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"apellidos" => "Paiva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620302280" "doi" => "10.1016/j.redar.2020.08.012" "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/S0034935620302280?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921001177?idApp=UINPBA00004N" "url" => "/23411929/0000006800000008/v1_202109260522/S2341192921001177/v1_202109260522/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192921001220" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.12.002" "estado" => "S300" "fechaPublicacion" => "2021-10-01" "aid" => "1282" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:443-71" "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">CONSENSUS STATEMENT</span>" "titulo" => "SEDAR/SECCE ECMO management consensus document" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "471" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso SEDAR/SECCE sobre el manejo de ECMO" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Zarragoikoetxea, A. Pajares, I. Moreno, J. Porta, T. Koller, V. Cegarra, A.I. Gonzalez, M. Eiras, E. Sandoval, J. Aurelio Sarralde, B. Quintana-Villamandos, R. Vicente Guillén" "autores" => array:12 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Zarragoikoetxea" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pajares" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Moreno" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Porta" ] 4 => array:2 [ "nombre" => "T." "apellidos" => "Koller" ] 5 => array:2 [ "nombre" => "V." "apellidos" => "Cegarra" ] 6 => array:2 [ "nombre" => "A.I." "apellidos" => "Gonzalez" ] 7 => array:2 [ "nombre" => "M." "apellidos" => "Eiras" ] 8 => array:2 [ "nombre" => "E." "apellidos" => "Sandoval" ] 9 => array:2 [ "nombre" => "J." "apellidos" => "Aurelio Sarralde" ] 10 => array:2 [ "nombre" => "B." "apellidos" => "Quintana-Villamandos" ] 11 => array:2 [ "nombre" => "R." "apellidos" => "Vicente Guillén" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621000554" "doi" => "10.1016/j.redar.2020.12.011" "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/S0034935621000554?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921001220?idApp=UINPBA00004N" "url" => "/23411929/0000006800000008/v1_202109260522/S2341192921001220/v1_202109260522/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Analysis of bupivacaine and ropivacaine-related cardiac arrests in regional anesthesia: A systematic review of case reports" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "472" "paginaFinal" => "483" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Viderman, B. Ben-David, A. Sarria-Santamera" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Viderman" "email" => array:1 [ 0 => "dmitriy.viderman@nu.edu.kz" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Ben-David" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Sarria-Santamera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Biomedical Sciences, Nazarbayev University School of Medicine, Nur-sultan, Kazakhstan" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, United States" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de las paradas cardiacas relacionadas con bupivacaína y ropivacaína en anestesia regional: una revisión sistemática de informes de casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1728 "Ancho" => 2175 "Tamanyo" => 166062 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PRISMA diagram.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Multimodal analgesia protocols that include regional anaesthesia are increasingly becoming a part of perioperative pain management. This is no doubt due primarily to the widespread introduction of ultrasound-guided regional anaesthesia, which greatly improves patient safety by reducing the incidence of nerve block failure and block-related complications<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. The rapid development of a wide variety of fascial plane blocks and their use in a growing number of surgeries has contributed to the widespread use of regional anaesthesia, and ultrasound guidance has been instrumental in changing the focus from a nerve-based approach to one based on locating the fascial plane. Our commitment to patient safety makes it important to identify the risks associated with these new techniques that have changed routine clinical practice. A particular concern in regional anaesthesia is the risk of local anaesthetic systemic toxicity (LAST), particularly when performing techniques that require the injection of large volumes of local anaesthetic.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Bupivacaine and ropivacaine are the most frequently used local anaesthetics in modern regional anaesthesia. Their mechanism of action is mainly attributed to a reversible inhibition of sodium and potassium channels and the resulting blockage of impulse conduction in nerve fibres<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Bupivacaine, being more lipophilic than ropivacaine, is more likely to penetrate large myelinated motor fibres, and therefore has a lower threshold for central and cardiovascular toxicity<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">LAST, unfortunately, still occurs and leads to serious and sometimes tragic consequences<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. The 2 most common mechanisms of LAST are intravascular injection or local anaesthetic overdose. In the first case, symptoms appear early due to the rapid increase in plasma concentrations, while single or incremental overdose causes a delayed reaction<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical consequences of bupivacaine and ropivacaine-induced LAST differ. Clinicians have often observed that bupivacaine is more likely to produce cardiotoxic effects, and can also cause fatal arrhythmias<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. These observations are supported by animal studies in local anaesthetic toxicity and LAST survivability<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. LAST-induced cardiac arrest is triggered by cardiac mechanisms, namely, blockade of cardiac sodium channels during systole and depression of cardiac conduction that causes re-entry ventricular arrhythmias<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, and also by central mechanisms<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, namely, high plasma levels of bupivacaine that can cause ventricular arrhythmias and directly affect the brainstem. It is widely believed that patients who develop ropivacaine-induced toxicity will respond better to resuscitation than patients who develop bupivacaine-induced toxicity<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. However, many authors stress the importance of rapid access to 20% lipid emulsion (LE) infusion when using any unsafe local anaesthetic to perform nerve block, unless LE is easily accessible<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this systematic review of case reports is to extract, analyse and synthesize the available clinical information on bupivacaine and ropivacaine-related cardiac arrest in order to give a clearer picture of the clinical presentation. We decided to focus on these two local anaesthetics because they are now widely used in fascial plane blocks (which require the injection of large doses of local anaesthetics). The study question was: “In what clinical setting does bupivacaine or ropivacaine-related perioperative cardiac arrest occur?".</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Study strategy</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protocol</span><p id="par0030" class="elsevierStylePara elsevierViewall">All authors agreed on a protocol that established the criteria for study inclusion and exclusion and the method of analysis. We restricted the scope of this review to articles (case reports) describing bupivacaine and ropivacaine-related cardiac arrest in humans. This systematic review was prepared according to PRISMA guidelines.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Participants/population</span><p id="par0035" class="elsevierStylePara elsevierViewall">Case reports were included if they mentioned any type of cardiac arrest (ventricular tachycardia, ventricular fibrillation, asystole, pulseless electrical activity) stemming from toxicity caused by the administration of bupivacaine or ropivacaine in any type of regional anaesthesia technique.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The exclusion criteria were:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1)</span><p id="par0045" class="elsevierStylePara elsevierViewall">reports involving cardiac arrest resulting from total spinal anaesthesia, hypovolaemia, or cardiac arrest induced by reflexes that may not be related to LAST;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0050" class="elsevierStylePara elsevierViewall">reports in which the clinical scenario was not clearly described;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0055" class="elsevierStylePara elsevierViewall">animal studies.</p></li></ul></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Type of studies included: studies, case reports or case series</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Literature search</span><p id="par0060" class="elsevierStylePara elsevierViewall">We conducted a literature search in PubMed and EMBASE using both free text and medical subject headings (MeSH) that included ("bupivacaine" [MeSH terms] OR "bupivacaine" [all fields]) OR ("ropivacaine" [MeSH terms] OR "ropivacaine "[All fields]) AND ("cardiac arrest” [MeSH terms] OR ("heart” [all fields] AND "arrest” [all fields]) OR "cardiac arrest” [all fields] OR (" cardiac” [all fields] AND “arrest” [all fields]) OR “cardiac arrest” [all fields]). Studies in humans published prior to 2019 and articles describing animal studies were excluded. Only English language articles were considered. DV and BB independently examined the results obtained from the search and identified potentially relevant abstracts. Any articles in which the title and abstract did not fully meet the inclusion criteria were ruled out. The bibliographies of all articles identified were examined and cross referenced to identify any additional relevant sources.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The following data were summarized: author, age, sex, weight, surgery (diagnosis), types of anaesthesia (general, regional, local anaesthetic [percentage, dose]), time from administration of local anaesthetic to development of toxicity, chronology of the episodes leading to cardiac arrest (seizures, tachycardia, bradycardia, hypotension, cardiac arrest), description of resuscitation, use of lipid emulsion, response to resuscitation, and outcome (survived, did not survive).</p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Study characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">The literature search retrieved 268 potentially relevant publications (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> PRISMA diagram). A total of 246 articles were excluded after reviewing the abstracts (animal studies, editorials, articles published not published in English), leaving 22 relevant case reports for inclusion in the review. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient characteristics, including author, year of publication, age and weight of the patients, surgery, type of anaesthesia, local anaesthetic dose, chronology of events, advanced cardiac life support (ACLS) and outcome. A total of 22 case reports were analysed (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patient demographics</span><p id="par0075" class="elsevierStylePara elsevierViewall">Patient age ranged from 3 to 92 years, with a mean age of 48.3 years: (34 [3–38]) and 62.7 years (25−92) in the bupivacaine and ropivacaine groups, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). There were 10 (44% of the total number) male patients: 7 (53.8%) and 3 (33.3%) in the bupivacaine (Group B) and ropivacaine (Group R) groups, respectively. There was 1 case of local infiltration of bupivacaine for anaesthesia in a 3-year-old paediatric patient who immediately developed cardiac arrest. The remaining case reports describe episodes of cardiac arrest in adult patients.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Types of regional anaesthesia and anaesthetist</span><p id="par0080" class="elsevierStylePara elsevierViewall">In all cases, regional anaesthesia was administered by an anaesthesiologist. There was 1 case of a surgeon who performed surgical wound infiltration with bupivacaine at the end of surgery. This led to cardiac arrest, and resuscitation was unsuccessful. In another case, due to a misunderstanding, the surgeon administered ropivacaine intraperitoneally without informing the anaesthesiologist, who subsequently performed transverse abdominis plane block, which caused cardiac arrest<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Cardiac arrest</span><p id="par0085" class="elsevierStylePara elsevierViewall">Most episodes of bupivacaine and ropivacaine-related cardiac arrest occurred after peripheral regional nerve block (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Of the 18 patients (81%) who developed cardiac arrest, 10 (76%) were in Group B and 8 (88%) in Group R.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Seizures</span><p id="par0090" class="elsevierStylePara elsevierViewall">Seventeen (77%) of the 22 patients – 9 (69.2%) in Group B and 6 (88.8%) in Group R – developed seizures prior to cardiac arrest. Group R patients were more likely to develop seizures prior to cardiac arrest. To treat these patients, the authors reported the use of midazolam in 5 (29.4%) cases, propofol in 3 (17.6%), sodium thiopental in 2 (11.7%), and diazepam in 1 (5.8%) case.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Bradycardia and hypotension</span><p id="par0095" class="elsevierStylePara elsevierViewall">Three (23%) patients in Group B and 6 (66.6%) in Group R presented bradycardia prior to cardiac arrest. Hypotension was only reported in 1 patient in each group (7.6% and 11.1%) prior to cardiac arrest.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Fatal outcomes</span><p id="par0100" class="elsevierStylePara elsevierViewall">We identified only 1 fatal outcome. In this case report, the surgeon had administered local infiltration anaesthesia with 6 ml of 0.25% bupivacaine in a 10 kg paediatric patient, who immediately presented bradycardia and asystole. ACLS performed for 1 h was unsuccessful. The authors did not report using lipid emulsion during resuscitation.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Importance of communication between members of the anaesthesia team</span><p id="par0105" class="elsevierStylePara elsevierViewall">There was 1 case of misunderstanding between a surgeon who administered intraperitoneal ropivacaine without informing the anaesthesiologist, who subsequently performed a TAP block, resulting in cardiac arrest. In another case, a nurse administered 1% ropivacaine instead of 0.5% prior to cardiac arrest. Both patients were successfully resuscitated.</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The main finding of this systematic review of case reports is that both bupivacaine and ropivacaine can produce systemic toxicity leading to cardiac arrest, regardless of the type of regional anaesthesia (central or peripheral) performed. Notably, cardiac arrest was typically preceded by seizures, suggesting that these could be taken as a potential predictor of serious problems. Survival rates were 92.3% in Group B and 100% in Group R. These low mortality rates may not be a true indication of survival probability, but rather of the reluctance among clinicians to publish cases with a fatal outcome. Therefore, no conclusions can be drawn regarding the probability of survival after LAST cardiac arrest. Neither was it possible to show conclusively that the return of spontaneous circulation (ROSC) and a more favourable prognosis was due to the administration of lipid emulsion, although reports suggest that this was indeed the case. As data on the number of doses of local anaesthetics administered was unavailable, we are also unable to draw conclusions regarding the incidence of cardiac arrest and local anaesthetic use. What this series of case reports did, however, show us was the general clinical picture of LAST cardiac arrest.</p><p id="par0115" class="elsevierStylePara elsevierViewall">LAST-induced cardiac arrest following peripheral nerve block should be differentiated from cardiac arrest due to total spinal anaesthesia. Although most cases are associated with neuraxial anaesthesia, total spinal anaesthesia can also be caused by inadvertent intrathecal injection during peripheral nerve block (e.g., interscalene, lumbar plexus, and paravertebral blocks). However, the clinical presentation of total spinal anaesthesia is quite different from that of LAST, and there is, therefore, little risk of diagnostic uncertainty or therapeutic ambiguity. Auroy et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> found the incidence of cardiac arrest to be significantly lower with epidural anaesthesia compared with spinal anaesthesia or peripheral nerve blocks (0.009%, 0.06%, and 0.01% respectively), and observed no fatal outcomes with epidural anaesthesia in contrast to spinal anaesthesia or peripheral nerve blocks (0%, 0.1%, and 0.004%, respectively). It should be noted that these regional anaesthesia-related complications were not specifically associated with LAST, but also included surgery-related complications (cement insertion, bleeding, etc.). The same authors also reported a significantly higher incidence of seizures after peripheral nerve blocks compared to epidural anaesthesia, while no seizures were reported with spinal anaesthesia (0.08%, 0.01% and 0%)<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Experimental models have shown that benzodiazepines prevent LAST-induced seizures, and are the treatment of choice in these cases<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>. Propofol, however, can exacerbate hemodynamic instability and increase the risk of cardiac arrest. Our data show that cardiac arrest is usually preceded by seizures (77% overall, 69.2% for bupivacaine, and 88.8% for ropivacaine), but our study methodology prevented us from determining how often seizures did not precede cardiac arrest, and we cannot therefore claim that seizures progress to cardiac arrest. Although the treatment of seizures in these reports varied: midazolam 29.4%, propofol 17.6%, thiopental sodium 11.7%, and diazepam in 5.8% of patients, we were unable to evaluate whether the treatment administered for the seizure somehow reduced the risk of progression to cardiac arrest.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Both bupivacaine and ropivacaine have negative inotropic, chronotropic, and hypotensive activity that may be due to reduced electrical excitability, inhibition of the nodule activation rate, and dilation of blood vessels<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>. Mio et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> showed that local anaesthetic-induced cardiac depression is the result of calcium channel blocking, which reduces peak values of systolic Ca2+. Bupivacaine is thought to suppress cardiac contractility by activating a calcium-independent pathway<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>. Local anaesthetic-induced (both ropivacaine and bupivacaine) cardiac depression causes oxidative phosphorylation uncoupling<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>. Bupivacaine also inhibits carnitine-acylcarnitine exchange in cardiac interfibrillary mitochondria<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>, a mechanism that may explain why bupivacaine-related cardiac arrest does not respond to ACLS<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Several animal studies have shown the efficacy of lipid emulsion in LAST. Weinberg et al.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> reported that dogs in the LE-treated group recovered from bupivacaine-induced cardiac arrest while untreated controls did not. Weinberg et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> showed that LE shortened time to ROSC and accelerated bupivacaine elimination from heart tissue. There is also evidence that LE is superior to epinephrine and/or vasopressin in facilitating resuscitation from bupivacaine toxicity, probably due to its effect in reducing bupivacaine content in myocardial tissue and improving cardiovascular recovery<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>.</p><p id="par0135" class="elsevierStylePara elsevierViewall">LE administration has consistently shown efficacy in treating LAST-induce cardiac arrest, even when refractory to standard resuscitation techniques<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>. The case reports included in our review suggest that ROSC is be related to lipid emulsion infusion, and support the view that local anaesthetic-induced cardiac arrest may be resistant to standard ACLS, and that early administration of lipid emulsion may be critical in reversing the situation. In some cases (particularly in Group B), cardiac arrest recurred after initial dose of LE had achieved ROSC. This highlights the importance of continuing LE administration after ROSC in order to prevent recurrence of cardiac arrest.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The Association of Anaesthetists of Great Britain and Ireland<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,41</span></a> and Weinberg<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> currently recommend treating LAST with an initial intravenous bolus injection of 20% lipid emulsion 1.5 ml/kg over 1 min. This bolus can be repeated twice at intervals of 5 min if adequate circulation has not been restored. After the bolus, infusion of 0.25 to 0.5 ml/kg/min should be started for 20 min – according to the Association of Anaesthetists of Great Britain and Ireland – and 30 min according to Weinberg. Patients are unlikely to need a cumulative dose of more than 8 ml/kg of 20% LE<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a>. These recommendations suggests that a single 500 ml bag will be sufficient for many patients aged 60–70 years.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Early identification of life-threatening complications will no doubt improve the likelihood of a favourable outcome. Balasanmugam et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> were able to rapidly observe the change from a normal pattern to severe bradycardia and sinus arrest using telemetry, and recommend this tool for early detection of sudden decompensation, Simulation-based training in resuscitation techniques can also improve survival in patients with LAST-induced cardiac arrest<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>. Such training should include rapid recognition of problems, rapid initiation of specific ACLS therapy, team coordination, and use of LE<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Routine use of LAST prevention strategies is equally as important as the foregoing considerations in improving the treatment of LAST-induced cardiac arrest<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>. LAST prevention is a multifactorial process, and no single intervention can fully eliminate the risk<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>. The most important preventive factors are: (1) avoid intravascular injection of local anaesthetic, (2) avoid accumulating toxic blood levels of local anaesthetic through absorption (reduce the absorption rate, pay attention to local anaesthetic dosage), and (3) identify high-risk patients most likely to develop LAST<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Ultrasound-guided nerve block can reduce the risk of LAST by 60%–65% compared to nerve stimulation techniques alone<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>. The use of ultrasound reduces the risk of accidental intravascular injection and the required volume and dose of local anaesthetic<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>. The local anaesthetic should be administered in small aliquots with a short gap between injection and gentle aspiration of the needle or catheter before each injection<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>. Markers of intravascular injection, such as epinephrine, can give an early indication of the need to stop local anaesthetic administration<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>. The risk of intravascular injection can be minimized with ultrasound guidance, the use of an intravascular marker (epinephrine), the administration of incremental doses of local anaesthetic with a pause between injections (longer pauses are recommended for high-risk heart failure patients, who have with slower circulation), and the use of the lowest effective dose of local anaesthetic<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>.</p><p id="par0160" class="elsevierStylePara elsevierViewall">It is important to identify patients at higher risk for LAST and adjust the dosage accordingly. According to Rosenblatt et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>, the presence of a major preoperative cardiac conduction disorder may increase the risks of local anaesthetic-induced cardiac toxicity, even when lower doses are used. Low muscle mass and low serum protein levels (which will result in a higher drug-free fraction) are risk factors for LAST. The rate of severe LAST has been reported to be 6 times higher in children under 6 years of age compared to other children<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>. There is also evidence that infants and neonates manifest a higher unbound fraction of local anaesthetic<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Summary of suggestions based on our analysis of results (naturally, more research is needed):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1</span><p id="par0170" class="elsevierStylePara elsevierViewall">Both surgical and anaesthesia teams should be aware of the possibility of LAST, and should be trained to identify and treat it promptly.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2</span><p id="par0175" class="elsevierStylePara elsevierViewall">Effective communication between all members of the surgical/anaesthesia team is essential.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3</span><p id="par0180" class="elsevierStylePara elsevierViewall">The concentration of the local anaesthetic used should be checked before administration.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4</span><p id="par0185" class="elsevierStylePara elsevierViewall">LE should be available whenever local anaesthetics are used, and should be started as soon as LAST is suspected.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">5</span><p id="par0190" class="elsevierStylePara elsevierViewall">The appearance of seizures can predict cardiac arrest. They should be treated with benzodiazepines alone, and LE administration should be started.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">6</span><p id="par0195" class="elsevierStylePara elsevierViewall">LE infusion should be continued after ROSC to prevent recurrent dysrhythmias or cardiac arrest.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">7</span><p id="par0200" class="elsevierStylePara elsevierViewall">Simulation-based training in resuscitation techniques can also improve survival in patients with LAST-induced cardiac arrest.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">8</span><p id="par0205" class="elsevierStylePara elsevierViewall">Telemetry monitoring can improve patient safety and contribute to a timely diagnosis of LAST.</p></li></ul></p><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitations</span><p id="par0210" class="elsevierStylePara elsevierViewall">Our literature search might have overlooked some case reports, particularly as we limited our search to articles written in English. The case reports reviewed differed considerably, and included patients with a wide variety of health conditions that had undergone different surgical procedures. The timing reported in most cases was imprecise, and in some it was difficult to calculate the time from injection of the local anaesthetic to the appearance of clinical manifestations (seizures, hypotension, bradycardia, dysrhythmia) and the start of ACLS to achieve ROSC. Many of the reports did not mention the patients’ ASA score. The choice and method of reporting clinical variables varied considerably between case reports. Some reports lacked important details, such as the timing episode onset or the dose of local anaesthetics or LE administered. Furthermore, we were only able to determine associations, not causes. We did not evaluate the quality of the reports reviewed by checking for specific biases. We also assume that cases of fatal LAST are underreported and that preference is given to reports of successful outcomes. The considerable variation and heterogeneity of the articles included in this review made it impossible to perform a quantitative meta-analysis of the findings.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Recommendations for future research</span><p id="par0215" class="elsevierStylePara elsevierViewall">The case reports published to date provide important information for anaesthesiologists. However, we found major differences between resuscitation algorithms and considerable variation in the structure of the reports. Case reporting guidelines should be followed to reduce the risks of bias and improve the quality of the information presented. We believe that the suggestion put forward by some authors to create national pharmacological registries on drug-induced adverse events could be extremely helpful in improving our understanding of these events and the safety and quality of anaesthesia practice.</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0220" class="elsevierStylePara elsevierViewall">Both bupivacaine and ropivacaine-induced LAST can cause cardiac arrest. The use of lipid emulsion, telemetry, and LAST resuscitation training appears to be a promising strategy to improve survival. Improving and encouraging the reporting of local anaesthesia-induced toxicity will improve the quality of the information available for analysis and help reach clearer conclusions.</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1577911" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1421913" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1577910" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1421914" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Study strategy" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protocol" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Participants/population" ] ] ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "Type of studies included: studies, case reports or case series" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Literature search" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Study characteristics" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Patient demographics" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Types of regional anaesthesia and anaesthetist" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Cardiac arrest" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Seizures" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Bradycardia and hypotension" ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Fatal outcomes" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Importance of communication between members of the anaesthesia team" ] ] ] 7 => array:3 [ "identificador" => "sec0085" "titulo" => "Discussion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Limitations" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Recommendations for future research" ] ] ] 8 => array:2 [ "identificador" => "sec0100" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-13" "fechaAceptado" => "2020-10-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1421913" "palabras" => array:5 [ 0 => "Bupivacaine" 1 => "Ropivacaine" 2 => "Cardiac arrest" 3 => "Regional anesthesia" 4 => "Local anesthetic systemic toxicity" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1421914" "palabras" => array:5 [ 0 => "Bupivacaína" 1 => "Ropivacaína" 2 => "Parada cardiaca" 3 => "Anestesia regional" 4 => "Toxicidad sistémica anestésica local" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Regional anesthesia as a component of multimodal analgesia protocols has become more and more a part of modern perioperative pain management. The widespread adoption of ultrasound guidance in regional anesthesia has surely played an important role in that growth and it has significantly improved patient safety, decreased the incidence of block failure, cardiac arrest, and reduced complication rates. The objective of this systematic review is to extract, analyze, and synthesize clinical information about bupivacaine and ropivacaine related cardiac arrest that we might have a clearer picture of the clinical presentation. The literature search identified 268 potentially relevant publications and 22 relevant case reports were included in the review. Patients’ demographics, types of regional anesthesia, hypotension, heart rhythm disorders, seizures, cardiac arrest, fatal outcome, recommendations and limitations on prevention and treatment of bupivacaine and ropivacaine related cardiac arrest are analyzed and discussed in the systematic review. Both bupivacaine and ropivacaine-induced local anesthetic toxicity can result in cardiac arrest. Lipid emulsion, telemetry, local anesthetic toxicity resuscitation training appears to be promising in improvement of survival but more research is needed. Improvement and encouragement of reporting the local anesthetic toxicity are warranted to improve the quality of information that can be analyzed in order to make more precise conclusion.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La anestesia regional como componente de los protocolos de analgesia multimodal se ha ido convirtiendo de manera creciente en una parte del tratamiento moderno del dolor perioperatorio. Seguramente, la adopción generalizada de la guía ecográfica en la anestesia regional ha jugado un papel importante en dicho crecimiento y ha mejorado significativamente la seguridad del paciente, disminuyendo la incidencia de fallos de los bloqueos y de paradas cardiacas, y reduciendo las tasas de complicaciones. El objetivo de esta revisión sistemática es extraer, analizar y sintetizar información clínica sobre la parada cardiaca relacionada con la bupivacaína y la ropivacaína, para poder tener una imagen más clara de la presentación clínica. La búsqueda bibliográfica identificó 268 publicaciones potencialmente relevantes y se incluyeron 22 informes de casos relevantes en la revisión. En la revisión sistemática se analizan los datos demográficos de los pacientes, los tipos de anestesia regional, la hipotensión, los trastornos del ritmo cardiaco, las convulsiones, la parada cardiaca, el desenlace fatal, las recomendaciones y las limitaciones en la prevención y el tratamiento de la parada cardiaca relacionada con la bupivacaína y la ropivacaína. La toxicidad de la anestesia local inducida tanto por bupivacaína como ropivacaína puede provocar una parada cardiaca. La emulsión lipídica, la telemetría, y la formación en la reanimación de la toxicidad anestésica local parecen ser prometedoras para mejorar la supervivencia, pero se necesita más investigación. Deben garantizarse la mejora y el estímulo de informar sobre la toxicidad de los anestésicos locales, para mejorar la calidad de la información que puede analizarse para llegar a una conclusión más precisa.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Viderman D, Ben-David B, Sarria-Santamera A. Análisis de las paradas cardiacas relacionadas con bupivacaína y ropivacaína en anestesia regional: una revisión sistemática de informes de casos. Rev Esp Anestesiol Reanim. 2021;68:472–483.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1728 "Ancho" => 2175 "Tamanyo" => 166062 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PRISMA diagram.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">F: female; GA: general anaesthesia; LA: local anaesthetic; M: male; PCA: patient-controlled analgesia.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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" scope="col" style="border-bottom: 2px solid black">Article; first author; year; country \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Age/sex/weight (kg) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Relevant surgery/comorbidities \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Type of anaesthesia, dose of local anaesthetic \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Chronology of events \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Resuscitation and ROSC \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Outcomes / details \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>. BalasanmuAGm et al., 2019; USA</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73/M/-</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">Total knee replacement (osteoarthritis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative right femoral nerve block with ropivacaine</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Developed severe sinus bradycardia with progressive sinus slowing to a heart rate in the 20 s, PR interval prolongation followed by a period of asystole</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ROSC was achieved within 20 s; a transvenous pacemaker was placed; return of heart rate and blood pressure to baseline after LE infusion</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary artery disease; first-degree atrioventricular (AV) node block and an incomplete right bundle branch block \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>. Rosenblatt et al., 2006; USA \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">58/M/82 \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">Arthroscopic repair of a torn rotator cuff in the right shoulder: coronary artery bypass graft surgery; lisinopril, atenolol isosorbide mononitrate, and clopidogrel and enteric-coated aspirin \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">Interscalene nerve block - 20 ml bupivacaine 0.5%, and 20 ml mepivacaine 1.5% \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">30 s after LA injection - tonic–clonic seizure > propofol 50 mg - cessation of seizure, resumption of spontaneous respiration Approximately 90 s later, seizures recurred > 100 mg propofol > asystole \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">CPR 20 min (3 mg epinephrine given in divided doses, 2 mg atropine, 300 mg amiodarone, and 40 U arginine vasopressin; 100 ml LE 20% - leading to ROSC \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">Survived; extubation 2.5 h later; no complications from LE administration; no neurological deficit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>. de Araújo et al., 2016; Brazil \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/M/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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypospadias repair \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">Induction of general anaesthesia (GA) with fentanyl 100 mcg, propofol 60 mg, and rocuronium 15 mg; caudal block - 12 mL of 0.5% bupivacaine with epinephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immediate hypotension followed by ventricular tachycardia (3 cardiac arrests over a 30-minute period) \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">ACLS + LE (which achieved ROSC) \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">Survived; extubated after 30 h; no neurological consequences \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>. Yeoh et al., 2018; USA \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">70/M/- \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">Hemicolectomy and debulking for tumour recurrence \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">General anaesthesia + epidural anaesthesia 20 mg bolus of bupivacaine (0.25%) epidurally 5 min before incision. Epidural infusion of bupivacaine (0.05%) and hydromorphone (8 mcg/mL) started at a rate of 6 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">Bradycardia 25 min after the start of epidural anaesthesia > asystole \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">ACLS - return of spontaneous circulation within 3 min (LE not used) \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>. Corey et al., 2013; USA \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">57/F/- \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">Arthroscopic right-sided rotator cuff repair \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">Interscalene block with 30 ml of 0.5% bupivacaine \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">Tonic-clonic seizures immediately after block - midazolam - ventricular fibrillation \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">ACLS, LE; pulse return \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">Survived; Brugada syndrome diagnosed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. Vijay et al., 2013; India \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">3/F/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anorectoplasty (anorectal malformation) \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">GA; local infiltration of the anorectal area with 6 ml of 0.25% bupivacaine for postoperative analgesia \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">Bradycardia followed by asystole \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">CPR for 60 min (use of LE not reported) \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">Died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>. Kumari et al., 2014 l India \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/M/60 \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">Orchidopexy \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">SA 15 mg 0.5% hyperbaric bupivacaine \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">15 min spinal block, sudden convulsions with tight jaw and flexural rigidity of both arms - midazolam > cardiac arrest \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">ACLS - return of spontaneous circulation in 1 min (tachycardia 200 with hypotension) with hypotension > adrenaline + lignocaine (100 mg) - ventricular tachycardia > ROSC (LE not reported) \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. Scherrer et al., 2013; Francia \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">25/F/57 \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">Laparoscopic examination due to salpingitis \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">GA (propofol, remifentanil, and atracurium); intraperitoneal infiltration of 20 ml 0.75% ropivacaine by the surgeon, without informing the anaesthesiologist; TAP block by the anaesthesiologist: 20 ml (150 mg) 0.75% ropivacaine \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">Clonic seizures 10 min after TAP block - thiopental 500 mg + intubation - bradycardia followed by asystole 2 min later \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">ACLS + LE (250 ml bolus 20% followed by continuous infusion of 10 ml/min) - immediate ROSC \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>. Yamane et al., 2015; Japan \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/F/14 \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">Elective pacemaker implantation, coarctation of the aorta, and atrioventricular septal defect \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">GA + thoracic paravertebral block (TPVB) 7 ml 0.375 % ropivacaine (1.85 mg/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">Asystole 2 min after TPVB \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">ACLS + LE 20 ml 20% - ROSC \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>. Gnaho et al., 2009; France \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">17/M/61 \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">Patellofemoral ligament tear repair \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">Femoral nerve block for postoperative analgesia - 20 ml of 0.5% bupivacaine \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">Immediately after block - seizures - midazolam 3 mg - lipid emulsion - cardiac arrest \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">ACLS +500 ml 20% LE (8 ml/kg) - ROSC (unspecified time) \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>. Sonsino et al., 2009; France \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">92/F/- \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">Humerus fracture repair \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">Infraclavicular block (20 ml 0.75% ropivacaine) \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">3 min later, tonic-clonic seizures - asystole \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">ACLS + LE 50 ml - ROSC in a few seconds \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>. Reinikainen et al., 2003; Finland \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">34/M/97 \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">Elective acromioplasty of the right shoulder \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">Interscalene brachial plexus block (12 ml lidocaine, 10 mg/mL epinephrine 10 μg ml, 12 ml lidocaine, 20 mg/mL, and 20 ml ropivacaine, 7.5 mg/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">Seconds later, loss of consciousness, tonic seizures - cardiac arrest \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">ACLS without LE -ROSC after several minutes \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>. Huet et al.; 2003; France \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">66/M/100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elective hip arthroplasty \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">Posterior lumbar plexus block - 25 ml (187.5 mg) 0.75% ropivacaine \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">Generalized tonic-clonic seizures 2 min later - diazepam 30 mg - asystole \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">ACLS without LE -ROSC after several minutes \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>. Chazalon et al.: 2003; France \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">66/F/45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right hallux valgus surgery \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">Lower extremity nerve blocks - 0.75% ropivacaine; total dose: 300 mg \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">60 min later - agitation and confusion, eye movements - IV midazolam - bradycardia, cardiac arrest \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">ACLS without LE -ROSC within 30 s \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>. Klein et al., 2003; USA \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">76/F/70 \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">Foot osteotomy \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">Femoral nerve block - 20 ml 1.5% mepivacaine with 1: 400,000 epinephrine; anterior sciatic nerve block with 32 ml (160 mg) 0.5% ropivacaine (at a dose not indicated) with 1: 400,000 epinephrine. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spasms shortly after nerve blockade, tachycardia > midazolam 2 mg - tonic-clonic seizures > propofol 20 mg IV > bradycardia > prolonged QRS complex > ventricular fibrillation \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">ACLS -ROSC within 60 s (without LE) \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>. Curtis et al., 2004; Brazil</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49/F/83</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal lipodystrophy correction; hypertension irregularly treated with propranolol (40 mg/day), which was spontaneously discontinued 2 weeks earlier, ischaemic stroke with no neurological sequelae</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural puncture performed using the Dogliotty technique in T10-T11 with 30 ml 0.5% ropivacaine</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immediate loss of consciousness, tonic-clonic seizures, bradycardia, hypotension and asystole</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">ACLS (without LE) -ROSC (time not specified) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived; could not remember anything, moved legs easily and did not report pain; discharged after 2 h. No sequelae observed over 6-month follow-up.</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">For neuroprotection 10 mg dexamethasone and mannitol 20% (1 g.kg<span class="elsevierStyleSup">−1</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>. Litz et al., 2006; Germany \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84/F/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgery for Dupuytren contracture; Morgagni – Adams – Stokes syndrome, left bundle branch block, and grade II mitral and tricuspid valve regurgitation \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">Brachial plexus block (misunderstanding between anaesthesiologist and nurse anaesthetist - total of 40 ml of 1% ropivacaine (instead of 0.5%) \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">After 15 min dizziness, drowsiness, generalized loss of consciousness, tonic-clonic seizures- thiopental 150; 2 min later ventricular extrasystoles followed by severe bradycardia and asystole \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">ACLS +100 ml 20% LE after a total dose of 200 ml (4 ml kg<span class="elsevierStyleSup">−1</span>) - complex tachyarrhythmia \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">Survived, extubation after 3 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>. Whiteman et al., 2014: USA</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32/F/67</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominoplasty-mastopexy</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">During anterior rectus sheath surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shortly after was confused, agitated, with generalized tonic-clonic seizures, cardiac arrest</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACLS+ 1.5-mg/kg bolus 20% LE, followed by infusion of 0.25 mg/kg over 60 min. Further seizures and multiple episodes of cardiac arrhythmia. A surgeon opened the abdominal incision and evacuated approximately 60 ml of fluid from the right rectus sheath. ROSC within 45 min</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 ml 0.5% Marcaine with epinephrine; \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>. Cordell et al., 2010; USA \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">17/F/- \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">Ulnar shortening osteoplasty \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">Axillary block (15 ml 0.5% bupivacaine with 1: 200,000 epinephrine) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immediately after nerve block developed tachycardia (180 bpm) > seizures > midazolam 2 mg and propofol 100 mg-ventricular tachycardia \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">ACLS +100 ml 20% LE > sinus rhythm; followed by 2 additional boluses \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>. Marwick et al., 2009; South Africa \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">33/M/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">Debridement of compound fracture of right humerus \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">Infraclavicular paracoracoid block (30 ml 0.375% bupivacaine \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">Immediately after nerve block - generalized seizures and apnoea > ventilation, 100 oxygen, V thiopental 100 mg followed by 150 mg (end of seizures - tachycardia narrow QRS complex - asystole \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">ACLS +150 ml 20% LE - narrow complex rhythm at 130 bpm - 350 ml 20% LE - sinus rhythm - 40 min later sinus tachycardia (140 bpm), multifocal ventricular extrasystoles and short episodes of ventricular tachycardia - loading dose 300 mg amiodarone \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>. Smith et al., 2008; USA \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">83/M/75 \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">Total knee replacement \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">GA + preoperative continuous femoral and single-injection sciatic nerve blocks (total 26 ml 0.5% bupivacaine) \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">Sudden loss of consciousness and tonic > clonic seizure > 100% oxygen by mask ventilation. Midazolam 2 mg - asystole \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">ACLS +250 ml 20% LE (3 ml/kg) - with sinus tachycardia after 2 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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>. JaAGdeesan et al., 2007; GB \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">51/F/- \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">TRAM flap breast reconstruction \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">Postoperative analgesia included morphine PCA and intrapleural catheter for administration of bupivacaine and epinephrine at a rate of 4 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">During the first postoperative day - symptomatic bradycardia and hypotension, weakness, lethargy > 4 h later - second episode of bradycardia (20/min) > 2 h later bradycardia and asystole \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">No description of ACLS, temporary pacemaker leads inserted \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">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705107.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Characteristics of studies included in the review.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Bupivacaine \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Ropivacaine \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of patients \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">13 \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 \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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age (range) \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">34(3−83) \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">62.7(25−92) \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">48.3 (3−92) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Men; n (%) \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 (53.8) \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">3 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (43.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural anaesthesia, n (%) \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">1 (7.6) \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">1 (11.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal anaesthesia, n (%) \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">2 (15.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">2 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peripheral nerve block \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 (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">8 (88%) \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 (81%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Brachial plexus block; n (%) \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 (30.7) \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">3 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (31) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lower limb block; n (%) \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">1 (7.6) \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">2 (22.2) \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">3 (13.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TAP; n (%) \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"> \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">1 (11.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thoracic paravertebral block; n (%) \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"> \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">1 (11.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anterior rectus sheath; n (%) \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">1 (7.6) \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"> \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">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Posterior lumbar plexus block; n (%) \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">1 (7.6) \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">1 (11.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caudal block; n (%) \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">1 (7.6) \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"> \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">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local infiltration; n (%) \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">1 (7.6) \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"> \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">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intrapleural anaesthesia; n (%) \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">1 (7.6) \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"> \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">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bradycardia; n (%) \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">3 (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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (66.6) \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 (40.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypotension, n (%) \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">1 (7.6) \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">1 (11.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seizures, n (%) \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 (69.2) \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">8 (88.8) \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">17 (77.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of LE; n (%) \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 (76.9) \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 (44.4) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (63.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Non-survivors \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">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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2705108.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Demographics, types of anaesthesia and complications.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:45 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fifteen years of ultrasound guidance in regional anaesthesia: part 1" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. 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