Health worker exposure risk during inhalation sedation with sevoflurane using the (AnaConDa®) anaesthetic conserving device | Revista Española de Anestesiología y Reanimación

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La parte delantera del collar debe ser quitada una vez establecida la estabilización manual para permitir la aplicación de presión cricoidea y facilitar la extensión de la mandíbula. El operador de la derecha aplica presión cricoidea, el de la izquierda realiza la maniobra de estabilización bimanual, y un tercero realiza la laringoscopia." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Barbeito, R.A. Guerri-Guttenberg" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Barbeito" ] 1 => array:2 [ "nombre" => "R.A." "apellidos" => "Guerri-Guttenberg" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935613001941?idApp=UINPBA00004N" "url" => "/00349356/0000006100000003/v1_201403030014/S0034935613001941/v1_201403030014/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0034935613003344" "issn" => "00349356" "doi" => "10.1016/j.redar.2013.11.014" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "419" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2014;61:125-32" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2923 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 2393 "PDF" => 522 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Validación de las escalas de APACHE II y SOFA en 2 cohortes de pacientes con sospecha de infección y sepsis, no ingresados en unidades de cuidados críticos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "125" "paginaFinal" => "132" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units" ] ] "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" => 1585 "Ancho" => 2479 "Tamanyo" => 193005 ] ] "descripcion" => array:1 [ "es" => "Análisis de calibración para mortalidad a los 28 días con el sistema de puntuación SOFA." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Cerro, J. Valencia, P. Calle, A. León, F. Jaimes" "autores" => array:5 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Cerro" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Valencia" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Calle" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "León" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Jaimes" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935613003344?idApp=UINPBA00004N" "url" => "/00349356/0000006100000003/v1_201403030014/S0034935613003344/v1_201403030014/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Health worker exposure risk during inhalation sedation with sevoflurane using the (AnaConDa®) anaesthetic conserving device" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "133" "paginaFinal" => "139" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. González-Rodríguez, A. Muñoz Martínez, J. Galan Serrano, M.V. Moral García" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "González-Rodríguez" "email" => array:2 [ 0 => "rgonzalezr@santpau.cat" 1 => "raul08015@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Muñoz Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Galan Serrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.V." "apellidos" => "Moral García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Riesgos Laborales y Medicina Preventiva, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Riesgo de exposición de los profesionales sanitarios durante sedación inhalatoria con sevoflurane a través del dispositivo anaesthetic conserving device (AnaConDa®)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1571 "Ancho" => 1583 "Tamanyo" => 168894 ] ] "descripcion" => array:1 [ "en" => "Picture and schematic diagram of the diffusive passive monitor badges SKC-575-002 used during EP and OE evaluation." ] ] ] "textoCompleto" => "IntroductionSedation of postoperative patients who require mechanical ventilation is routinely performed using intravenous drugs.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Inhalational anaesthetic agents (IAA) are an effective and promising alternative to intravenous sedation. IAA such as sevoflurane, desflurane or isoflurane can be administered through the AnaConDa® device (Anaesthetic Conserving Device; Sedana Medical AB, Sweden) during mechanical ventilation. AnaConDa® is a bacterial filter and gas humidifier that allows direct administration of IAA to the respiratory system through a continuous infusion syringe pump without the need for vapourisers. The IAA most commonly used in our setting is sevoflurane. This drug has myocardial protection effects and it produces fewer hemodynamic alterations than other IAA. Furthermore, systemic accumulation is low because only 10% of sevoflurane is metabolised. The remaining 90%, however, is eliminated to the atmosphere, posing a potential environmental risk to healthcare workers.<a class="elsevierStyleCrossRefs" href="#bib0015">3–9</a>In 1967, Vaisman suggested that environmental contamination by old IAA in operating rooms was associated with headache, fatigue and irritability. He also reported that anaesthetists using IAA had more spontaneous abortions and their offspring had a higher rate of congenital abnormalities than the general population. These data have since been corroborated in other studies and in a meta-analysis. Sevoflurane, desflurane or isofluorane were not analysed by this meta-analysis.<a class="elsevierStyleCrossRefs" href="#bib0050">10–11</a>Acute exposure to sevoflurane above 1000ppm can lead to confusion, vertigo, nausea, somnolence, and dryness and reddening of the mucosae. In rare instances, cases of hepatic necrosis have been described. Chronic exposure to lower concentrations of sevoflurane can lead to perception disorders, cognitive and motor ability changes, and liver function changes.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Occupational exposure (OE) risk to the inhalation of a gas is evaluated by comparing the concentration of this gas with the environmental level value (ELV). ELV is the time-weighted average representing the permissible average ambient air concentration underlying an 8-h exposure.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>For many years, there has been considerable controversy to regulations concerning the ELV to IAA. In 1977 the National Institute for Occupational Safety and Health (NIOSH) established a recommended ELV of exposure of 2ppm for 60min for IAA such as chloroform, trichloroethylene, nitrous oxide, halothane, methoxyflurane, fluroxene and enflurane. Isoflurane, desflurane and sevoflurane were later included in this recommendation. These values proposed by NIOSH are based on the lowest concentration able to be detected using the procedures described for sample collection and analysis and not based on studies on OE. Once again, in 1996, the Health Services Advisory Committee (HSAC) published the ELV for nitrous oxide (100ppm), isoflurane (50ppm), enflurane (50ppm) and halothane (10ppm). However, sevoflurane was not included. It was decided that the limit of 20ppm recommended by the sevoflurane manufacturer on the technical data sheet would be imposed. This strategy of using the ELV of other IAA for sevoflurane is due to the NIOSH recognition that adverse effects can occur in exposed workers, but the data available on exposure in humans and animals are insufficient to establish a safe and specific ELV for sevoflurane.<a class="elsevierStyleCrossRefs" href="#bib0060">12–15</a>We took 2ppm as the ELV for sevoflurane because to date, neither NIOSH, the Occupational Safety and Health Administration (OSHA), the American Conference of Industrial Hygienists (ACGIH), nor the Spanish or European Community agencies that are responsible for workplace safety have specific ELV for sevoflurane. This way, 2ppm is the strictest limit to guarantee worker safety for exposure to this drug.Safety data concerning reduction of sevoflurane traces during inhalation sedation have not been clearly established. During inhalation sedation, waste gas can be scavenged actively or passively. Gas from the ventilator and the gas analyser can be actively led into a central evacuation system, a gas extraction system (SEGA), or through a specially designed, commercially available, active carbon canister. This type of canister, such as CONTRAfluran™ (ZeoSys, Berlin, Germany), is a passive scavenger system that passively absorbs waste sevoflurane.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>There is considerable controversy about the use of scavenging systems during inhalation sedation. The manufacturer of the AnaConDa® device and several recent studies recommend that SEGA systems or scavenging systems should be applied to ventilators to reduce the amount of gas in working areas. Other investigators, however, consider this unnecessary.<a class="elsevierStyleCrossRefs" href="#bib0080">16–23</a>Sevoflurane contamination has been studied during inhalation sedation but no specific studies have yet compared levels of waste sevoflurane in the different possible scenarios of AnaConDa® use.The aim of the present study was to evaluate OE and environmental pollution (EP) levels of sevoflurane during inhalation sedation using AnaConDa® in different scenarios of during postoperative mechanical ventilation.Materials and methodsThis study was carried out in a cardio-thoracic post-surgical critical care unit (PACU) at a Spanish tertiary care university hospital. The study was approved by the institutional review board and written informed consent to participate in the study was obtained from all patients (Trial registration: No. 08-123OBS.Ref.HSCSP). All patients had undergone cardio-thoracic surgery under general anaesthesia with inhaled sevoflurane.We measured trace concentrations of sevoflurane using diffusive passive monitor badges (DPMB) (Halogenated Anaesthetics Vapour Monitor Cat No. H-10) that have been validated in both laboratory and field experiments<a class="elsevierStyleCrossRefs" href="#bib0120">24–25</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>We used DPMB instead of a portable ambient air analyser, which uses a single infrared spectrophotometer, because they allowed us to obtain four samples simultaneously.The DPMB is worn near the breathing zone to measure personal exposure to the vapour, or placed in a room to measure the area contamination.We followed UNE-EN 689 recommendations concerning the minimum number of samples needed to study exposure to gases over a period of at least 2h.The minimum level that can be measured with the analytical procedure is about 6μm per sample. Based on the collection rates this corresponds to 0.07ppm for an 8-h exposure time.US OSHA 29 methods were used to detect traces of sevoflurane in each DPMB, and a time-weighted average was calculated for each sample over an 8-h period.<a class="elsevierStyleCrossRefs" href="#bib0130">26–27</a>Scenario designThe study was carried out during the post-operative sedation period in the PACU. We studied the OE in conjunction with the EP of sevoflurane in four different scenarios of mechanical ventilation after major surgery. We called them scenarios A, B, C and 0.As we assumed that the nurse was the team member with the highest risk of exposure, a DPMB was attached to the uniform of the nurse in charge of patient care.Three other DPMB were distributed in the same location in all four scenarios to measure sevoflurane levels in two different working areas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Two passive diffusion monitors were placed 1.5m apart at both left and right sides of the ventilator, and the third monitor was placed 8m away from the ventilator. The distance of 1.5m was chosen because it is at this point where most care tasks are carried out. The distance of 8m was chosen because we considered it represents the common working area required for all staff in the post-operative care unit.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>In scenario A we used sevoflurane as a sedation drug via the AnaConDa® system without scavenging waste gas. In scenario B we used sevoflurane via the AnaConDa® system and we connected a gas extraction system (SEGA) to the ventilator gas outlet (the flow used on the SEGA's is 25lmin−1). In scenario C we used sevoflurane via the AnaConDa® system, and a scavenging canister of contrafluran was connected to the ventilator gases outlet.Scenario 0 was the control situation in which we used intravenous sedation and measured basal sevoflurane waste gas levels in the atmosphere.We recorded how long each passive diffusion monitor was exposed to the atmosphere.Sedation managementSevoflurane syringes were prepared following the AnaConDa® manufacturer's instructions prior to sedation. This was performed outside the PACU.The sevoflurane infusion regimen was calculated based on minute volume and the patients’ weight to obtain an ETsevo of 0.5%, measured using a gas analyser (Sam Module, General Electrics, Wisconsin, USA).<a class="elsevierStyleCrossRefs" href="#bib0140">28–30</a>A remifentanil infusion-based sedation (0.05–0.15μg/kg/min) was administered in scenario 0.Sevoflurane and remifentanil were administered to achieve a RASS score (Anexo see additional material online) of −1 or −2 for a minimum of 2h, until stop sedation criteria for extubation were met.Supplementary data associated with this article can be found, in the online version, at <a id="intr0005" class="elsevierStyleInterRef" href="http://dx.doi.org/10.1016/j.rear.2013.11.011">http://dx.doi.org/10.1016/j.redar.2013.11.011</a>.<elsevierMultimedia ident="upi0005"></elsevierMultimedia>Depth of sedation, processing EEG waves, was monitored using the IoC-View (Morpheus Medical, Barcelona, Spain) anaesthesia monitor.<a class="elsevierStyleCrossRefs" href="#bib0155">31–32</a>When the stop sedation criteria were fulfilled, the sevoflurane and remifentanil infusions were interrupted and all four passive diffusion monitors were closed down.The stop sedation criteria were: PAFI (PaO2/FiO2)≥200 with a positive end-expiratory pressure ≤5 and arterial carbon dioxide tension <7kPa; body temperature between 36.5 and 37.5°C; decreased infusion rates of cathecolamines (upper limit norepinephrine)<0.25μg/kg/min, dobutamine<10μg/kg/min or epinephrine<0.25μg/kg/min; bleeding in drains<100ml/h for 2 consecutive hours; RASS score>−1; a revision surgery deemed not necessary; and confirmation of the above by the attending physician.Any type of disconnection from the ventilation system was noted.The thermo-hygrometric conditions and the quality of the air inside the unit were recorded before the treatment, as well as the number of air exchanges.ResultsThe four sedation scenarios were analysed on different days.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows data describing the physical conditions in the PACU immediately prior to sedation. Number of air changes (in changes per hour) and the unit volume (in cubic meters) were the same in all four scenarios.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows data concerning the sedation characteristics for the different scenarios.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>A total of sixteen sevoflurane samples were taken, four samples in each scenario: three measured the environmental pollution levels of sevoflurane and one measured the occupational exposure.<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the time-weighted average of sevoflurane values for EP and OE over an 8-h period for each scenario.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>All DPMBs corresponding to the nurses’ breathing zone was below 2ppm.Levels of sevoflurane detected using prevention systems were lower than results obtained in the control situation.We found little variance of environmental sevoflurane traces in scenarios B and C. Only the sampler placed further away in scenario C detected a higher amount of sevoflurane than the other samplers.Only one determination over 2ppm was found during the study. This corresponded to the DPMB placed nearest to the gas outlet of the ventilator in scenario A.Trace concentrations of sevoflurane were found in scenario 0 during the intravenous sedation.DiscussionThe main finding in our study was that the 2ppm limit of OE to sevoflurane was not exceeded in any of the three scenarios during inhalation sedation using the AnaConDa® device. This study illustrates the safety of inhalation sedation in PACU through the AnaConDa® and shows that the preventive measures, SEGA and CONTRAfluran™, effectively reduce sevoflurane OE.The 2ppm ELV for sevoflurane recommended by NIOSH was surpassed only in one sample, this being one of the 3 samples collected to measure the EP in scenario A, the scenario with no preventive measures. It was obtained from the DBPM located 1.5m from the gas outlet of the ventilator. These results indicate that there is a sevoflurane exposure risk in this area but not 8m apart due to the rate of air changes.Furthermore, our results obtained following application of prevention systems (scenarios B and C) show that exposure reduction methods such as SEGA and contrafluran reduce the levels of OE and EP sevoflurane.It is of interest to point out that traces of sevoflurane were found during intravenous sedation. These traces were very small and most likely were remains from the inhalation general anaesthesia during surgery. This suggests that contamination in the other scenarios could also be partly due to basal waste sevoflurane.Our EP results obtained with the SEGAs and contrafluran are similar to those found in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0160">32–36</a> The homogeneity in the results obtained from scenario B, C and 0 suggests that SEGA and contraflura scavenging systems have a similar efficacy but specific studies are necessary to confirm this.This study is limited by its sample size but it is the first report to compare sevoflurane exposure in all possible combinations of inhalation sedation, with and without preventive measures. Although the low OE observed to sevoflurane through the AnaConDa® system without scavenging waste gas during inhalation sedation in PACU, preventive measures such as SEGA or the scavenger contraflura should be routinely attached to the mechanical ventilators to reduce occupational exposure risk as much as possible.The regulations of the control of substances hazardous to health and the occupational exposure standards have been enforced since January 1996 in an attempt to control the healthcare workers working environment. It appears that using the AnaConDa® system during inhalation sedation with sevoflurane administered by the technique we have described complies with environmental standards and it is not necessarily associated with grater sevoflurane gas exposure over 2ppm, especially when scavenging systems are available.Role of the funding sourceDepartmental funding only.Conflict of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres315242" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec297982" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres315241" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec297981" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Scenario design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Sedation management" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Role of the funding source" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-13" "fechaAceptado" => "2013-11-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec297982" "palabras" => array:4 [ 0 => "Professional exposure" 1 => "Sevoflurane" 2 => "Inhalation sedation" 3 => "Post-surgical intensive care unit" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec297981" "palabras" => array:4 [ 0 => "Exposición profesional" 1 => "Sevoflurano" 2 => "Sedación inhalatoria" 3 => "Cuidados intensivos postoperatorios" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Introduction and objectiveOccupational exposure to sevoflurane should not exceed 2ppm. During inhalation sedation with sevoflurane using the anaesthetic conserving device (AnaConDa®) in the post-anaesthesia care unit, waste gases can be reduced by gas extraction systems or scavenging devices such as CONTRAfluran™. However, the efficacy of these methods has not been clearly established. To determine the safest scenario for healthcare workers during inhalation sedation with sevoflurane in the post-surgical intensive care unit. Materials and methodsAn experimental study on occupational exposure was conducted in a post-cardiothoracic care unit during March–August 2009. The measurements were performed in four post-cardiac surgery sedated adults in post-surgical intensive care unit and four nurses at the bedside, and at four points: scenario A, inhalation sedation without gas extraction system or contrafluran as a reference scenario; scenario B, applying a gas extraction system to the ventilator; scenario C, using contrafluran; and scenario 0, performing intravenous isolation sedation. Sevoflurane concentrations were measured in the nurses’ breathing area during patient care, and at 1.5 and 8m from the ventilator using diffusive passive monitor badges. ResultsAll badges corresponding to the nurses’ breathing area were below 2ppm. Levels of sevoflurane detected using prevention systems were lower than that in the control situation. Only one determination over 2ppm was found, corresponding to the monitor placed nearest the gas outlet of the ventilator in scenario A. Trace concentrations of sevoflurane were found in scenario 0 during intravenous sedation. ConclusionsAdministration of sevoflurane through the AnaConDa® system during inhalation sedation in post-surgical intensive care units is safe for healthcare workers, but gas extraction systems or scavenging systems, such as CONTRAfluran™ should be used to reduce occupational exposure as much as possible." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivoLa exposición profesional a sevoflurano no debe exceder las 2ppm. Los gases contaminantes de las unidades de cuidados postoperatorios procedentes de la sedación inhalatoria con sevoflurano, a través del sistema “anaesthesic conserving device” (AnaConDa®), se pueden reducir a través de los sistemas de extracción de gases o de dispositivos secuestradores como contrafluoran. La eficacia de estos métodos no está aún claramente establecida.Nuestro objetivo fue determinar el escenario más seguro para los trabajadores durante la sedación inhalatoria en las una unidad de cuidados intensivos postoperatorios. Material y métodosEstudio experimental de exposición profesional en unidades postoperatorias de cirugía cardiaca de un hospital terciario desde Marzo a Agosto del 2009. Medimos en cuatro pacientes postoperados de cirugía cardiaca ingresados en la una unidad de cuidados intensivos postoperatorios y en cuatro enfermeras encargadas de sus cuidados los niveles de sevoflurano en cuatro situaciones de sedación diferentes. El objetivo principal fue la determinación de las concentraciones de sevoflurano en los mismos cuatro puntos en: escenario A, sedación inhalatoria sin utilización de sistema extractor de gases o contrafluran como escenario de referencia; escenario B, usando un sistema de extracción de gases adaptado al respirador; escenario C, usando el sistema contrafluran; y un escenario 0, con una sedación endovenosa.Las concentraciones de sevoflurano se midieron lo más cercano a la zona respiratoria de las enfermeras a cargo de los cuidados del paciente, a 1,5 y 8 metros del ventilador a través de unos monitores de difusión pasiva para halogenados. ResultadosTodas las muestras correspondientes a la zona respiratoria de las enfermeras ofrecieron mediciones por debajo de 2ppm. Los niveles de sevoflurano detectados usando los sistemas de prevención fueron menores que en la situación control. Sólo encontramos una determinación por encima de 2ppm que correspondió al monitor colocado en la salida de gases del ventilador en el escenario A. Se encontraron trazas de sevoflurano durante la sedación endovenosa en el escenario 0. ConclusionesLa administración de sevoflurano a través del sistema AnaConDa® durante la sedación inhalatoria en unidades postoperatorias es segura para los trabajadores sanitarios, pero el uso de los sistemas de extracción de gases y los sistemas secuestradores tipo contrafluran se deberían generalizar para reducir la exposición profesional el máximo posible." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1571 "Ancho" => 1583 "Tamanyo" => 168894 ] ] "descripcion" => array:1 [ "en" => "Picture and schematic diagram of the diffusive passive monitor badges SKC-575-002 used during EP and OE evaluation." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1051 "Ancho" => 1571 "Tamanyo" => 59411 ] ] "descripcion" => array:1 [ "en" => "Schematic diagram of the distribution of the DPMB SKC-575-002. It represents the patient bedroom and the post-anaesthesia care unit where A represents the ventilator and B represents the patient's bed. Number 1 corresponds to the monitor located inside the box at 1.5m radius to the right of the respirator, 2 corresponds to the monitor at 1.5m on the opposite side. Number 3 corresponds to the monitor placed outside the room at a 6–8m radius from the ventilator." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario C \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unit volume (m<a class="elsevierStyleCrossRef" href="#bib0015">3</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">270 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">270 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">270 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">270 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Air changes (cph) [>6cph] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temperature (°C) [24–26°C] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Humidity (%) [45–55%] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CO2 (ppm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">764 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">871 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">756 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">789 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463649.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Physical conditions in the postoperative unit at the beginning of the sedation periods. Values in brackets indicate values according to the UNE-100713:2005." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario C \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary bypass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary bypass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary bypass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic valve replacement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of anaesthesia (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">280 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">285 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">270 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventilator minute volume (l/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time sedation began \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18:47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14:20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19:52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18:52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time sedation ended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22:34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16:20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22:24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20:50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sedation time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">227 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">152 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">118 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean sevoflurane velocity (ml/h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total sevoflurane consumption (ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of circuit disconnection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of healthcare staff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients in the unit (total number) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463648.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics corresponding to the sedations carried out." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Scenario C \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Environmental contamination</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sample 1–1.5m to the right of the ventilator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sample 2–1.5m to the left of the ventilator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sample 3–8m from the ventilator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Occupational exposure</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sample 4–personnel monitor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463650.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Time-weighted average of sevoflurane concentrations over an 8-h period in the four different scenarios (in parts per million). Samples 1, 2 and 3 correspond to the environmental sevoflurane levels. Sample 4 corresponds to the personnel diffusive passive monitor badge." ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 28643 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Martin" 1 => "M. Franck" 2 => "M. Fischer" 3 => "C. Spies" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-006-0214-6" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2006" "volumen" => "32" "paginaInicial" => "1137" "paginaFinal" => "1142" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16741692" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Analgesia and sedation of mechanically ventilated critical patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Ramos" 1 => "E. 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Health worker exposure risk during inhalation sedation with sevoflurane using the (AnaConDa®) anaesthetic conserving device

Riesgo de exposición de los profesionales sanitarios durante sedación inhalatoria con sevoflurane a través del dispositivo anaesthetic conserving device (AnaConDa®)

R. González-Rodrígueza,

Corresponding author

rgonzalezr@santpau.cat
raul08015@gmail.com

Corresponding author.

, A. Muñoz Martínezb, J. Galan Serranoa, M.V. Moral Garcíaa

a Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

b Servicio de Riesgos Laborales y Medicina Preventiva, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

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The IAA most commonly used in our setting is sevoflurane&#46; This drug has myocardial protection effects and it produces fewer hemodynamic alterations than other IAA&#46; Furthermore&#44; systemic accumulation is low because only 10&#37; of sevoflurane is metabolised&#46; The remaining 90&#37;&#44; however&#44; is eliminated to the atmosphere&#44; posing a potential environmental risk to healthcare workers&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1967&#44; Vaisman suggested that environmental contamination by old IAA in operating rooms was associated with headache&#44; fatigue and irritability&#46; He also reported that anaesthetists using IAA had more spontaneous abortions and their offspring had a higher rate of congenital abnormalities than the general population&#46; These data have since been corroborated in other studies and in a meta-analysis&#46; Sevoflurane&#44; desflurane or isofluorane were not analysed by this meta-analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Acute exposure to sevoflurane above 1000<span class="elsevierStyleHsp" style=""></span>ppm can lead to confusion&#44; vertigo&#44; nausea&#44; somnolence&#44; and dryness and reddening of the mucosae&#46; In rare instances&#44; cases of hepatic necrosis have been described&#46; Chronic exposure to lower concentrations of sevoflurane can lead to perception disorders&#44; cognitive and motor ability changes&#44; and liver function changes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Occupational exposure &#40;OE&#41; risk to the inhalation of a gas is evaluated by comparing the concentration of this gas with the environmental level value &#40;ELV&#41;&#46; ELV is the time-weighted average representing the permissible average ambient air concentration underlying an 8-h exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">For many years&#44; there has been considerable controversy to regulations concerning the ELV to IAA&#46; In 1977 the National Institute for Occupational Safety and Health &#40;NIOSH&#41; established a recommended ELV of exposure of 2<span class="elsevierStyleHsp" style=""></span>ppm for 60<span class="elsevierStyleHsp" style=""></span>min for IAA such as chloroform&#44; trichloroethylene&#44; nitrous oxide&#44; halothane&#44; methoxyflurane&#44; fluroxene and enflurane&#46; Isoflurane&#44; desflurane and sevoflurane were later included in this recommendation&#46; These values proposed by NIOSH are based on the lowest concentration able to be detected using the procedures described for sample collection and analysis and not based on studies on OE&#46; Once again&#44; in 1996&#44; the Health Services Advisory Committee &#40;HSAC&#41; published the ELV for nitrous oxide &#40;100<span class="elsevierStyleHsp" style=""></span>ppm&#41;&#44; isoflurane &#40;50<span class="elsevierStyleHsp" style=""></span>ppm&#41;&#44; enflurane &#40;50<span class="elsevierStyleHsp" style=""></span>ppm&#41; and halothane &#40;10<span class="elsevierStyleHsp" style=""></span>ppm&#41;&#46; However&#44; sevoflurane was not included&#46; It was decided that the limit of 20<span class="elsevierStyleHsp" style=""></span>ppm recommended by the sevoflurane manufacturer on the technical data sheet would be imposed&#46; This strategy of using the ELV of other IAA for sevoflurane is due to the NIOSH recognition that adverse effects can occur in exposed workers&#44; but the data available on exposure in humans and animals are insufficient to establish a safe and specific ELV for sevoflurane&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We took 2<span class="elsevierStyleHsp" style=""></span>ppm as the ELV for sevoflurane because to date&#44; neither NIOSH&#44; the Occupational Safety and Health Administration &#40;OSHA&#41;&#44; the American Conference of Industrial Hygienists &#40;ACGIH&#41;&#44; nor the Spanish or European Community agencies that are responsible for workplace safety have specific ELV for sevoflurane&#46; This way&#44; 2<span class="elsevierStyleHsp" style=""></span>ppm is the strictest limit to guarantee worker safety for exposure to this drug&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Safety data concerning reduction of sevoflurane traces during inhalation sedation have not been clearly established&#46; During inhalation sedation&#44; waste gas can be scavenged actively or passively&#46; Gas from the ventilator and the gas analyser can be actively led into a central evacuation system&#44; a gas extraction system &#40;SEGA&#41;&#44; or through a specially designed&#44; commercially available&#44; active carbon canister&#46; This type of canister&#44; such as CONTRAfluran&#8482; &#40;ZeoSys&#44; Berlin&#44; Germany&#41;&#44; is a passive scavenger system that passively absorbs waste sevoflurane&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There is considerable controversy about the use of scavenging systems during inhalation sedation&#46; The manufacturer of the AnaConDa<span class="elsevierStyleSup">&#174;</span> device and several recent studies recommend that SEGA systems or scavenging systems should be applied to ventilators to reduce the amount of gas in working areas&#46; Other investigators&#44; however&#44; consider this unnecessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sevoflurane contamination has been studied during inhalation sedation but no specific studies have yet compared levels of waste sevoflurane in the different possible scenarios of AnaConDa<span class="elsevierStyleSup">&#174;</span> use&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The aim of the present study was to evaluate OE and environmental pollution &#40;EP&#41; levels of sevoflurane during inhalation sedation using AnaConDa<span class="elsevierStyleSup">&#174;</span> in different scenarios of during postoperative mechanical ventilation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">This study was carried out in a cardio-thoracic post-surgical critical care unit &#40;PACU&#41; at a Spanish tertiary care university hospital&#46; The study was approved by the institutional review board and written informed consent to participate in the study was obtained from all patients &#40;Trial registration&#58; No&#46; 08-123OBS&#46;Ref&#46;HSCSP&#41;&#46; All patients had undergone cardio-thoracic surgery under general anaesthesia with inhaled sevoflurane&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We measured trace concentrations of sevoflurane using diffusive passive monitor badges &#40;DPMB&#41; &#40;Halogenated Anaesthetics Vapour Monitor Cat No&#46; H-10&#41; that have been validated in both laboratory and field experiments<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;25</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">We used DPMB instead of a portable ambient air analyser&#44; which uses a single infrared spectrophotometer&#44; because they allowed us to obtain four samples simultaneously&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The DPMB is worn near the breathing zone to measure personal exposure to the vapour&#44; or placed in a room to measure the area contamination&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We followed UNE-EN 689 recommendations concerning the minimum number of samples needed to study exposure to gases over a period of at least 2<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The minimum level that can be measured with the analytical procedure is about 6<span class="elsevierStyleHsp" style=""></span>&#956;m per sample&#46; Based on the collection rates this corresponds to 0&#46;07<span class="elsevierStyleHsp" style=""></span>ppm for an 8-h exposure time&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">US OSHA 29 methods were used to detect traces of sevoflurane in each DPMB&#44; and a time-weighted average was calculated for each sample over an 8-h period&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#8211;27</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Scenario design</span><p id="par0090" class="elsevierStylePara elsevierViewall">The study was carried out during the post-operative sedation period in the PACU&#46; We studied the OE in conjunction with the EP of sevoflurane in four different scenarios of mechanical ventilation after major surgery&#46; We called them scenarios A&#44; B&#44; C and 0&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">As we assumed that the nurse was the team member with the highest risk of exposure&#44; a DPMB was attached to the uniform of the nurse in charge of patient care&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Three other DPMB were distributed in the same location in all four scenarios to measure sevoflurane levels in two different working areas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Two passive diffusion monitors were placed 1&#46;5<span class="elsevierStyleHsp" style=""></span>m apart at both left and right sides of the ventilator&#44; and the third monitor was placed 8<span class="elsevierStyleHsp" style=""></span>m away from the ventilator&#46; The distance of 1&#46;5<span class="elsevierStyleHsp" style=""></span>m was chosen because it is at this point where most care tasks are carried out&#46; The distance of 8<span class="elsevierStyleHsp" style=""></span>m was chosen because we considered it represents the common working area required for all staff in the post-operative care unit&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In scenario A we used sevoflurane as a sedation drug via the AnaConDa<span class="elsevierStyleSup">&#174;</span> system without scavenging waste gas&#46; In scenario B we used sevoflurane via the AnaConDa<span class="elsevierStyleSup">&#174;</span> system and we connected a gas extraction system &#40;SEGA&#41; to the ventilator gas outlet &#40;the flow used on the SEGA&#39;s is 25<span class="elsevierStyleHsp" style=""></span>l<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; In scenario C we used sevoflurane via the AnaConDa<span class="elsevierStyleSup">&#174;</span> system&#44; and a scavenging canister of contrafluran was connected to the ventilator gases outlet&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Scenario 0 was the control situation in which we used intravenous sedation and measured basal sevoflurane waste gas levels in the atmosphere&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We recorded how long each passive diffusion monitor was exposed to the atmosphere&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Sedation management</span><p id="par0120" class="elsevierStylePara elsevierViewall">Sevoflurane syringes were prepared following the AnaConDa<span class="elsevierStyleSup">&#174;</span> manufacturer&#39;s instructions prior to sedation&#46; This was performed outside the PACU&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The sevoflurane infusion regimen was calculated based on minute volume and the patients&#8217; weight to obtain an ET<span class="elsevierStyleInf">sevo</span> of 0&#46;5&#37;&#44; measured using a gas analyser &#40;Sam Module&#44; General Electrics&#44; Wisconsin&#44; USA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;30</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">A remifentanil infusion-based sedation &#40;0&#46;05&#8211;0&#46;15<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41; was administered in scenario 0&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Sevoflurane and remifentanil were administered to achieve a RASS score &#40;Anexo see additional material online&#41; of &#8722;1 or &#8722;2 for a minimum of 2<span class="elsevierStyleHsp" style=""></span>h&#44; until stop sedation criteria for extubation were met&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewcompact-standard">Supplementary data associated with this article can be found&#44; in the online version&#44; at <a id="intr0005" class="elsevierStyleInterRef" href="http://dx.doi.org/10.1016/j.rear.2013.11.011">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;redar&#46;2013&#46;11&#46;011</a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewextended"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p><p id="par0150" class="elsevierStylePara elsevierViewall">Depth of sedation&#44; processing EEG waves&#44; was monitored using the IoC-View &#40;Morpheus Medical&#44; Barcelona&#44; Spain&#41; anaesthesia monitor&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;32</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">When the stop sedation criteria were fulfilled&#44; the sevoflurane and remifentanil infusions were interrupted and all four passive diffusion monitors were closed down&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The stop sedation criteria were&#58; PAFI &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>200 with a positive end-expiratory pressure &#8804;5 and arterial carbon dioxide tension &#60;7<span class="elsevierStyleHsp" style=""></span>kPa&#59; body temperature between 36&#46;5 and 37&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; decreased infusion rates of cathecolamines &#40;upper limit norepinephrine&#41;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#44; dobutamine<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min or epinephrine<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#59; bleeding in drains<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml&#47;h for 2 consecutive hours&#59; RASS score<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#8722;1&#59; a revision surgery deemed not necessary&#59; and confirmation of the above by the attending physician&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Any type of disconnection from the ventilation system was noted&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The thermo-hygrometric conditions and the quality of the air inside the unit were recorded before the treatment&#44; as well as the number of air exchanges&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0175" class="elsevierStylePara elsevierViewall">The four sedation scenarios were analysed on different days&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows data describing the physical conditions in the PACU immediately prior to sedation&#46; Number of air changes &#40;in changes per hour&#41; and the unit volume &#40;in cubic meters&#41; were the same in all four scenarios&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows data concerning the sedation characteristics for the different scenarios&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">A total of sixteen sevoflurane samples were taken&#44; four samples in each scenario&#58; three measured the environmental pollution levels of sevoflurane and one measured the occupational exposure&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the time-weighted average of sevoflurane values for EP and OE over an 8-h period for each scenario&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">All DPMBs corresponding to the nurses&#8217; breathing zone was below 2<span class="elsevierStyleHsp" style=""></span>ppm&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Levels of sevoflurane detected using prevention systems were lower than results obtained in the control situation&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">We found little variance of environmental sevoflurane traces in scenarios B and C&#46; Only the sampler placed further away in scenario C detected a higher amount of sevoflurane than the other samplers&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Only one determination over 2<span class="elsevierStyleHsp" style=""></span>ppm was found during the study&#46; This corresponded to the DPMB placed nearest to the gas outlet of the ventilator in scenario A&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Trace concentrations of sevoflurane were found in scenario 0 during the intravenous sedation&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0225" class="elsevierStylePara elsevierViewall">The main finding in our study was that the 2<span class="elsevierStyleHsp" style=""></span>ppm limit of OE to sevoflurane was not exceeded in any of the three scenarios during inhalation sedation using the AnaConDa<span class="elsevierStyleSup">&#174;</span> device&#46; This study illustrates the safety of inhalation sedation in PACU through the AnaConDa<span class="elsevierStyleSup">&#174;</span> and shows that the preventive measures&#44; SEGA and CONTRAfluran&#8482;&#44; effectively reduce sevoflurane OE&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The 2<span class="elsevierStyleHsp" style=""></span>ppm ELV for sevoflurane recommended by NIOSH was surpassed only in one sample&#44; this being one of the 3 samples collected to measure the EP in scenario A&#44; the scenario with no preventive measures&#46; It was obtained from the DBPM located 1&#46;5<span class="elsevierStyleHsp" style=""></span>m from the gas outlet of the ventilator&#46; These results indicate that there is a sevoflurane exposure risk in this area but not 8<span class="elsevierStyleHsp" style=""></span>m apart due to the rate of air changes&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Furthermore&#44; our results obtained following application of prevention systems &#40;scenarios B and C&#41; show that exposure reduction methods such as SEGA and contrafluran reduce the levels of OE and EP sevoflurane&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">It is of interest to point out that traces of sevoflurane were found during intravenous sedation&#46; These traces were very small and most likely were remains from the inhalation general anaesthesia during surgery&#46; This suggests that contamination in the other scenarios could also be partly due to basal waste sevoflurane&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Our EP results obtained with the SEGAs and contrafluran are similar to those found in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#8211;36</span></a> The homogeneity in the results obtained from scenario B&#44; C and 0 suggests that SEGA and contraflura scavenging systems have a similar efficacy but specific studies are necessary to confirm this&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">This study is limited by its sample size but it is the first report to compare sevoflurane exposure in all possible combinations of inhalation sedation&#44; with and without preventive measures&#46; Although the low OE observed to sevoflurane through the AnaConDa<span class="elsevierStyleSup">&#174;</span> system without scavenging waste gas during inhalation sedation in PACU&#44; preventive measures such as SEGA or the scavenger contraflura should be routinely attached to the mechanical ventilators to reduce occupational exposure risk as much as possible&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The regulations of the control of substances hazardous to health and the occupational exposure standards have been enforced since January 1996 in an attempt to control the healthcare workers working environment&#46; It appears that using the AnaConDa<span class="elsevierStyleSup">&#174;</span> system during inhalation sedation with sevoflurane administered by the technique we have described complies with environmental standards and it is not necessarily associated with grater sevoflurane gas exposure over 2<span class="elsevierStyleHsp" style=""></span>ppm&#44; especially when scavenging systems are available&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Role of the funding source</span><p id="par0260" class="elsevierStylePara elsevierViewall">Departmental funding only&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Occupational exposure to sevoflurane should not exceed 2<span class="elsevierStyleHsp" style=""></span>ppm&#46; During inhalation sedation with sevoflurane using the anaesthetic conserving device &#40;AnaConDa<span class="elsevierStyleSup">&#174;</span>&#41; in the post-anaesthesia care unit&#44; waste gases can be reduced by gas extraction systems or scavenging devices such as CONTRAfluran&#8482;&#46; However&#44; the efficacy of these methods has not been clearly established&#46; To determine the safest scenario for healthcare workers during inhalation sedation with sevoflurane in the post-surgical intensive care unit&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An experimental study on occupational exposure was conducted in a post-cardiothoracic care unit during March&#8211;August 2009&#46; The measurements were performed in four post-cardiac surgery sedated adults in post-surgical intensive care unit and four nurses at the bedside&#44; and at four points&#58; scenario A&#44; inhalation sedation without gas extraction system or contrafluran as a reference scenario&#59; scenario B&#44; applying a gas extraction system to the ventilator&#59; scenario C&#44; using contrafluran&#59; and scenario 0&#44; performing intravenous isolation sedation&#46; Sevoflurane concentrations were measured in the nurses&#8217; breathing area during patient care&#44; and at 1&#46;5 and 8<span class="elsevierStyleHsp" style=""></span>m from the ventilator using diffusive passive monitor badges&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All badges corresponding to the nurses&#8217; breathing area were below 2<span class="elsevierStyleHsp" style=""></span>ppm&#46; Levels of sevoflurane detected using prevention systems were lower than that in the control situation&#46; Only one determination over 2<span class="elsevierStyleHsp" style=""></span>ppm was found&#44; corresponding to the monitor placed nearest the gas outlet of the ventilator in scenario A&#46; Trace concentrations of sevoflurane were found in scenario 0 during intravenous sedation&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Administration of sevoflurane through the AnaConDa<span class="elsevierStyleSup">&#174;</span> system during inhalation sedation in post-surgical intensive care units is safe for healthcare workers&#44; but gas extraction systems or scavenging systems&#44; such as CONTRAfluran&#8482; should be used to reduce occupational exposure as much as possible&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La exposici&#243;n profesional a sevoflurano no debe exceder las 2<span class="elsevierStyleHsp" style=""></span>ppm&#46; Los gases contaminantes de las unidades de cuidados postoperatorios procedentes de la sedaci&#243;n inhalatoria con sevoflurano&#44; a trav&#233;s del sistema &#8220;anaesthesic conserving device&#8221; &#40;AnaConDa<span class="elsevierStyleSup">&#174;</span>&#41;&#44; se pueden reducir a trav&#233;s de los sistemas de extracci&#243;n de gases o de dispositivos secuestradores como contrafluoran&#46; La eficacia de estos m&#233;todos no est&#225; a&#250;n claramente establecida&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue determinar el escenario m&#225;s seguro para los trabajadores durante la sedaci&#243;n inhalatoria en las una unidad de cuidados intensivos postoperatorios&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio experimental de exposici&#243;n profesional en unidades postoperatorias de cirug&#237;a cardiaca de un hospital terciario desde Marzo a Agosto del 2009&#46; Medimos en cuatro pacientes postoperados de cirug&#237;a cardiaca ingresados en la una unidad de cuidados intensivos postoperatorios y en cuatro enfermeras encargadas de sus cuidados los niveles de sevoflurano en cuatro situaciones de sedaci&#243;n diferentes&#46; El objetivo principal fue la determinaci&#243;n de las concentraciones de sevoflurano en los mismos cuatro puntos en&#58; escenario A&#44; sedaci&#243;n inhalatoria sin utilizaci&#243;n de sistema extractor de gases o contrafluran como escenario de referencia&#59; escenario B&#44; usando un sistema de extracci&#243;n de gases adaptado al respirador&#59; escenario C&#44; usando el sistema contrafluran&#59; y un escenario 0&#44; con una sedaci&#243;n endovenosa&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las concentraciones de sevoflurano se midieron lo m&#225;s cercano a la zona respiratoria de las enfermeras a cargo de los cuidados del paciente&#44; a 1&#44;5 y 8 metros del ventilador a trav&#233;s de unos monitores de difusi&#243;n pasiva para halogenados&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Todas las muestras correspondientes a la zona respiratoria de las enfermeras ofrecieron mediciones por debajo de 2<span class="elsevierStyleHsp" style=""></span>ppm&#46; Los niveles de sevoflurano detectados usando los sistemas de prevenci&#243;n fueron menores que en la situaci&#243;n control&#46; S&#243;lo encontramos una determinaci&#243;n por encima de 2<span class="elsevierStyleHsp" style=""></span>ppm que correspondi&#243; al monitor colocado en la salida de gases del ventilador en el escenario A&#46; Se encontraron trazas de sevoflurano durante la sedaci&#243;n endovenosa en el escenario 0&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La administraci&#243;n de sevoflurano a trav&#233;s del sistema AnaConDa<span class="elsevierStyleSup">&#174;</span> durante la sedaci&#243;n inhalatoria en unidades postoperatorias es segura para los trabajadores sanitarios&#44; pero el uso de los sistemas de extracci&#243;n de gases y los sistemas secuestradores tipo contrafluran se deber&#237;an generalizar para reducir la exposici&#243;n profesional el m&#225;ximo posible&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1571
            "Ancho" => 1583
            "Tamanyo" => 168894
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Picture and schematic diagram of the diffusive passive monitor badges SKC-575-002 used during EP and OE evaluation&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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            "Tamanyo" => 59411
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of the distribution of the DPMB SKC-575-002&#46; It represents the patient bedroom and the post-anaesthesia care unit where A represents the ventilator and B represents the patient&#39;s bed&#46; Number 1 corresponds to the monitor located inside the box at 1&#46;5<span class="elsevierStyleHsp" style=""></span>m radius to the right of the respirator&#44; 2 corresponds to the monitor at 1&#46;5<span class="elsevierStyleHsp" style=""></span>m on the opposite side&#46; Number 3 corresponds to the monitor placed outside the room at a 6&#8211;8<span class="elsevierStyleHsp" style=""></span>m radius from the ventilator&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unit volume &#40;m<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Air changes &#40;cph&#41; &#91;&#62;6<span class="elsevierStyleHsp" style=""></span>cph&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temperature &#40;&#176;C&#41; &#91;24&#8211;26<span class="elsevierStyleHsp" style=""></span>&#176;C&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Humidity &#40;&#37;&#41; &#91;45&#8211;55&#37;&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CO<span class="elsevierStyleInf">2</span> &#40;ppm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">764&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">871&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">756&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">789&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab463649.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Physical conditions in the postoperative unit at the beginning of the sedation periods&#46; Values in brackets indicate values according to the UNE-100713&#58;2005&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surgical diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary bypass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary bypass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary bypass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aortic valve replacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of anaesthesia &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">285&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilator minute volume &#40;l&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Time sedation began&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#58;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#58;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#58;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#58;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Time sedation ended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#58;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#58;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#58;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#58;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sedation time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">227&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">152&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean sevoflurane velocity &#40;ml&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total sevoflurane consumption &#40;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of circuit disconnection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of healthcare staff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients in the unit &#40;total number&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab463648.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Characteristics corresponding to the sedations carried out&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scenario C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Environmental contamination</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sample 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>m to the right of the ventilator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sample 2&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>m to the left of the ventilator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sample 3&#8211;8<span class="elsevierStyleHsp" style=""></span>m from the ventilator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Occupational exposure</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sample 4&#8211;personnel monitor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information

ISSN: 00349356
Original language: English

DOI:10.1016/j.redar.2013.11.011

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Year/Month	Html	Pdf	Total

2024 November	1	1	2
2023 March	3	2	5
2022 October	1	2	3
2022 June	1	0	1
2021 September	1	0	1
2019 March	1	0	1
2018 November	1	0	1
2017 July	12	2	14
2017 June	33	5	38
2017 May	29	5	34
2017 April	23	7	30
2017 March	28	32	60
2017 February	22	5	27
2017 January	23	0	23
2016 December	43	5	48
2016 November	42	2	44
2016 October	76	4	80
2016 September	61	11	72
2016 August	34	7	41
2016 July	30	2	32
2016 June	48	8	56
2016 May	33	9	42
2016 April	19	10	29
2016 March	26	9	35
2016 February	22	8	30
2016 January	28	2	30
2015 December	27	8	35
2015 November	73	13	86
2015 October	44	10	54
2015 September	34	8	42
2015 August	45	9	54
2015 July	45	5	50
2015 June	37	3	40
2015 May	49	5	54
2015 April	34	17	51
2015 March	35	14	49
2015 February	6	3	9
2015 January	0	3	3
2014 November	0	2	2
2014 October	0	1	1
2014 July	0	2	2
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