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Romera Rabasa, M. Lema Tomé, A. Garrido Sánchez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Romera Rabasa" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Lema Tomé" ] 2 => array:2 [ "nombre" => "A." 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Colás Borrás, C. Subirá Alsina, E. Tria Galera, M.C. de la Torre Terrón, I. Martínez De Lagrán Zurbano" "autores" => array:5 [ 0 => array:4 [ "nombre" => "F.M." "apellidos" => "Colás Borrás" "email" => array:1 [ 0 => "fcolas@csdm.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Subirá Alsina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Tria Galera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.C." "apellidos" => "de la Torre Terrón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "I." "apellidos" => "Martínez De Lagrán Zurbano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, CSDM, Hospital de Mataró, Mataró, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, CSDM, Hospital de Mataró, Mataró, 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" => "Edema agudo de pulmón secundario a síndrome de absorción intravascular durante histeroscopia: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1452 "Ancho" => 1508 "Tamanyo" => 127878 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Radiograph 72 h post-ICU.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hysteroscopy is an exploratory endoscopic technique that studies the interior of the uterine cavity and the endocervical canal. A uterine distending medium is used (such as physiological saline or glycine) to obtain a better view and to extend the working field in the uterine cavity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is used routinely for endometrial ablation, septal resection, myomectomy, and polypectomy. Potential serious complications include: uterine perforation, haemorrhage, gas embolism, sepsis, and fluid overload with hyponatraemia.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report a case of acute pulmonary oedema (APO) after operative hysteroscopy secondary to intravascular absorption of irrigation fluid. This is a rare entity caused by intravascular absorption of distending fluid, in this case physiological saline.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This syndrome is usually accompanied by arterial hypotension, generalized oedema, and metabolic acidosis with electrolyte imbalance, and may require respiratory support and admission to the intensive care unit.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 36-year-old female patient, with no allergies or toxic habits, with a history of bilateral pulmonary embolism (PE) in 2020 that required outpatient admission and that, after study, was attributed to contraceptive medication. Two months prior to the current intervention, she had also presented metrorrhagia with dysmenorrhea that had been studied with hysteroscopy and vaginal ultrasound that identified a 3.3 × 2.9 cm submucous myoma located in the fundus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She was taken to the operating room for hysteroscopic myomectomy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">General anaesthesia was induced with lidocaine, fentanyl, and propofol, and a large laryngeal mask was inserted without incident to deliver volume-controlled lung-protective mechanical ventilation with tidal volume set to 6−8 mL/kg, PEEP 5, and initial FiO<span class="elsevierStyleInf">2</span> of 0.4. Intraoperatively, she was given ondansetron 4 mg and dexamethasone 4 mg for postoperative nausea and vomiting prophylaxis, and intravenous analgesia with paracetamol 1 g and dexketoprofen 50 mg. During surgery, she occasionally required phenylephrine to correct a tendency toward arterial hypotension. (On arrival in the operating room, her mean BP was 77 mmHg, with HR 65–70 bpm and SatO<span class="elsevierStyleInf">2</span> 99% on room air. During surgery, the minimum mean BP was 60 mmHg (varying by 22%) with slight tachycardia of 90 bpm).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hysteroscopy was performed and an examination of the uterine cavity showed a large submucous fibroid embedded in the fundus. The fibroid was extracted by morcellation, and the rest of the cavity was unremarkable. Surgical time from anaesthesia induction to completion was 80 min. A vaginal ultrasound performed during surgery showed free fluid in the cavity that was not under tension and did not require drainage; however, intravenous furosemide was required to reduce the excess fluid.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the end of the surgery, EtCO<span class="elsevierStyleInf">2</span> fell from 35 to 30 mmHg, and the patient exhibited wheezing on breathing. FiO<span class="elsevierStyleInf">2</span> was increased to 1, and suspecting bronchospasm, 100 mg of intravenous hydrocortisone was administered together with nebulizations of salbutamol and budesonide. She remained haemodynamically stable with normal blood oxygen levels. We observed considerable oedema of the face and eyes together with erythroderma, predominantly on the trunk. Suspecting anaphylaxis, an additional 100 mg of hydrocortisone was administered.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the patient’s overall stability, and considering any further complications unlikely, the patient was woken up and the laryngeal mask removed without incident. A few minutes later, the patient complained of difficulty breathing and nausea, so she was given supplemental oxygen and a complete blood panel was ordered, including tryptase and complement proteins to rule out anaphylaxis. An arterial blood gas analysis showed mixed acidosis and hypoxaemia (pH 7.059, HCO<span class="elsevierStyleInf">3</span> 12 mmol/L, pO<span class="elsevierStyleInf">2</span> 75 mmHg, pCO<span class="elsevierStyleInf">2</span> 49.8 mmHg); oxygen therapy was maintained due to a significant fall in blood oxygen levels when withdrawn, and swelling of the face and lips persisted. Her preoperative X-ray was reviewed, but no obvious alterations were observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Based on her history, we initially suspected a new pulmonary thromboembolism or anaphylaxis. Given the impossibility of transferring her or of withdrawing oxygen therapy, we decided to intubate, and performed preoxygenation, rapid sequence induction (fentanyl 150 mcg, propofol 120 mg and succinylcholine 70 mg) followed by intubation with a <span class="elsevierStyleItalic">Glidescope</span>® video laryngoscope. After induction, we observed a whitish foam emerging from the nostrils, and after introducing the laryngoscope blade we observed abundant pink foam in the glottis. An endotracheal tube was inserted under glottic visualization, the foam was aspirated, and invasive mechanical ventilation was started. Crackles were heard during lung auscultation. Suspecting APO, and given the need for prolonged ventilation, she was transferred to the ICU. On arrival, a further analysis was carried out that showed hyperchloremia of 117 mmol/L, hypocalcaemia of 5.9 mg/dL with hypoproteinaemia of 5.8 g/dL and hypokalaemia of 3.2 mmol/L. On the basis of these findings, she was given calcium gluconate and potassium chloride. A chest X-ray was performed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which showed bilateral perihilar infiltrates. Blood gas analysis showed persistent metabolic acidosis with pH 7.041, HCO<span class="elsevierStyleInf">3</span> 11.9 mmol/L and EB —15.3 mmol/L. She was given 100 mEq of HCO3, and a repeat analysis showed that pH levels had normalised.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Given the patient’s clinical signs, the surgical context, and the electrolyte and blood gas alterations, we suspected operative hysteroscopy intravascular absorption. Intravenous diuretics were started to evacuate the excess fluid (diuresis was 4600 cc in 12 h) and invasive mechanical ventilation was maintained.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once her breathing had improved, we were able to reduce ventilation and oxygen therapy, and finally extubate her 6 h of admission. She was discharged to the ward after 24 h in the ICU. A control X-ray was performed at 72 h, and showed almost total resolution of her symptoms (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Hysteroscopic myomectomy is the treatment of choice for submucosal fibroids measuring 6 cm or less in diameter.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Morcellation is a safe technique that is associated with few complications, the most important being direct injury to surrounding viscera such as the intestine and bladder, ureteral lesions, and vascular lesions. It is contraindicated in patients with suspected malignant lesions due to the risk of spread. During hysteroscopy, a solution 0.9% normal saline solution is administered to distend the uterus and facilitate visualization.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The incidence of fluid overload during hysteroscopic surgery is less than 5%. With the advent of bipolar electrosurgical systems using isotonic solutions, fluid deficits >1000 mL are tolerated by healthy women, but a safe, upper limit has not yet been defined and will depend upon an individual’s size, age, and medical fitness.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The main complications are intraoperative fluid absorption that leads to fluid overload with or without electrolyte imbalance.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this case, the procedure was complicated and time-consuming, and this led to volume overload and the appearance of intravascular absorption syndrome. There are several strategies to minimise the risk of fluid absorption, including maintaining intrauterine pressure as low as possible (allowing adequate visualization below mean arterial pressure), intracervical injection of dilute vasopressin prior to cervical dilation, and using regional or local anaesthesia plus sedation instead of general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Some authors have reported cases of APO and hyperchloremic metabolic acidosis secondary to intravascular absorption during operative hysteroscopy with normal saline.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,8</span></a> The exact incidence and prevalence is unclear, but what is believed to be the first case describing absorption of physiological saline solution was published in 2013.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Intravascular absorption has some similarities with transurethral resection syndrome.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinically, the consequences of this syndrome are haemodilution with acidosis, electrolyte disturbances, anaemia, hypervolaemia, and third-space losses with systemic and pulmonary oedema. In our patient, the first indication of this complication was a drop in EtCO<span class="elsevierStyleInf">2</span>, a sign also described by Silva Santos and Coelho<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> together with a decrease in tidal volume as the ventilatory capacity of the congested lungs worsens. In our case, SpO<span class="elsevierStyleInf">2</span> was maintained at >95% by increasing FiO<span class="elsevierStyleInf">2</span>, given the initial diagnostic suspicion of anaphylaxis with possible bronchospasm.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the limited haemodynamic impact of intravascular absorption, once surgery had been completed the patient was woken up without reducing FiO<span class="elsevierStyleInf">2</span> because the anaphylaxis was considered resolved. In hindsight, even though the patient was able to breathe spontaneously, it would have been advisable to wean her from oxygen therapy by gradually reducing FiO<span class="elsevierStyleInf">2</span> and determining whether she was able to tolerate lower fractions. Fluid overload was managed with loop diuretics in order to restore the fluid balance.</p><p id="par0075" class="elsevierStylePara elsevierViewall">APO management includes supplemental oxygen, tilting the patient’s bed to facilitate ventilation, administering morphine in case of dyspnoea, and ventilation therapy if necessary. There is solid evidence to support the use of non-invasive ventilation (NIV), provided the patient has no neurological deficits and there is no risk of bronchial aspiration, both of which are absolute contraindications for NIV. Given the patient’s progressive dyspnoea and desaturation following removal of the face mask, and as we were initially unable to rule out PE, our main priority was to ensure adequate ventilation and oxygenation, and for this purpose were decided to intubate. Lung protective ventilation (LPV) is recommended in volume-controlled ventilation. All guidelines recommend setting tidal volume at around 6 mL/kg of ideal weight to achieve plateau pressure <30 cmH<span class="elsevierStyleInf">2</span>O.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">With regard to the electrolyte imbalance, in our patient sodium levels were normal but potassium and calcium were low, so they were supplemented until they had normalised. The patient’s acute anaemia was attributed to haemodilution due to increased intravascular volume, so we followed a restrictive transfusion strategy.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Although the patient was ultimately diagnosed with APO due to intravascular absorption syndrome, we believe that both anaphylaxis and PE were valid differential diagnoses.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The symptoms of dyspnoea together with erythema and oedema initially suggested NSAID-induced anaphylaxis, so these were discontinued. Having previously considered the possibility of anaphylaxis as a differential diagnosis, the same drugs should not have been administered during the second anaesthesia induction. Given their association with anaphylaxis, NSAIDs were thought to be likely culprits, even though propofol-induced anaphylaxis has been reported in only 1 in 60,000 anaesthesias.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Anaphylaxis was correctly treated with fluid therapy, ventilatory support, corticosteroid therapy, and inhaled bronchodilators.</p><p id="par0095" class="elsevierStylePara elsevierViewall">PE was also evaluated as a differential diagnosis, given the patient’s history of PE and the observed drop in EtCO<span class="elsevierStyleInf">2</span>. Echocardiography would have been an ideal tool to rule out right ventricular overload on the basis of the presence of B lines suggestive of pulmonary oedema; however, an ultrasound system with pulmonary or cardiac transducers was not immediately available in this emergency situation. Our suspicion of pulmonary oedema was confirmed during intubation, and this guided the subsequent diagnosis. The rapid administration of diuretics and prompt airway management with ventilatory support and oxygen therapy allowed us to extubate the patient and discharge her to the ward within 24 h.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although intravascular absorption syndrome is relatively rare, anaesthesiologists need to be aware of this possibility, since a delay in diagnosis can worsen the clinical outcome. With early diagnosis and correct management, this syndrome can be resolved without major complications.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical considerations</span><p id="par0105" class="elsevierStylePara elsevierViewall">The patient was duly informed that their data would be processed and their confidentiality guaranteed, and that the case report would be published for scientific purposes. The patient understood and accepted these conditions, and gave her written informed consent. The consent was obtained following the check-list of good clinical practice.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2165858" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1836888" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2165859" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1836889" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical considerations" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-10-02" "fechaAceptado" => "2023-04-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1836888" "palabras" => array:6 [ 0 => "Hysteroscopy" 1 => "Oedema" 2 => "Lung" 3 => "Absorption" 4 => "Intravascular" 5 => "Serum" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1836889" "palabras" => array:6 [ 0 => "Histeroscopia" 1 => "Edema" 2 => "Pulmón" 3 => "Absorción" 4 => "Intravascular" 5 => "Suero" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hysteroscopy is an exploratory endoscopic technique that studies the interior of the uterine cavity and the endocervical canal. Various fluids, such as physiological saline, are used to optimise visualisation of the internal structures during this procedure. A rare complication of hysteroscopy is fluid overload, which can be associated with intravascular absorption syndrome, usually after lengthy procedures or tissue dissection. There are no data on the incidence and prevalence of this syndrome, and few cases involving physiological saline solution have been reported. We present a case of hysteroscopic myomectomy complicated by vascular absorption syndrome, which gave rise to acute pulmonary oedema that required admission to the intensive care unit.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La histeroscopia es un procedimiento endoscópico que estudia el interior de la cavidad uterina y del canal endocervical con objetivo diagnóstico-terapéutico. Para obtener una visualización óptima de las estructuras se utilizan diversos fluidos como el suero salino fisiológico. Una complicación poco frecuente es la sobredosificación de volumen, lo cual puede asociarse a un síndrome de absorción intravascular tras histeroscopia, normalmente tras procedimientos largos o disección de tejidos. Respecto a este síndrome, no se disponen datos de incidencia y prevalencia, existiendo pocos casos reportados en relación a solución salina fisiológica. Se presenta el caso de una paciente sometida a resección miomatosa, que, como consecuencia del síndrome de absorción vascular, dio lugar a edema agudo de pulmón que requirió ingreso en la unidad de cuidados intensivos.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1144 "Ancho" => 1675 "Tamanyo" => 166281 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Preoperative vaginal ultrasound.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1437 "Ancho" => 1508 "Tamanyo" => 122445 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Preoperative radiograph.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1491 "Ancho" => 1508 "Tamanyo" => 145652 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiograph on admission to ICU.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1452 "Ancho" => 1508 "Tamanyo" => 127878 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Radiograph 72 h post-ICU.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Histeroscopia diagnóstica ambulatoria. 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