" => "Manejo de l&#237;quidos&#44; lidoca&#237;na y epinefrina en liposucci&#243;n&#46; La forma correcta"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "95"
            "paginaFinal" => "100"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Liquid handling&#44; lidocaine and epinephrine in liposuction&#46; The properly form"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0010"
            "etiqueta" => "Figura 2"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr2.jpeg"
                "Alto" => 2473
                "Ancho" => 1670
                "Tamanyo" => 507862
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Rescate y resucitaci&#243;n con l&#237;pidos al 20&#37; ante una intoxicaci&#243;n con anest&#233;sicos locales que lleve a parada cardiaca&#46; Tomado de la p&#225;gina <span class="elsevierStyleInterRef" id="intr0005" href="http://www.lipidrescue.org/">www&#46;lipidrescue&#46;org</span> y avalado por la Sociedad Americana de Anestesia Regional y la Sociedad Americana de Cirug&#237;a Pl&#225;stica&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Jorge Enrique Bayter Marin"
            "autores" => array:1 [
              0 => array:2 [
                "nombre" => "Jorge Enrique"
                "apellidos" => "Bayter Marin"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S225620871400114X"
          "doi" => "10.1016/j.rcae.2014.10.003"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225620871400114X?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0120334714001324?idApp=UINPBA00004N"
      "url" => "/01203347/0000004300000001/v2_201706012200/S0120334714001324/v2_201706012200/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2256208714001187"
    "issn" => "22562087"
    "doi" => "10.1016/j.rcae.2014.10.006"
    "estado" => "S300"
    "fechaPublicacion" => "2015-01-01"
    "aid" => "176"
    "copyright" => "Sociedad Colombiana de Anestesiolog&#237;a y Reanimaci&#243;n"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Rev Colomb Anestesiol. 2015;43:101-3"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 2897
      "formatos" => array:3 [
        "EPUB" => 90
        "HTML" => 2340
        "PDF" => 467
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Essay</span>"
      "titulo" => "Intrathecal opioids and respiratory depression: Is it myth in obstetrics?"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "101"
          "paginaFinal" => "103"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Opioides intratecales y depresión respiratoria: ¿un mito en obstetricia?"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Pedro José Herrera Gómez, Juan Federico Garzón"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "Pedro José Herrera"
              "apellidos" => "Gómez"
            ]
            1 => array:2 [
              "nombre" => "Juan Federico"
              "apellidos" => "Garzón"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S012033471400135X"
        "doi" => "10.1016/j.rca.2014.09.009"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S012033471400135X?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714001187?idApp=UINPBA00004N"
    "url" => "/22562087/0000004300000001/v1_201501210932/S2256208714001187/v1_201501210932/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2256208714000741"
    "issn" => "22562087"
    "doi" => "10.1016/j.rcae.2014.06.004"
    "estado" => "S300"
    "fechaPublicacion" => "2015-01-01"
    "aid" => "149"
    "copyright" => "Sociedad Colombiana de Anestesiolog&#237;a y Reanimaci&#243;n"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Rev Colomb Anestesiol. 2015;43:87-94"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 2362
      "formatos" => array:3 [
        "EPUB" => 89
        "HTML" => 1729
        "PDF" => 544
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Scientific and Technological Research</span>"
      "titulo" => "Cost/effectiveness evaluation of three fixed combinations of acetaminophen and opioids in the management of acute pain in Colombia"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "87"
          "paginaFinal" => "94"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Evaluación de costo/efectividad de tres combinaciones fijas de acetaminofén y opiáceos para el manejo del dolor agudo en Colombia"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0010"
          "etiqueta" => "Fig. 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "fuente" => "Source: Authors"
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 2170
              "Ancho" => 1625
              "Tamanyo" => 214300
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A) Codeine/Acet vs. hydrocodone/Acet. B) Codeine/Acet vs. tramadol/Acet.</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Rafael Alfonso Cristancho, Andres I. Vecino, Juan Diego Misas"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Rafael Alfonso"
              "apellidos" => "Cristancho"
            ]
            1 => array:2 [
              "nombre" => "Andres I."
              "apellidos" => "Vecino"
            ]
            2 => array:2 [
              "nombre" => "Juan Diego"
              "apellidos" => "Misas"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S012033471400080X"
        "doi" => "10.1016/j.rca.2014.05.006"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S012033471400080X?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714000741?idApp=UINPBA00004N"
    "url" => "/22562087/0000004300000001/v1_201501210932/S2256208714000741/v1_201501210932/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
    "titulo" => "Liquid handling, lidocaine and epinephrine in liposuction. The properly form"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "95"
        "paginaFinal" => "100"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "Jorge Enrique Bayter Marin"
        "autores" => array:1 [
          0 => array:3 [
            "nombre" => "Jorge Enrique Bayter"
            "apellidos" => "Marin"
            "email" => array:1 [
              0 => "jokibay@yahoo.com"
            ]
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "MD, Anesthesiologist and Intensivist, Medical Director Clínica El Pinar, Bucaramanga, Colombia. Anesthesia for Plastic Surgery Coordinating Committee, Sociedad Colombiana de Antesiología y Reanimación (S.C.A.R.E.), Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)"
            "identificador" => "aff0005"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Manejo de líquidos, lidocaína y epinefrina en liposucción. La forma correcta"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig. 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2445
            "Ancho" => 2177
            "Tamanyo" => 556123
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Rescue and resuscitation with 20% lipid, before a local anesthetic intoxication leading to heart arrest. Taken from the page <span class="elsevierStyleInterRef" id="intr0005" href="http://www.lipidrescue.org/">www.lipidrescue.org</span> and endorsed by the American Society of Regional Anesthesia and the American Society of Plastic Surgeons.</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Liposuction is the most common cosmetic surgery procedure performed in the United States<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and also in Colombia. Advances in the techniques for infiltration, designed to allow placement of epinephrine in a solution, thus reducing bleeding during lipoaspiration, have enabled removal in large volumes during liposuction. This induces significant changes in fluid behaviour inside the compartment, with the risk of pulmonary oedema and heart failure.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Added to the invention by Klein in 1987 of a tumescent solution that included 500&#8211;1000<span class="elsevierStyleHsp" style=""></span>mg of lidocaine plus 1<span class="elsevierStyleHsp" style=""></span>mg of epinephrine for every 1000<span class="elsevierStyleHsp" style=""></span>cc of NSS<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and which is widely used today for subcutaneous infiltration, the risk of lidocaine toxicity is a reality and the second cause of death in plastic surgery according to the American Society of Plastic Surgeons (ASPS).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The biggest problem with these new infiltration techniques, in particular the super wet and the tumescent techniques is associated with the large infiltration volumes, at infiltration/aspiration ratios ranging from 1:1 in the super wet technique up to 2&#8211;3:1 in the tumescent technique.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This means that in a 3-litre liposuction, subcutaneous fluid infiltration may amount to 3&#8211;9 litres, and this fluid volume requires special consideration from the point of view of anaesthesia.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Non-systematic review of the literature using the PubMed and Medline databases, introducing key words in English like Fluid Management, Liposuction, pulmonary oedema, larger infiltration, Aspiration volumes. All the articles were read and other articles of the selected references regarding the topic were also queried. Overall, 151 references were selected using this methodology.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Review</span><p id="par0025" class="elsevierStylePara elsevierViewall">The use of large infiltration volumes in the tumescent solutions increases the difficulty of anaesthetic management in liposuction significantly. The risk of hypervolemia, pulmonary oedema, epinephrine-related cardiovascular effects, and lidocaine toxicity is always present.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The purpose of using infiltration solutions with 1<span class="elsevierStyleHsp" style=""></span>mg of epinephrine in 1000<span class="elsevierStyleHsp" style=""></span>cc of Hartman&#39;s or NSS is to reduce bleeding into the lipoaspirate down to less than 5% of the extracted volume.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This results in the ability to perform large-volume liposuction, with the ensuing complications. Some studies conducted by Burk and Vasconez<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> have shown the use of up to 10<span class="elsevierStyleHsp" style=""></span>mg of epinephrine at concentrations of 1:1,000,000 in healthy patients, with no deleterious effects from toxicity such as tachycardia and hypertension, although these megadoses may lead to fatal consequences in patients with underlying cardiac disease in whom no workup has been done.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The second problem, when Klein solutions are used, is the infiltration of high doses of lidocaine (500&#8211;1000<span class="elsevierStyleHsp" style=""></span>mg of 1% lidocaine for every 1000<span class="elsevierStyleHsp" style=""></span>cc of NSS). There are multiple studies in the world literature conducted in plastic surgery patients that show that very high doses of lidocaine (up to 35&#8211;55<span class="elsevierStyleHsp" style=""></span>mg/kg) could be safe<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> considering that the infiltration is applied to scarcely vascularized adipose tissue and, moreover, considering the additional vasoconstriction derived from the use of epinephrine in the dilution. These studies have shown a margin of safety in thousands of liposuction procedures performed, with no risk of toxic levels despite the high doses of infiltrated lidocaine.</p><p id="par0040" class="elsevierStylePara elsevierViewall">As far as anaesthesia is concerned, the FDA only accepts maximum doses of 7&#8211;10<span class="elsevierStyleHsp" style=""></span>mg/kg. The ASPS has reported that lidocaine toxicity may be an important cause of death in plastic surgery and might account for some intra- and post-operative deaths resulting from cardiac arrest in conditions of normal oxygen saturation. However, this is very difficult to demonstrate because of the difficulty in measuring post-mortem serum levels, something that is usually done late or not done at all. It is worth noting that the use of high lidocaine doses has enabled dermatologists and surgeons to perform liposuction in their offices using local anaesthesia without the support of an anaesthetist, with the sole purpose of lowering the costs associated with the use of the operating room and the support of the anaesthetist. For this reason, our recommendation, when large quantities of lidocaine are used for infiltration, is that an anaesthetist must be present in the room and must be prepared to manage lidocaine toxicity-related cardiac arrest. Additionally, 20% lipids must be available in the room as the only effective measure to revert cardiac arrest while waiting for resuscitation. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, shows the protocol for the management of local anaesthetic toxicity-related cardiac arrest, endorsed by the American Society of Regional Anaesthesia and the American Society of Plastic Surgeons, and published in <a href="http://www.lipidrescue.org/">www.lipidrescue.org</a> together with the supporting literature.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The third issue relates to the large volumes of infiltrated fluids and volume overloading: in a 4-litre liposuction, subcutaneous fluid infiltration may be as high as 12 litres.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In 1998, the University of Texas Southwestern Medical Centre defined that a large-volume liposuction is the removal of more than 4000<span class="elsevierStyleHsp" style=""></span>cc of fat, while a small-volume liposuction corresponds to the removal of less than 4000<span class="elsevierStyleHsp" style=""></span>cc. The same study determined that the volume of fluids delivered is equal to the volume of infiltration fluids given by the plastic surgeon plus the volume of intravenous fluids given by the anaesthetist. When added together and then divided by the liposuction volume, the ratio should not be greater than 2 for liposuctions under 4<span class="elsevierStyleHsp" style=""></span>L (or 8 litres of fluids administered when intravenous and infiltration fluids are added together, in a 4-litre liposuction), or greater than 1.4 for liposuctions of more than 4 litres. In this study of 53 patients there were no cases of complications or fluid overload, and diuresis was maintained at a level higher than 1<span class="elsevierStyleHsp" style=""></span>cc/k/h. In a later study by Rohrich in 89 patients,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> it was shown, in essence, that the use of this same formula for liposuction does not result in complications.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In plastic surgery, pulmonary oedema is the third cause of death, resulting mainly from human error associated with the lack of knowledge of the basic physiological principles of infiltration, the lack of protocols, and poor communication between the surgeon and the anaesthetist. In a study conducted in The Netherlands in 50% of the hospitals between 1995 and 1997, it was found that 2&#8211;4% of all anaesthesia-related deaths were due to poor fluid management and pulmonary oedema, and medical error was demonstrated in 85% of these fatal cases.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The main physiological consideration is that most of the infiltrated fluids go into the general circulation and only 22&#8211;29% is recovered with lipoaspiration.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> This means that up to 70% of infiltration fluids, lidocaine and epinephrine go into the intravascular space. Later studies have shown that 1 litre of subcutaneous infiltration is fully resorbed if not removed within 163<span class="elsevierStyleHsp" style=""></span>min, and that 70% of the lidocaine and epinephrine is totally resorbed, with maximum peaks at 12 and 5<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In a study of 5 healthy ASA 1 women<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> undergoing large-volume liposuction, a Swan-Ganz catheter was used for 24-h monitoring in the ICU, with continuous measurement of the haemodynamic parameters in order to assess the effects of the infiltration and the high adrenaline doses. It was determined that cardiac index, heart rate and mean pulmonary artery pressure increased by more than 45%, while central venous pressure increased from 4 to 14<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O 8<span class="elsevierStyleHsp" style=""></span>h into the postoperative period.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Moreover, the same study showed that all patients were hypothermic during surgery with recorded temperatures under 35.5<span class="elsevierStyleHsp" style=""></span>&deg;C.</p><p id="par0070" class="elsevierStylePara elsevierViewall">High doses of epinephrine are used routinely in liposuction, with all the haemodynamic implications. Epinephrine reaches maximum concentration levels 3&#8211;5<span class="elsevierStyleHsp" style=""></span>h after subcutaneous administration. After infiltrating 7<span class="elsevierStyleHsp" style=""></span>mg of adrenaline, serum levels reach 323<span class="elsevierStyleHsp" style=""></span>pg/ml, very similar to the levels found in aortic clamping or coronary bypass,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,7</span></a> which are 3 or 4 times as high as baseline levels. In fact, there are anecdotal reports on epinephrine-related complications in patients with previously undiagnosed coronary heart disease; this is due to the low rate of its systemic absorption in fat and to its vasoconstriction effect, and the potential protective anti-arrhythmic effect of lidocaine.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The presence of lidocaine in the infiltration may lead to serious and even fatal complications. Neurological symptoms appear when levels are above 5<span class="elsevierStyleHsp" style=""></span>¿g/cc, and there is cardiovascular collapse with levels higher than 10<span class="elsevierStyleHsp" style=""></span>¿g/cc.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">16</span></a> Apparently, many studies have shown a certain margin of safety with subcutaneous lidocaine infiltration, even in doses as high as 55<span class="elsevierStyleHsp" style=""></span>mg/kg, due to the low vascularity of fat and the vasoconstrictor effect of adrenaline.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">17&#8211;19</span></a> The problem is that its release from fat is also slow, and it has been shown that maximum levels are reached within 8&#8211;12<span class="elsevierStyleHsp" style=""></span>h after the infiltration<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">20</span></a> when the patient is already at home, creating an additional risk. It is also important to take into consideration differential absorption rates, given that when the face is infiltrated, maximum concentrations are reached after 5<span class="elsevierStyleHsp" style=""></span>h, but when the abdomen and the thighs are infiltrated, they peak at 12<span class="elsevierStyleHsp" style=""></span>h, and at some point there may be a summation effect.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">18</span></a> Lidocaine metabolism may worsen the situation in cases of toxicity. Lidocaine is cleared mainly through liver metabolism (95%) while only 5% is cleared through the urine.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">21</span></a> It is deacetylated to monoethyliglycinexylidine (MEGX) which is then deacetylated to glycinexylidine (GX). The two enzymes responsible for this action are CYP3A4 and CYP1A2 which belong to the cytochrome P450 family of isoenzymes.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">21,22</span></a> These isoenzymes may be inhibited by various commonly used drugs, including ciprofloxacin, cimetidine, erythromycin, amiodarone, ketoconazole, fluconazole and even propofol;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">21,22</span></a> or the metabolism may be altered by drugs that compete for the same enzyme, as is the case of midazolam and fentanyl, which are also metabolized by CYP3A4.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">21,22</span></a> This is very important because these drugs not only may alter the metabolism but also may mask the initial signs of intoxication, leading to serious neurological or cardiovascular symptoms. Although these subcutaneous megadoses of 35&#8211;50<span class="elsevierStyleHsp" style=""></span>mg/kg of lidocaine may seem suboptimal, intraoperative deaths have been reported due to heart block in conditions of normal oxygen saturation. In those cases, the autopsy does not find any abnormality,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">23</span></a> and lidocaine levels may appear normal; however post-mortem stability of lidocaine has not been demonstrated so far. In a census carried out among all the members of the American Society of Plastic Surgeons in 2000, mortality from liposuction was shown to be 1 out of every 5000 procedures. The primary cause of death was PTE, but it was also found that most deaths occurred on the first postoperative night, so lidocaine toxicity and residual anaesthetic effects are not ruled out as an important cause of mortality.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Although PTE is the main cause of death, there are stringent, well developed protocols for prophylaxis that may lower the incidence of DVT and PTE by 85%, and of fatal PTE by 95%. The problem with fluid management in liposuction is that with the new super wet and tumescent infiltration techniques, fluid overload is a potential risk and there is no consensus regarding its management to this date. There are only a few empirical division formulae for fluid delivery versus infiltration fluids to guide the management of fluid therapy.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">24&#8211;26</span></a> Using these formulae, fluid delivery in a liposuction under 4 litres must follow a ratio of 2 between infiltrated plus intravenous fluids divided by the aspirate, and a ratio of 1.4 in a liposuction of more than 4 litres.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">24&#8211;26</span></a> Despite these formulae, fluid overload continues to be a problem, and there are reports of deaths in liposuction when they are applied. Intravenous fluids are being used less in liposuction, and although the standard is not to use the tumescent technique (3:1) but the super wet technique (1:1), this has contributed to a lowering of fluid delivery down to a ratio of 1.2 between fluids delivered (intravenous plus infiltration) and fat removed, according to Rohrich.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">24</span></a> Recently, a study was conducted with 30 patients undergoing large volume liposuctions of more than 6 litres in which half of the patients received fluids according to Rohrich, i.e. a 1.2 ratio (for a 6-litre liposuction they could receive only a maximum of 7200<span class="elsevierStyleHsp" style=""></span>cc of infiltrated plus intravenous fluids) and the other half of the patients received fluids on the basis of systolic volume variation using the arterial line thermodilution technique (LIDCO).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">27</span></a> This study showed that, in large-volume liposuction where infiltration was greater than 1:1, intravenous fluids were used only for maintenance &#8722;500 to 600<span class="elsevierStyleHsp" style=""></span>cc over the 5<span class="elsevierStyleHsp" style=""></span>h of surgery &#8211; and an excellent stroke volume was achieved, with diuresis remaining always above 1.2<span class="elsevierStyleHsp" style=""></span>cc/k/h.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">27&#8211;29</span></a> Studies show that intravenous fluid quantities must be as low as possible when super wet techniques are used<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">30,31</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), and there are some that have even proposed abolishing intravenous fluids.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">32</span></a> In conclusion, when liposuction is performed as a single procedure, conservative management of intravenous fluids is required, considering that infiltration fluids go into the central circulation. Consequently, the recommendation is to use only maintenance fluids.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">As stated above, fluid management also involves managing infiltration, lidocaine and epinephrine levels, and hypothermia.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">33</span></a> Together, these factors are responsible for numerous reports of deaths due to myocardial infarction, pulmonary oedema and lidocaine toxicity.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">33&#8211;43</span></a><span class="elsevierStyleSup">.</span></p><p id="par0090" class="elsevierStylePara elsevierViewall">Although it is not within the scope of this paper, it needs to be mentioned that the subcutaneous infusion of these large volumes of infiltration fluids at ambient temperature means that temperature in all patients remains under 36<span class="elsevierStyleHsp" style=""></span>&deg;C. Consequently, we are required to take the necessary steps to avoid hypothermia, considering that it may lead to problems such as bleeding, AMI and seromas.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">44&#8211;47</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">Correct fluid and infiltration management, together with the steps for preventing DVT and PTE, is the most important measure to reduce complications and deaths in plastic surgery. Regarding fluid management in liposuction, when super wet or tumescent techniques are used, the worldwide recommendation is to use a minimum amount of intravenous fluids, that is, only maintenance fluids, because the infiltrated volume is sufficient (1.2 maximum ratio between fluid delivery and fat removal).</p><p id="par0100" class="elsevierStylePara elsevierViewall">As for the dose of epinephrine in the infiltration, it should not be higher than 6<span class="elsevierStyleHsp" style=""></span>mg or 1<span class="elsevierStyleHsp" style=""></span>kg/kg, as long as the patient does not have an underlying cardiovascular disease.</p><p id="par0105" class="elsevierStylePara elsevierViewall">As for lidocaine, although the FDA recommends a maximum of 7&#8211;10<span class="elsevierStyleHsp" style=""></span>mg/kg, there are multiple studies showing that higher doses (35<span class="elsevierStyleHsp" style=""></span>mg/kg) are relatively safe. Consequently, in cases of infiltration with large volumes of lidocaine, our recommendation is that the procedure must be performed under the constant supervision of an anaesthetist who must be prepared to manage lidocaine toxicity-related cardiac arrest. Moreover, 20% lipids must be available in the room as the sole effective measure to revert cardiac arrest while waiting for resuscitation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financing</span><p id="par0115" class="elsevierStylePara elsevierViewall">No.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The author is coordinator of the Committee on Anesthesia for Plastic Surgery, Sociedad Colombiana de Anestesiolog&iacute;a y Reanimaci&oacute;n (S.C.A.R.E.).</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres412682"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Introduction"
            2 => "Objectives"
            3 => "Methods"
            4 => "Results and conclusions"
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec388406"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres412681"
          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Introducci&oacute;n"
            2 => "Objetivos"
            3 => "M&eacute;todos"
            4 => "Resultados y conclusiones"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec388407"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Review"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusions"
        ]
        8 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Financing"
        ]
        9 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-04-28"
    "fechaAceptado" => "2014-09-13"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec388406"
          "palabras" => array:5 [
            0 => "Lipectomy"
            1 => "Pulmonary edema"
            2 => "Anesthetics, local"
            3 => "Toxicity"
            4 => "Surgery, plastic"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec388407"
          "palabras" => array:5 [
            0 => "Lipiectomía"
            1 => "Edema Pulmonar"
            2 => "Anestésicos locales"
            3 => "Toxicidad"
            4 => "Cirugía plástica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fluid mismanagement in liposuction leads to pulmonary edema in a previously healthy individual. Pulmonary edema is considered the third cause of death in plastic surgery after PTE and lidocaine toxicity. The most important risk factor leading to this outcome is inadequate knowledge of fluid management and poor communication between the surgeon and the anaesthetist.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To review the causes leading up to pulmonary edema in liposuction and the valid options for correct fluid management.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Non-systematic review of the literature in PubMed and Medline.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results and conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Correct fluid management in liposuction is based on a close communication between the surgeon and the anaesthetist in order to keep track of the total amount of subcutaneous fluid infiltration plus fluids delivered intravenously, always bearing in mind that infiltration fluids go to the central circulation.</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&oacute;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El mal manejo de l&iacute;quidos en liposucci&oacute;n, conlleva a edema pulmonar en un paciente previamente sano. El edema pulmonar se considera la tercera causa de muerte en cirug&iacute;a pl&aacute;stica despu&eacute;s del TEP y la Intoxicaci&oacute;n por lidoca&iacute;na. El principal factor de riesgo que conlleva a este desenlace es el desconocimiento en el manejo de l&iacute;quidos y la mala comunicaci&oacute;n entre el cirujano y el anestesi&oacute;logo.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisar las causas que llevan a edema pulmonar en liposucci&oacute;n y las opciones validas de manejo correcto de l&iacute;quidos.</p> <span class="elsevierStyleSectionTitle" id="sect0045">M&eacute;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realiz&oacute; una revisi&oacute;n de la literatura no sistem&aacute;tica en las bases de datos PubMed y Medline.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Resultados y conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El correcto manejo de l&iacute;quidos en liposucci&oacute;n se basa en una estrecha comunicaci&oacute;n entre el cirujano y el anestesi&oacute;logo para sumar los l&iacute;quidos infiltrados a nivel subcut&aacute;neo y los colocados por v&iacute;a venosa, siempre teniendo en cuenta que los l&iacute;quidos de la infiltraci&oacute;n pasan a la circulaci&oacute;n central.</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Marin JEB. Manejo de l&iacute;quidos, lidoca&iacute;na y epinefrina en liposucci&oacute;n. La forma correcta. Rev Colomb Anestesiol. 2015;43:95&#8211;100.</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig. 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors."
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 760
            "Ancho" => 2389
            "Tamanyo" => 115900
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Klein&#39;s solution composition and advantages for bleeding in liposuction.</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig. 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2445
            "Ancho" => 2177
            "Tamanyo" => 556123
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Rescue and resuscitation with 20% lipid, before a local anesthetic intoxication leading to heart arrest. Taken from the page <span class="elsevierStyleInterRef" id="intr0005" href="http://www.lipidrescue.org/">www.lipidrescue.org</span> and endorsed by the American Society of Regional Anesthesia and the American Society of Plastic Surgeons.</p>"
        ]
      ]
      2 => 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"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group A: Fluids based on systolic volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group B: Formula-guided fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Infiltration fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7400<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6700<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lipoaspirate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8500<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8100<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">IV fluids administered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">560<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2400<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">INF+IV fluids/aspirate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">IO maintenance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">122<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;1<span class="elsevierStyleHsp" style=""></span>cc/k/h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;1<span class="elsevierStyleHsp" style=""></span>cc/k/h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab642078.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison between formula-guided and systolic volume-guided intravenous fluid administration using the LIDCO method in large-volume liposuction.</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:47 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of subcutaneous infiltration in suction-assisted lipoplasty: a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R.J. Rohrich"
                            1 => "S.J. Beran"
                            2 => "P.B. Fodor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1996"
                        "volumen" => "9"
                        "paginaInicial" => "514"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factors contributing to adverse effects of the tumescent technique (surgical strategies)"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F.M. Grazer"
                            1 => "F.L. Meister"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Aesthetic Surg J"
                        "fecha" => "1997"
                        "volumen" => "7"
                        "paginaInicial" => "411"
                        "paginaFinal" => "416"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The tumescent technique for liposuction surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J.A. Klein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Cosmetic Surg"
                        "fecha" => "1987"
                        "volumen" => "4"
                        "paginaInicial" => "263"
                        "paginaFinal" => "266"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S.A. Trott"
                            1 => "S.J. Beran"
                            2 => "R.J. Rohrich"
                            3 => "J.M. Kenkel"
                            4 => "W.P. Adams"
                            5 => "K.W. Klein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1998"
                        "volumen" => "102"
                        "paginaInicial" => "2220"
                        "paginaFinal" => "2225"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9811024"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lidocaine and epinephrine levels in tumescent technique liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R.W. Burk"
                            1 => "G. Guzman-Stein"
                            2 => "L.O. Vasconez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1996"
                        "volumen" => "97"
                        "paginaInicial" => "1379"
                        "paginaFinal" => "1385"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8643720"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumescent technique for local anesthesia improves safety in large-volume liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J.A. Klein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1993"
                        "volumen" => "92"
                        "paginaInicial" => "1085"
                        "paginaFinal" => "1090"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8234507"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lidocaine and epinephrine levels in tumescent technique liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R.W. Burk"
                            1 => "G. Guzman-Stein"
                            2 => "L.O. Vasconez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1996"
                        "volumen" => "97"
                        "paginaInicial" => "1379"
                        "paginaFinal" => "1384"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8643720"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumescent technique for regional anesthesia permits lidocaine doses of 35<span class="elsevierStyleHsp" style=""></span>mg/kg for liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J.A. Klein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dermatol Surg Oncol"
                        "fecha" => "1990"
                        "volumen" => "16"
                        "paginaInicial" => "248"
                        "paginaFinal" => "252"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2179348"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumescent anesthesia with a lidocaine dose of 55<span class="elsevierStyleHsp" style=""></span>mg/kg is safe for liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A. Ostad"
                            1 => "N. Kageyama"
                            2 => "R. Moy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Surg"
                        "fecha" => "1996"
                        "volumen" => "22"
                        "paginaInicial" => "921"
                        "paginaFinal" => "928"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9063507"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fluid resuscitation in liposuction: a retrospective review of 89 consecutive patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R.J. Rohrich"
                            1 => "E. Jason"
                            2 => "Leedy"
                            3 => "J.R. Swamy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.prs.0000201477.30002.ce"
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2006"
                        "volumen" => "117"
                        "paginaInicial" => "431"
                        "paginaFinal" => "436"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16462322"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality associated with anaesthesia: a qualitative analysis to identify risk factors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M.S. Arbous"
                            1 => "D.E. Grobbee"
                            2 => "J.W. van Kleef"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "2001"
                        "volumen" => "56"
                        "paginaInicial" => "1141"
                        "paginaFinal" => "1153"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11736769"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Blood loss during liposuction using the tumescent technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F. Samdal"
                            1 => "P.F. Amland"
                            2 => "J.F. Bugge"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Aesthetic Plast Surg"
                        "fecha" => "1994"
                        "volumen" => "18"
                        "paginaInicial" => "157"
                        "paginaFinal" => "162"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8017219"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumescent liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G.H. Pitman"
                            1 => "J.S. Aker"
                            2 => "Z.D. Tripp"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Plast Surg"
                        "fecha" => "1996"
                        "volumen" => "23"
                        "paginaInicial" => "633"
                        "paginaFinal" => "638"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8906394"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hemodynamic physiology and thermoregulation in liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J.M. Kenkel"
                            1 => "A.H. Lipschitz"
                            2 => "M. Luby"
                            3 => "I. Kallmeyer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2004"
                        "volumen" => "114"
                        "paginaInicial" => "503"
                        "paginaFinal" => "513"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15277823"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pharmacokinetics and safety of epinephrine use in liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S.A. Brown"
                            1 => "A.H. Lipschitz"
                            2 => "J.M. Kenkel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2004"
                        "volumen" => "114"
                        "paginaInicial" => "756"
                        "paginaFinal" => "765"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15318058"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rapid absorption of tumescent lidocaine above the clavicles: a prospective clinical study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J.P. Rubin"
                            1 => "X. Zhongcong"
                            2 => "Ch. Davidson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2005"
                        "volumen" => "115"
                        "paginaInicial" => "1744"
                        "paginaFinal" => "1751"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15861085"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of anesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L.A. Feisher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Anesthesia"
                        "paginaInicial" => "893"
                        "paginaFinal" => "920"
                        "serieFecha" => "2005"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reduction of lipoplasty risks and mortality: an ASAPS survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C.E. Hughes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Plast Surg"
                        "fecha" => "2001"
                        "volumen" => "21"
                        "paginaInicial" => "120"
                        "paginaFinal" => "127"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lidocaine levels during the first two hours of infiltration of dilute anesthetic solution for tumescent liposuction: rapid versus slow delivery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K.J. Butterwick"
                            1 => "M.P. Goldman"
                            2 => "S. Sriprachya-Anunt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Surg"
                        "fecha" => "1999"
                        "volumen" => "25"
                        "paginaInicial" => "681"
                        "paginaFinal" => "685"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10491056"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Liver enzyme induction and inhibition: implications for anaesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B.P. Sweeney"
                            1 => "J. Bromilow"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2044.2005.04462.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "159"
                        "paginaFinal" => "177"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16430569"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Deaths related to liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R.B. Rao"
                            1 => "S.F. Ely"
                            2 => "R.S. Hoffman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199905133401904"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1999"
                        "volumen" => "340"
                        "paginaInicial" => "1471"
                        "paginaFinal" => "1475"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10320385"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An update on the role of subcutaneous infiltration in suction-assisted lipoplasty"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R.J. Rohrich"
                            1 => "J.M. Kenkel"
                            2 => "J.E. Janis"
                            3 => "S.J. Beran"
                            4 => "P.B. Fodor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.PRS.0000039396.69495.C5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2003"
                        "volumen" => "111"
                        "paginaInicial" => "926"
                        "paginaFinal" => "927"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12560722"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fluid resuscitation in liposuction: a prospective analysis of infiltrate total-aspirate ratios lower than used for the super wet technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A.R. Basile"
                            1 => "F. Fernandes"
                            2 => "V.V. Basile"
                            3 => "F.V. Basile"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00266-006-0118-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aesthetic Plast Surg"
                        "fecha" => "2006"
                        "volumen" => "30"
                        "paginaInicial" => "659"
                        "paginaFinal" => "665"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17093883"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S.A. Trott"
                            1 => "S.J. Beran"
                            2 => "R.J. Rohrich"
                            3 => "J.M. Kenkel"
                            4 => "W.P. Adams Jr."
                            5 => "K.W. Klein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1998"
                        "volumen" => "102"
                        "paginaInicial" => "2220"
                        "paginaFinal" => "2229"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9811024"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Stroke volume variation as a guide for fluid resuscitation in patients undergoing large-volume liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A.K. Jain"
                            1 => "A.M. Khan"
                            2 => "M.M. Asma"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2012"
                        "volumen" => "130"
                        "paginaInicial" => "462"
                        "paginaFinal" => "469"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Optimizing fluid therapy in mechanically ventilated patients after cardiac surgery by on-line monitoring of left ventricular stroke volume variations: a comparison to aortic systolic pressure variations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D.A. Reuter"
                            1 => "T.W. Felbinger"
                            2 => "E. Kilger"
                            3 => "C. Schmidt"
                            4 => "P. Lamm"
                            5 => "A.E. Goetz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2002"
                        "volumen" => "88"
                        "paginaInicial" => "124"
                        "paginaFinal" => "126"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11881866"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "D.A. Reuter"
                            1 => "A. Kirchner"
                            2 => "T.W. Felbinger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000059442.37548.E1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "1399"
                        "paginaFinal" => "1404"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12771609"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perioperative management of cosmetic liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R.H. de Jong"
                            1 => "F.M. Grazer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2011"
                        "volumen" => "107"
                        "paginaInicial" => "1039"
                        "paginaFinal" => "1044"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11252101"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumescent liposuction: a surgeon&#39;s perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G.H. Pitman"
                            1 => "J.S. Aker"
                            2 => "Z.D. Tripp"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Plast Surg"
                        "fecha" => "1996"
                        "volumen" => "23"
                        "paginaInicial" => "633"
                        "paginaFinal" => "641"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8906394"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Larger infiltration/aspiration volumes, plasma/subcutaneous fluid lidocaine levels and quantitative abdominal tissue accommodation after water-assisted liposuction (WAL): comparative safety and efficacy to traditional liposuction (TL) in advanced techniques in liposuction and fat transfer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G.H. Sasaki"
                            1 => "A. Tevez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "11th ed."
                        "fecha" => "2011"
                        "paginaInicial" => "81"
                        "paginaFinal" => "94"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fatal outcomes from liposuction: census survey of cosmetic surgeons"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F.M. Grazer"
                            1 => "R.H. de Jong"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2000"
                        "volumen" => "105"
                        "paginaInicial" => "436"
                        "paginaFinal" => "442"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10627013"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fatal and near fatal complications of liposuction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "D.J. Barillo"
                            1 => "L.C. Cancio"
                            2 => "S.H. Kim"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "South Med J"
                        "fecha" => "1998"
                        "volumen" => "91"
                        "paginaInicial" => "487"
                        "paginaFinal" => "494"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9598863"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Suction-assisted lipoplasty: complications and fatal outcomes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M. Gorney"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:3 [
                        "titulo" => "Presented at the annual meeting of the American Society of Plastic and Reconstructive Surgeons"
                        "conferencia" => "Boston, MA, October"
                        "serieFecha" => "1998"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lipoplasty complications and their prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M.G. Gingrass"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Plast Surg"
                        "fecha" => "1999"
                        "volumen" => "26"
                        "paginaInicial" => "341"
                        "paginaFinal" => "349"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10549434"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumescent liposuction alert: deaths from lidocaine cardiotoxicity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R.H. de Jong"
                            1 => "F.M. Grazer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Forensic Med Pathol"
                        "fecha" => "1999"
                        "volumen" => "20"
                        "paginaInicial" => "100"
                        "paginaFinal" => "107"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Deaths associated with liposuction: case reports and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M.S. Platt"
                            1 => "L.J. Kohler"
                            2 => "R. Ruiz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Forensic Sci"
                        "fecha" => "2002"
                        "volumen" => "47"
                        "paginaInicial" => "205"
                        "paginaFinal" => "209"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12064654"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Procedural Statistics Report. Arlington Heights Ill"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "American Society of Plastic Surgeons"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:2 [
                        "fecha" => "2001"
                        "editorial" => "American Society of Plastic Surgeons"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The tumescent technique: anesthesia and modified liposuction technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J.A. Klein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Clin"
                        "fecha" => "1990"
                        "volumen" => "8"
                        "paginaInicial" => "425"
                        "paginaFinal" => "432"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2199105"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Blood loss during liposuction using the tumescent technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F. Samdal"
                            1 => "P.F. Amland"
                            2 => "J.F. Bugge"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Aesthetic Plast Surg"
                        "fecha" => "1994"
                        "volumen" => "18"
                        "paginaInicial" => "157"
                        "paginaFinal" => "163"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8017219"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P.J. Lillis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dermatol Surg Oncol"
                        "fecha" => "1988"
                        "volumen" => "14"
                        "paginaInicial" => "1145"
                        "paginaFinal" => "1152"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3170931"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Patient safety in office-based surgery facilities: 1. Procedures in the office-based surgery setting"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R.E. Iverson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.PRS.0000025306.15589.FA"
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2002"
                        "volumen" => "110"
                        "paginaInicial" => "1337"
                        "paginaFinal" => "1345"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12360080"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perioperative heat balance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D.I. Sessler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2000"
                        "volumen" => "92"
                        "paginaInicial" => "578"
                        "paginaFinal" => "584"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10691247"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictive variables of hypothermia in the early phase of general anesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M.Y. Yamakage"
                            1 => "Y. Kamada"
                            2 => "Y. Homma"
                            3 => "N. Tsujiguchi"
                            4 => "A. Namiki"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2000"
                        "volumen" => "90"
                        "paginaInicial" => "456"
                        "paginaFinal" => "463"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10648339"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Postanesthetic shivering: epidemiology, pathophysiology, and approaches to prevention and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P. Alfonsi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Drugs"
                        "fecha" => "2001"
                        "volumen" => "61"
                        "paginaInicial" => "2193"
                        "paginaFinal" => "2199"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11772130"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relation between oxygen consumption and cardiac output during inhalation anesthesia under the influence of catecholamines: a study in dogs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "T.W. Scheeren"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-2000-306"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anasthesiol Intensivmed Notfallmed Schmerzther"
                        "fecha" => "2000"
                        "volumen" => "35"
                        "paginaInicial" => "214"
                        "paginaFinal" => "222"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10830073"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Catecholamines, sympathomimetic drugs and adrenergic receptors antagonists"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B.B. Hoffman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "titulo" => "The pharmacological basis of therapeutics"
                        "paginaInicial" => "215"
                        "paginaFinal" => "268"
                        "edicion" => "10th ed."
                        "serieFecha" => "2001"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effects of dopamine and epinephrine on hemodynamics and oxygen metabolism in hypoxic anesthetized piglets"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P.Y. Cheung"
                            1 => "K.J. Barrington"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2001"
                        "volumen" => "5"
                        "paginaInicial" => "158"
                        "paginaFinal" => "165"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11353933"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/22562087/0000004300000001/v1_201501210932/S225620871400114X/v1_201501210932/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "34050"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Review articles"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/22562087/0000004300000001/v1_201501210932/S225620871400114X/v1_201501210932/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225620871400114X?idApp=UINPBA00004N"
]

Article information

ISSN: 22562087
Original language: English

DOI:10.1016/j.rcae.2014.10.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	16	2	18
2024 October	67	9	76
2024 September	79	32	111
2024 August	122	38	160
2024 July	77	9	86
2024 June	65	8	73
2024 May	67	5	72
2024 April	73	16	89
2024 March	106	8	114
2024 February	121	24	145
2024 January	108	19	127
2023 December	126	12	138
2023 November	87	11	98
2023 October	124	11	135
2023 September	83	6	89
2023 August	80	7	87
2023 July	92	7	99
2023 June	96	10	106
2023 May	118	3	121
2023 April	190	15	205
2023 March	115	11	126
2023 February	64	5	69
2023 January	91	14	105
2022 December	60	7	67
2022 November	93	6	99
2022 October	87	7	94
2022 September	55	14	69
2022 August	53	7	60
2022 July	48	5	53
2022 June	68	16	84
2022 May	66	6	72
2022 April	55	11	66
2022 March	65	13	78
2022 February	76	7	83
2022 January	86	9	95
2021 December	59	16	75
2021 November	69	19	88
2021 October	105	14	119
2021 September	92	14	106
2021 August	95	15	110
2021 July	58	11	69
2021 June	54	10	64
2021 May	85	15	100
2021 April	133	9	142
2021 March	50	4	54
2021 February	45	6	51
2021 January	49	6	55
2020 December	45	6	51
2020 November	32	7	39
2020 October	33	7	40
2020 September	67	4	71
2020 August	16	11	27
2020 July	12	7	19
2020 June	45	2	47
2020 May	16	4	20
2020 April	5	3	8
2020 March	7	0	7
2020 February	12	2	14
2020 January	7	2	9
2019 December	9	10	19
2019 November	2	2	4
2019 October	6	3	9
2019 September	8	2	10
2019 July	1	3	4
2019 June	2	2	4
2019 May	2	5	7
2019 March	1	0	1
2018 October	1	0	1
2018 September	1	0	1
2018 June	9	1	10
2018 May	40	8	48
2018 April	56	6	62
2018 March	37	7	44
2018 February	29	6	35
2018 January	48	1	49
2017 December	40	6	46
2017 November	42	5	47
2017 October	32	7	39
2017 September	40	8	48
2017 August	45	4	49
2017 July	59	2	61
2017 June	67	13	80
2017 May	70	8	78
2017 April	75	14	89
2017 March	61	12	73
2017 February	39	2	41
2017 January	43	8	51
2016 December	84	9	93
2016 November	62	4	66
2016 October	88	8	96
2016 September	135	11	146
2016 August	85	10	95
2016 July	52	11	63
2016 June	0	14	14
2016 May	3	27	30
2016 April	1	32	33
2016 March	7	0	7
2016 February	5	24	29
2015 December	25	9	34
2015 November	78	14	92
2015 October	74	18	92
2015 September	70	13	83
2015 August	69	5	74
2015 July	89	19	108
2015 June	43	8	51
2015 May	60	16	76
2015 April	73	15	88
2015 March	68	11	79
2015 February	67	12	79
2015 January	37	12	49

Show all

Indexed in:

Follow us:

Statistics

Indexed in:

Follow us:

Statistics

Subscribe to our newsletter