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Sánchez Zamora, R.A. Mejía Arnaud, R. Saz Castro, B. Gómez del Pulgar Vázquez, J.J. Correa Barrera" "autores" => array:5 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Sánchez Zamora" ] 1 => array:2 [ "nombre" => "R.A." "apellidos" => "Mejía Arnaud" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Saz Castro" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Gómez del Pulgar Vázquez" ] 4 => array:2 [ "nombre" => "J.J." "apellidos" => "Correa Barrera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621000153" "doi" => "10.1016/j.redar.2020.11.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621000153?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922000269?idApp=UINPBA00004N" "url" => "/23411929/0000006900000002/v1_202203120614/S2341192922000269/v1_202203120614/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192922000245" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.11.012" "estado" => "S300" "fechaPublicacion" => "2022-02-01" "aid" => "1267" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2022;69:105-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Late bilateral vocal cord palsy following endotracheal intubation due to COVID-19 pneumonia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "108" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Parálisis bilateral tardía de cuerdas vocales trasintubación endotraqueal por neumonía COVID-19" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Curros Mata, S. Alvarado de la Torre, J. Carballo Fernández, A. Martínez Morán, F. Álvarez Refojo, P. Rama-Maceiras" "autores" => array:6 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Curros Mata" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Alvarado de la Torre" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Carballo Fernández" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Martínez Morán" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Álvarez Refojo" ] 5 => array:2 [ "nombre" => "P." 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A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "109" "paginaFinal" => "113" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.M. Gómez Tarradas, A. Calvo, I. Belda, T. Topczewski, F.J. Tercero, R. Valero" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Gómez Tarradas" "email" => array:1 [ 0 => "jgomezt@clinic.ub.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Calvo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Belda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "T." "apellidos" => "Topczewski" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "F.J." "apellidos" => "Tercero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Valero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Clínic de Barcelona, 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" => "Manejo anestésico en neurocirugía de paciente con síndrome de Eisenmenger y síndrome de Down. Reporte de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1397 "Ancho" => 1750 "Tamanyo" => 178518 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiographic image. Note the large septal defect with a right-to-left shunt, typical of Eisenmenger syndrome.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Adults with congenital heart disease (CHD) are more likely to present perioperative mortality and morbidity, but guidelines have been developed to guide management in these situations<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Anaesthesia must be carefully planned when performing neurosurgery in these types of patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Dexmedetomidine (DEX) can have significant advantages over conventional anaesthetic agents, but clinicians also need to be aware of its limitations<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a patient with CHD, Eisenmenger syndrome (ES) and Down syndrome (DS), with difficult haemodynamic, respiratory and airway management, who presented acute neurological symptoms requiring 2 separate neurosurgical interventions. We analyse and compare the 2 anaesthesia approaches used.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 42-year-old woman (47 kg, 140 cm) with DS and ES secondary to atrioventricularis communis, limited aerobic capacity (<4 metabolic equivalents of task), central cyanosis, nail clubbing, heart rate (HR) 86 bpm, blood pressure (BP) 85/50 mmHg and baseline pulse oximetry oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) 75%, severe atrioventricular valve regurgitation treated solely with acetylsalicylic acid. A pre-operative echocardiography study showed severe pulmonary hypertension (PH) (pulmonary artery pressure [PAP] 98 mmHg). She presented in the emergency room with a 4-day history of asthenia and right frontal headache with recent onset left hemiparesis (4/5). Glasgow Coma Scale (GCS): 12 (eye opening: 3, verbal response: 4, motor response: 5). A cranial computed tomography was performed that showed a tumour (49 × 45 mm) suggestive of an abscess with mass effect with signs of hydrocephalus and herniation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A multidisciplinary team made up of a cardiologist, neurosurgeon and anaesthesiologist decided to perform trephine drainage due to the patient’s high anaesthesia and surgical risk.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Blood tests showed haemoglobin: 19 g dL<span class="elsevierStyleSup">−1</span>; haematocrit: 66%; platelets: 131,000 L<span class="elsevierStyleSup">−1</span>; leukocytes: 4109 L<span class="elsevierStyleSup">−1</span>; INR: 1.16. The airway assessment showed limited mouth opening (3.5 cm), Mallampati III, macroglossia, prominent incisors, and retrognathism.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Standard monitoring was performed in addition to regional oxygen saturation (SrO<span class="elsevierStyleInf">2</span>) (Invos Cerebral Oximeter, Somanetics, Troy, USA), administering 5 L/min oxygen through nasal prongs. Linezolid and meropenem were administered. Sedation was started with DEX perfusion at a rate of 1 μg kg<span class="elsevierStyleSup">−1</span> h<span class="elsevierStyleSup">−1</span>. After 30 min, RASS –3 was reached (eye opening to voice) and the patient was placed in the lateral position. RASS –4 was reached (no response to voice, but response to physical stimulus) 1 h after DEX was updosed to 1.3 μg kg<span class="elsevierStyleSup">−1</span> h<span class="elsevierStyleSup">−1</span>. This level was maintained throughout the procedure, although complete immobility was not achieved, which made the procedure difficult. Skull block was performed with 1% lidocaine and 0.35% ropivacaine at the level of the lesser and greater occipital nerves and auriculotemporal nervc. The Mayfield placement points and trephine incision were infiltrated. Haemodynamic stability was maintained (minimum HR 45 bpm, baseline BP 101/68 [78] mmHg, minimum BP 90/62 [72] mmHg) without the need for vasoactive drugs, despite transient bradycardia (43 bpm) during drainage of the abscess. SpO<span class="elsevierStyleInf">2</span> did not vary from baseline (70%). Baseline right SrO<span class="elsevierStyleInf">2</span> was 47%, the minimum recorded was 43%. The patient remained in spontaneous ventilation with a patent airway and a respiratory rate of between 14 and 18 rpm. The abscess could not be fully drained. At the end of the intervention, in the post anaesthesia care unit, she presented good recovery (GCS 13; eye-opening: 4, verbal response: 3, motor response: 6) with residual left hemiparesis (4/5). She remained hospitalised until a new imaging test had been performed, which showed persistence of the lesion, and the patient was scheduled for complete drainage.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the second intervention, in the neurosurgery operating room, antibiotic therapy (ampicillin, ceftriaxone, cotrimoxazole and linezolid) was maintained, the patient was pre-oxygenated with 95% fraction of inspired oxygen (FiO<span class="elsevierStyleInf">2</span>) to achieve SpO<span class="elsevierStyleInf">2</span> 85%, and monitored with ECG, SpO<span class="elsevierStyleInf">2</span>, ETCO<span class="elsevierStyleInf">2</span>, invasive BP, BIS [Bispectral index™, Medtronic, Minneapolis, USA] and LiDCO™ [LiDCO Ltd., London, UK]). Anaesthesia was induced with propofol, fentanyl, ketamine and rocuronium while administering phenylephrine perfusion at 0.28 μg kg min<span class="elsevierStyleSup">−1</span>. A fibreoptic bronchoscope was on hand throughout the procedure. A #4 Fastrach laryngeal mask airway was inserted and controlled mechanical ventilation was started, maintaining general anaesthesia with target-controlled infusion (TCI) of propofol at a rate of 1 μg mL<span class="elsevierStyleSup">−1</span> and TCI of remifentanil at a rate of 0.8 μg mL<span class="elsevierStyleSup">−1</span>, titrating the doses for a BIS of between 40 and 60. The patient remained haemodynamically stable, with SpO<span class="elsevierStyleInf">2</span> (70%), cardiac output (3.2 L/min) and pCO<span class="elsevierStyleInf">2</span> (38 mmHg) remaining at baseline levels. Craniotomy was performed in the supine position with the head rotated to the right, and several millilitres of purulent material were drained. At the end of the procedure, the patient was woken up, neuromuscular blockade was reversed with Sugammadex, the supraglottic airway was removed once reflexes had returned, and she was transferred to the ICU under spontaneous ventilation (SpO<span class="elsevierStyleInf">2</span> 91%).</p><p id="par0045" class="elsevierStylePara elsevierViewall">After 2 days in the ICU, she was discharged to the neurosurgery room. She was re-admitted 48 later due to decompensation that was diagnosed as acute pulmonary oedema and respiratory superinfection that resolved satisfactorily with antibiotic treatment, diuretic therapy (furosemide) and oxygen support (high-flow nasal cannula [HFNC]). After 10 days in the ICU, she was discharged to the ward and made a satisfactory recovery. <span class="elsevierStyleItalic">Streptococcus intermedius</span> was grown in the brain abscess culture; blood cultures were negative.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">A difficult airway, cognitive disability and advanced CHD, all present in our patient, together with the need for urgent surgery, forced us to take a different approach to anaesthesia management. Airway problems (atlantoaxial instability, retrognathia, macroglossia, limited mouth opening, airway stenosis, etc.) requires good planning to minimise risks<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. Anaesthesia management in surgical patients with CHD is highly complex due to their haemodynamic abnormalities, chronic hypoxaemia, and the type of intervention. In our case, the presence of complete atrioventricular canal, the most frequent CHD in DS<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, progressed to ES required us to choose an approach that would minimise impact on cardiovascular balance, bearing in mind the corresponding side effects (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In the first intervention, we chose sedation with DEX and specific monitoring. The use of DEX, which does not produce respiratory depression, prevented hypercapnia and loss of control over a difficult airway.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the most common form of administration consists of a bolus followed by perfusion, the bolus was eliminated in order to minimize possible haemodynamic changes. One of the requirements for performing a procedure under sedation is patient collaboration. In our case, the patient was reasonably cooperative, despite her DS and the stress created by the emergency situation; however, the lack of absolute immobility could have been a factor that prevented resolution in the first procedure. Another drawback of DEX in the emergency room is that it must be titrated to achieve an adequate level of sedation. One hour of perfusion was required in our case. This is far longer than other sedatives, and delays the start of surgery. SrO<span class="elsevierStyleInf">2</span> was monitored to detect cerebral hyperaemia or ischaemia.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the second intervention, general anaesthesia was administered with propofol and remifentanil, a supraglottic airway device was placed for airway management, a vasoconstrictor was administered, and the patient was extensively monitored. The Fastrach laryngeal mask airway can be inserted without mobilizing the upper spine. It facilitates tracheal intubation, minimizes the haemodynamic response, and reduces potentially fatal hypercapnia and hypoxemia due to vasoconstriction and the patient’s existing PH due to increased shunt. General anaesthesia with controlled ventilation allowed us to better adjust pCO<span class="elsevierStyleInf">2</span>, a critical factor in interventions with risk of intracranial hypertension. In terms of haemodynamics, positive intrathoracic pressure can place strain on the RV, exaggerate the fall in preload, and promote a right-to-left shunt<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Vasopressors are recommended to stabilise systemic vascular resistance, since they prevent abnormalities in diastolic filling that can lead to a decrease in cardiac output and potential myocardial ischaemia<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. Administration of ketamine during induction and phenylephrine infusion prevented BP decline and tachycardia<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. The patient’s HR was stable throughout surgery, with no episodes of arterial hypotension. Continuous cardiac output monitoring allowed us to assess the patient’s intraoperative haemodynamic status.</p><p id="par0070" class="elsevierStylePara elsevierViewall">During the postoperative period, the patient tolerated HFNC oxygenation for several days. This is an option in patients who require high FiO<span class="elsevierStyleInf">2</span> but whose lack of cooperation rules out non-invasive mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>. HFNC oxygenation could have been indicated during the first intervention.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In highly complex situations such as the one described, many different options are available, each with its pros and cons, and it is up to the anaesthesiologist to choose the best approach.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Data availability</span><p id="par0085" class="elsevierStylePara elsevierViewall">Data will be made available on request.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1679090" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1489817" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1679089" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1489816" "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" => "Conflict of interests" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Data availability" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-02" "fechaAceptado" => "2020-10-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1489817" "palabras" => array:12 [ 0 => "Anesthesia" 1 => "Neurosurgery" 2 => "Dexmedetomidine" 3 => "Down syndrome" 4 => "Eisenmenger Complex" 5 => "Pain" 6 => "Analgesia" 7 => "Anesthesia intravenous" 8 => "Anesthesia general" 9 => "Perioperative care" 10 => "Intraoperative care" 11 => "Emergency" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1489816" "palabras" => array:12 [ 0 => "Anestesia" 1 => "Neurocirugía" 2 => "Dexmedetomidina" 3 => "Síndrome de Down" 4 => "Síndrome de Eisenmenger" 5 => "Dolor" 6 => "Analgesia" 7 => "Anestesia intravenosa" 8 => "Anestesia general" 9 => "Cuidados perioperatorios" 10 => "Cuidados intraoperatorios" 11 => "Emergencias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El número de pacientes con patología cardíaca congénita que se intervienen de cirugía no cardíaca está en aumento. El manejo de este tipo de pacientes en neurocirugía requiere de una planificación anestésico-quirúrgica minuciosa. La necesidad de intervención urgente junto con la presencia de una cardiopatía congénita evolucionada a síndrome de Eisenmenger, asociadas a una vía aérea difícil, van a suponer un reto para el anestesiólogo. La utilización de dexmedetomidina puede ser una alternativa. Presentamos el caso de una paciente con síndrome de Down y síndrome de Eisenmenger que fue sometida a un drenaje de absceso cerebral de urgencias siendo posteriormente reintervenida de forma programada. Se comparan las diferentes técnicas anestésicas empleadas en ambos procedimientos, analizando las implicaciones que tuvieron sobre las principales alteraciones fisiopatológicas que presentaba la paciente.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez Tarradas JM, Calvo A, Belda I, Topczewski T, Tercero FJ, Valero R. Manejo anestésico en neurocirugía de paciente con síndrome de Eisenmenger y síndrome de Down. Reporte de un caso. Rev Esp Anestesiol Reanim. 2022;69:109–113.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 815 "Ancho" => 1300 "Tamanyo" => 110644 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal section of preoperative head CT. Note the temporoparietal abscess.</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" => 1397 "Ancho" => 1750 "Tamanyo" => 178518 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiographic image. Note the large septal defect with a right-to-left shunt, typical of Eisenmenger syndrome.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthesia for noncardiac surgery in adults with congenital heart disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Cannesson" 1 => "M.G. Earing" 2 => "V. Collange" 3 => "J.R. 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