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"apellidos" => "Anglada Casas" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192918300817" "doi" => "10.1016/j.redare.2018.01.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300817?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561830015X?idApp=UINPBA00004N" "url" => "/00349356/0000006500000006/v1_201805300407/S003493561830015X/v1_201805300407/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192918300751" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.02.012" "estado" => "S300" "fechaPublicacion" => "2018-06-01" "aid" => "915" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:314-22" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Morbidity and mortality of acute renal failure in the Critical Care Unit of a regional hospital" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "314" "paginaFinal" => "322" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Morbimortalidad del fracaso renal agudo en la Unidad de Cuidados Críticos de un hospital comarcal" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 839 "Ancho" => 1642 "Tamanyo" => 61658 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage of deaths according to AKI-KDIGO at end of follow-up (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001; no AKI vs AKI).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.E. Esteban Ciriano, J.M. Peña Porta, C. Vicente de Vera Floristán, S. Olagorta García, R. Álvarez Lipe, J.M. Vicente de Vera Floristán" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M.E." "apellidos" => "Esteban Ciriano" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Peña Porta" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Vicente de Vera Floristán" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Olagorta García" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Álvarez Lipe" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Vicente de Vera Floristán" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935618300501" "doi" => "10.1016/j.redar.2018.02.002" "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/S0034935618300501?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300751?idApp=UINPBA00004N" "url" => "/23411929/0000006500000006/v1_201806130410/S2341192918300751/v1_201806130410/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192918300775" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.03.001" "estado" => "S300" "fechaPublicacion" => "2018-06-01" "aid" => "920" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:303-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "PDF" => 1 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Recertification is comming. Afraid? Not at all" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "303" "paginaFinal" => "305" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La recertificación que se avecina. ¿Miedo? Ninguno" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. García Romero, J.M. Sistac Ballarín, J.A. Escudero" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "García Romero" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Sistac Ballarín" ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Escudero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935618300550" "doi" => "10.1016/j.redar.2018.03.001" "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/S0034935618300550?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300775?idApp=UINPBA00004N" "url" => "/23411929/0000006500000006/v1_201806130410/S2341192918300775/v1_201806130410/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Outpatient intravenous multimodal elastomeric pump with methadone in ambulatory surgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "306" "paginaFinal" => "313" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L. Gómez-López, X. Sala-Blanch, P.L. Gambús Cerrillo, A. López Gutiérrez, M. Agustí Lasús, M.T. Anglada Casas" "autores" => array:6 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Gómez-López" "email" => array:1 [ 0 => "LGOMEZ2@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "X." "apellidos" => "Sala-Blanch" ] 2 => array:2 [ "nombre" => "P.L." "apellidos" => "Gambús Cerrillo" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "López Gutiérrez" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Agustí Lasús" ] 5 => array:2 [ "nombre" => "M.T." "apellidos" => "Anglada Casas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Analgesia multimodal domiciliaria con metadona en perfusión intravenosa mediante bomba elastomérica en cirugía mayor ambulatoria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2405 "Ancho" => 1583 "Tamanyo" => 127281 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing VAS scores at 24 and 48<span class="elsevierStyleHsp" style=""></span>h in the different surgical groups analysed. Variables were measured at rest and on movement.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Major day surgery (MDS) is in increasing demand because it spares resources and cuts down waiting lists.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> In 2011, 39% of surgeries in public hospitals and 34% in private hospitals were performed in the outpatient setting. This is in line with national figures, but far from those of countries such as Denmark (91%) or Norway (64%), or other Mediterranean countries, such as Italy or Portugal (around 50%).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> Despite the economic downturn, the number of MDS procedures in Spain increased by 3.7% between 2012 and 2014.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Surgical interventions have increased not only in number, but also in aggressiveness, and these invasive procedures cause acute postoperative pain (APP).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> This in turn creates the need for better analgesic techniques and drug combinations. APP is the main quality indicator in MDS and can prevent discharge home, lead to readmission, or simply cause suffering to the patient and their family members.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Oral analgesics are usually insufficient in moderate to severe APP, and intravenous administration, with its rapid onset of action and direct access to systemic circulation, is usually the route of choice.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The elastomeric pumps can be used for simultaneous delivery of several drugs with different mechanisms of action (multimodal analgesia), and are safe and easy to use in outpatients. However, optimal control of APP<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> is not always achieved, perhaps due to the wide variety of interventions, patients and postoperative management guidelines. The use of non-steroidal anti-inflammatory drugs and minor opioids at variable doses in the outpatient setting is common practice. Major, particularly extended-release, opioids are less common in MDS, even though they are more effective and are often given to hospitalised patients. Nevertheless, they can cause undesirable effects, such as postoperative nausea and vomiting (PONV), particularly after administration of intermittent boluses.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4–6</span></a> This is why analgesic strategies that can improve management of APP without increasing adverse effects must be found.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We designed this observational study in order to evaluate the analgesic efficacy, safety and side effects of an intravenous, low-dose infusion of methadone, tramadol, dexketoprofen and ondansetron delivered through an elastomeric infusion system for 48<span class="elsevierStyleHsp" style=""></span>h. The analgesic combination was given to MDS patients undergoing interventions associated with moderate to severe postoperative pain.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">An observational study was designed to evaluate the evolution of a series of patients undergoing painful MDS procedures (herniorrhaphy, haemorrhoidectomy and perineal surgery). The study was conducted in a tertiary level hospital catering for complex procedures and only adult patients, and was approved by the Clinical Research Ethics Committee of the Hospital Clínic of Barcelona. All patients received detailed information about the study and its possible consequences, and all were asked to give both oral and written informed consent.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was conducted over a period of 12 months, during which we evaluated the analgesic quality, side effects and quality and safety indicators of an intravenous multimodal analgesia combination of methadone, dexketoprofen, tramadol and ondansetron, administered for 48<span class="elsevierStyleHsp" style=""></span>h by elastomeric pump. The inclusion and exclusion criteria are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A portable, non-electronic, disposable low-flow continuous elastomeric infuser (Infuser FOLFusor LV 5 Baxter<span class="elsevierStyleSup">®</span>) was used to deliver the study drug. This device had a maximum capacity of 300<span class="elsevierStyleHsp" style=""></span>ml, and the drugs were administered at a rate of 5<span class="elsevierStyleHsp" style=""></span>ml/h for 48<span class="elsevierStyleHsp" style=""></span>h. The pumps were prepared by an anaesthesia nurse, and started immediately after the intervention. The reservoir was loaded with 0.1<span class="elsevierStyleHsp" style=""></span>mg/kg methadone (0.002<span class="elsevierStyleHsp" style=""></span>mg/kg/h), 200<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen (4<span class="elsevierStyleHsp" style=""></span>mg/h), 100<span class="elsevierStyleHsp" style=""></span>mg tramadol (2<span class="elsevierStyleHsp" style=""></span>mg/h) and 8<span class="elsevierStyleHsp" style=""></span>mg ondansetron (0.16<span class="elsevierStyleHsp" style=""></span>mg/h). A solution of 0.9% saline was administered to bring the volume up to 250<span class="elsevierStyleHsp" style=""></span>ml. Patients used the pump for 48<span class="elsevierStyleHsp" style=""></span>h, and 1<span class="elsevierStyleHsp" style=""></span>g oral paracetamol every 8<span class="elsevierStyleHsp" style=""></span>h was prescribed for additional analgesia, together with 2<span class="elsevierStyleHsp" style=""></span>g metamizol (up to 2 doses per day) as rescue analgesia.</p><p id="par0045" class="elsevierStylePara elsevierViewall">During the pre-surgery visit, patients received information about the type of anaesthesia to be used, the postoperative analgesic regimen, and the home monitoring programme. The usual preoperative workup was performed, included kidney function tests to rule out delay in drug elimination. A 12-lead ECG was performed to rule out pathologically prolonged QT interval. All patients were asked to give their oral and written informed consent.</p><p id="par0050" class="elsevierStylePara elsevierViewall">On the day of the procedure, patients were given 1–2<span class="elsevierStyleHsp" style=""></span>mg midazolam, 50<span class="elsevierStyleHsp" style=""></span>mg ranitidine, 4<span class="elsevierStyleHsp" style=""></span>mg dexamethasone, and 50<span class="elsevierStyleHsp" style=""></span>mg intravenous dexketoprofen in the surgical prep room, as per the protocol in force in the unit. The intervention was carried out by the specialist surgical team, following routing surgical and anaesthetic practice. Immediately after surgery, the elastomeric pump was started through a peripheral venous catheter located in an area of the patient's arm where it would not become kinked if the patient changed position. This ensured continuous perfusion. After transfer to the post-anaesthesia care unit, patients were given successive intravenous boluses of 2<span class="elsevierStyleHsp" style=""></span>mg methadone until they reported a score of 3 on the visual analogue scale (VAS), after which they were transferred to the recovery unit (RU) A single bolus of ondansetron was administered in the case of PONV. The usual discharge criteria were followed. The RU nurse taught the patient and their carer care how to manage the catheter and pump, described the possible side effects and their warning signs, explained the postoperative monitoring protocol, and gave them a 24-h telephone number to call if they had any questions related to the intervention and the treatment. All phone calls were answered by an anaesthesiologist.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients received 2 home visits from study nurses, at 24 and 48<span class="elsevierStyleHsp" style=""></span>h, to monitor the quality and safety of the treatment. During these visits, the catheter and pump were checked to ensure they were working correctly, and the infusion site was examined for abnormalities, and the following variables were collected: clinical status of the patient, adverse effects, the degree of pain at rest and on movement (using the VAS, Andersen scale, and the Lattinen test), the need for rescue analgesia, the status of the surgical wound, and finally, the patient's performance status, level of comfort and satisfaction. In the 48-h visit, in addition to the above, the pump and catheter were removed and the puncture site was treated.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patients’ received a follow-up phone call from the RU nurse 72<span class="elsevierStyleHsp" style=""></span>h after surgery (24<span class="elsevierStyleHsp" style=""></span>h after completion of the infusion) to enquire after the patient's pain status, degree of recovery and physical and mental status. Seven days after the intervention, the RU nurse contacted the patient and the carer to conduct a telephone satisfaction survey. Both were asked to rate the treatment and care received, whether they would be willing to repeat the programme in the future, and were invited to add any additional comments.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This was an observational study. Based on the annual case load of the MDS unit and the estimated time required to complete the study, we calculated that a sample size of 100 patients would suffice, taking into account that between 30% and 40% of patients would not satisfy the criteria established for postoperative home follow-up. We considered that a sample of at least 60 patients would be representative of the population. The data were presented as number and percentage of patients, or as mean and standard deviation, according to the characteristics of the variables analysed. The nonparametric Kruskal–Wallis test was used to analyse the different surgical procedures, and the Wilcoxon test was used to analyse VAS scores at 24 and 48<span class="elsevierStyleHsp" style=""></span>h. In both tests, significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 104 potentially eligible patients, 22 were immediately excluded because they lived too far from the hospital to receive home follow-up, 1 was excluded due to technical contraindications, 2 were excluded due to the impossibility of receiving home visits, and 4 due to biological risk. Two of the remaining 75 cases were also excluded: 1 due to refusal to take part, and the other due to a psychiatric disorder that was not detected during the initial interview (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The analysis was performed on the remaining 73 patients. All patients, 42 men and 31 women, finished the study.</p><p id="par0080" class="elsevierStylePara elsevierViewall">With respect to surgery, 27 patients (37%) underwent inguinal herniorrhaphy surgery, 22 (30%) proctologic surgery (haemorrhoidectomy), and the remaining 24 (33%) underwent minor perineal surgery. The mean age was 55 years in the herniorrhaphy group, 46 years in the haemorrhoidectomy group, and 38 years in the perineal surgery group. The body mass index was similar in all 3 groups (herniorrhaphy<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>26.18<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, haemorrhoidectomy<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25.62<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>; perineal surgery<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25.03<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>). The predominant anaesthetic technique used was balanced general anaesthesia with inhalational agents, used in 71 patients (97%); general intravenous anaesthesia was used in 2 patients (3%). All study patients were discharged home with good pain control and no PONV.</p><p id="par0085" class="elsevierStylePara elsevierViewall">At 24<span class="elsevierStyleHsp" style=""></span>h, 86% reported mild pain at rest (VAS<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>3) and 62% reported mild pain on movement (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>); at 48<span class="elsevierStyleHsp" style=""></span>h, 90% reported mild pain at rest and 77% on movement. Around 30% required rescue analgesia. On the Andersen scale at 24<span class="elsevierStyleHsp" style=""></span>h (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), 89% presented a score of ≤1; none reported a high score. In the Lattinen test (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), most (more than 90%) reported low scores (≤6) in all items.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">There were no statistically significant differences between postoperative pain according to the type of surgery performed. Pain at rest appeared to be slightly more intense in the haemorrhoidectomy group, although the herniorrhaphy and perineal surgery groups reported greater pain on movement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding adverse effects (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), 2.7% presented vomiting at 24 and 48<span class="elsevierStyleHsp" style=""></span>h, 4.1% had problems with venous access and with the pump at 24 and 48<span class="elsevierStyleHsp" style=""></span>h. There was 1 case of accidental catheter removal, 2 of extravasation, 2 of localised phlebitis, and 1 unspecified problem with the catheter in a patient who underwent perianal polypectomy; VAS: at rest<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4; on movement<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6). There was 1 case of minor skin reaction at 72<span class="elsevierStyleHsp" style=""></span>h (1 day after removal of the pump). In 1 patient, the pump reservoir had not emptied completely by the 48-h visit (haemorrhoidectomy; VAS: at rest<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0; on movement<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4), and in another, the visiting nurse found that the valve was closed. In 1 case, premature emptying of the pump was discovered during the 48-h visit (haemorrhoidectomy; VAS: at rest<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0; on movement<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7), albeit with no side effects. None of the study patients presented serious problems.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Thirty-four patients and their respective carers responded to the 7-day telephone survey. All (100%) considered the treatment received to be good/very good, and the medical team to have been supportive. All (100%) carers and 85% of the patients would repeat the programme without any changes; 14% would do so under certain conditions.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">APP in MDS continues to be a major factor that can lengthen recovery, affect the patient's perception of the quality of care received, and lead to long-term complications, such as chronic pain syndrome.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3–5</span></a> Our study has shown that continuous intravenous administration of multimodal analgesia containing methadone using an elastomeric pump is effective in alleviating at-rest and on-movement pain in patients receiving home treatment. The addition of low-dose intravenous methadone does not increase the incidence of side effects. However, despite the good pain management results, catheter-related complications (phlebitis, extravasation, device dysfunction, etc.) can put the patient at risk. This is why, although complications are rare, patients receiving this therapy must be monitored by a healthcare professional.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In our study, VAS scores are slightly lower than those observed in similar studies, even though our analgesia combination contained lower doses of tramadol and dexketoprofen.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5,7</span></a> For example, Rodríguez de la Torre et al. reported a mean at-rest VAS score of 2.13 at the 24-h telephone follow-up,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> while Serra et al. reported a mean VAS of 1.35, and 1.28 at 24 and 48<span class="elsevierStyleHsp" style=""></span>h, respectively.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> In our study, mean VAS scores were 1.21 at 24<span class="elsevierStyleHsp" style=""></span>h and 0.57 at 48<span class="elsevierStyleHsp" style=""></span>h. On the second postoperative day, all our patients reported a VAS of ≤3. An interesting feature of our study is the inclusion of APP variables both at rest and on movement, since the latter is a key factor in indicating early recovery of mobility.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">APP was evaluated in greater depth using the Andersen scale, an observational test that assesses both static and dynamic pain, and which has a good correlation with other APP scales.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> In our case, 84% of patients reported a score of 0–1, which indicate good pain management both at rest and on movement.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The other scale used was the Lattinen test, a multidimensional scale that evaluates several parameters that measure not only the degree of pain, but also its emotional component and effect on the patient's well-being. Although it is more often used in chronic pain, we believed this scale would also provide important information in acute processes. More than 90% of our patients had a score of ≤6 (4 being the minimum and 20 the maximum), indicating minimal pain with little impact on well-being.</p><p id="par0125" class="elsevierStylePara elsevierViewall">No statistically significant differences in the degree of postoperative pain were found when comparing surgical procedures. However, pain at rest appears to be slightly more intense in the haemorrhoidectomy group, while patients in the herniorrhaphy and perineal group reported greater pain on movement.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Pain at rest was well controlled in all groups overall; it was slightly greater in the haemorrhoidectomy group, but without reaching the level of severe pain (median VAS<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0; 75th percentile<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3 in the haemorrhoidectomy group at 24<span class="elsevierStyleHsp" style=""></span>h).</p><p id="par0135" class="elsevierStylePara elsevierViewall">Pain on movement was greater in the herniorrhaphy and perineal surgery groups vs the haemorrhoidectomy group, particularly at 24<span class="elsevierStyleHsp" style=""></span>h (median 24-h VAS score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2 and 75th percentile<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3 in haemorrhoidectomies; median 24-h VAS score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3 and 75th percentile<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5 in herniorrhaphy and perineal surgery).</p><p id="par0140" class="elsevierStylePara elsevierViewall">On-movement pain scores were similar in all groups at the 48-h follow-up. However, in the perineal surgery group, outlying on-movement VAS scores were higher. The male:female ratio of this group was 3:7, inverse to that of the other groups, and the average age (38 years) is lower. This suggests that the higher pain scores could be due to either a predominantly lower pain threshold, or to a trend towards greater activity in younger patients. If the latter hypothesis is true, it would explain why at-rest pain scores were similar in all 3 groups.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The side effects observed were similar to those reported in comparable studies.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5</span></a> The addition of low-dose methadone to the elastomeric pump did not increase the incidence of side effects, and none were serious. Although some catheter-related complications arose, these were infrequent and did not cause serious problems; however, we believe they require professional monitoring.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Elastomeric pumps can deliver continuous intravenous infusion of multimodal analgesia regimens, and are therefore ideally suited for APP management. These devices can deliver combinations of drugs with different mechanisms of action, thus increasing the analgesic effect while minimising the risk of side effects by reducing the dose required of each drug.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,8,9</span></a> The intravenous route delivers the analgesics directly into the systemic circulation. This facilitates titration, particularly in intravenous infusion where plasma levels remain stable over time.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> The absence of peaks and troughs reduces the risk of side effects and pain, respectively. However, there is always the danger of pump malfunction leading to premature emptying of the reservoir, and with it, extremely high plasma levels of the drug combination. For this reason, it is important to keep the total dose of all drugs in the pump reservoir below toxic levels, particularly in view of the effects of methadone. Problems such as extravasation or phlebitis should also be treated professionally.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding satisfaction, 100% of patients and carers interviewed considered the treatment received to be good/very good, and the great majority would repeat the experience. It is vital to achieve a high degree of satisfaction on the part of patients and relatives in order to promote the use of day surgery programmes, which will in turn optimise resources and reduce waiting lists.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> The key to achieving this is good pain management with minimal side effects and good home nursing care.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Several different analgesic regimens for intravenous elastomeric pumps have been described in the MDS setting. These usually include non-steroidal anti-inflammatory drugs and minor opioids, such as tramadol in variable doses, and sometimes antiemetics.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5,7</span></a> However, these do not always provide sufficient relief of APP. In the case of moderate to severe pain, adequate analgesia may only be possible with major opioids. Long-acting opioids are usually the treatment of choice for oncological and chronic pain because of their stability and duration of effect. However, despite their many advantages, they are not often used to treat APP.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10,11</span></a> Long-acting opioids provide a continuous level of analgesia and are as potent as shorter-acting drugs, such as morphine, at far lower doses, thus reducing daily drug consumption<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> and opioid-related side effects, and improving the quality of the analgesia. Despite the scarcity of studies in methadone for postoperative pain management, some groups, such as Miranda et al., have shown the synergistic effect of the methadone-morphine, methadone-fentanyl and methadone-tramadol combination in a model of visceral pain in mice.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> For all the above, methadone has been the major opioid of choice for parenteral treatment of moderate to severe APP in our hospital for over 30 years, and has achieved good results. This is why we believe it could be effective in MDS patients undergoing procedures associated with severe APP.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Methadone is a synthetic opioid equipotent to morphine.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10,13</span></a> It acts on μ and δ opioid receptors by blocking N-methyl-<span class="elsevierStyleSmallCaps">d</span>-aspartate receptors and inhibiting the reuptake of noradrenaline and serotonin in the central nervous system. This is why it useful in the treatment and prevention of neuropathic pain, chronic pain, opioid tolerance and hyperalgesia.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10,11,13,14</span></a> Other advantages are its haemodynamic stability at therapeutic doses, absence of euphoria, milder withdrawal syndrome than morphine, and low cost.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Although it can be cardio toxic (causing pathological lengthening of the QT interval and severe ventricular arrhythmias), these effects have so far been described in patients receiving long-term methadone to treat addiction at doses far higher than those used for APP, or in cases of methadone overdose and association with other drugs or narcotics that also lengthen the QT interval.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> Studies such as those published by Anderson or Alvarado, for example, do not report haemodynamic changes in cardiac surgery patients receiving methadone at therapeutic doses. Nevertheless, it is advisable not to administer methadone when the QTc interval is ≥450<span class="elsevierStyleHsp" style=""></span>ms.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10,15,16</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">The addition of dexketoprofen and tramadol to our multimodal regimen allowed us to modulate other nociceptive pathways. Tramadol is a μ, δ and κ agonist, and acts on neuropathic pain by inhibiting the reuptake of noradrenaline and serotonin. It does not create tolerance or dependence, and causes few cardiovascular or respiratory side effects. Theoretically, both tramadol and methadone act on opioid receptors. However, studies have shown the existence of several μ, δ and κ receptor subtypes unevenly distributed across the nervous system. The simultaneous activation of certain combinations of receptors at different sites can cause very different analgesic effects, and therefore the association of several opioids can enhance the antinociceptive effect.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> Other studies suggest that opioid interactions also depend on both the type of nociceptive stimulus and non-opioid-related mechanisms.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12,17</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The capacity of opioids such as tramadol and methadone to increase intrasynaptic serotonin concentration could cause serotonin syndrome,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> although this is highly unlikely. Onset of this syndrome is typically dose-dependent,<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18,19</span></a> and usually occurs after the administration of combinations of several drugs that increase serotonin or stimulate secretion of 5-HT<span class="elsevierStyleInf">2A</span> and 5-HT<span class="elsevierStyleInf">1A</span> serotonin receptors.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> Severe cases are usually associated with use of a high-risk drug (such as monoamine oxidase inhibitors [MAOI] antidepressants or serotonin reuptake inhibitors [SRI]),<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18,20</span></a> although they can also be caused by high-dose combinations of several low to intermediate risk drugs. It is important to bear in mind that drugs such as linezolid are MAOIs. In these cases, alternative treatment with non-serotonergic drugs such as morphine should be considered.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18,19</span></a> Symptoms are mild in most documented cases, although the syndrome can be fatal.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Both tramadol and methadone are weak SRIs. Tramadol also slightly increases serotonin release at the synaptic level.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> We debated the interaction of these drugs before starting the study, but decided to include them because their use in combination they allowed us to significantly reduce the total dose, thus considerably reducing the risk of side effects. According to authors such as Hillman et al., the association of several morphine-based drugs is a common clinical practice that, under normal conditions, does not usually cause serotonin syndrome. These authors associated the onset of symptoms to the simultaneous use of drugs with more serotonergic activity than opiates.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> In the studies consulted, daily doses of methadone 90–120<span class="elsevierStyleHsp" style=""></span>mg were used, whereas in our study only 3–4<span class="elsevierStyleHsp" style=""></span>mg per day were administered. However, patients under psychiatric treatment were excluded from the study, and the nurse who followed up patients both in their homes and via the telephone interviews during and after treatment observed no signs of serotonin syndrome. Neither were any incidences reported on the 24-h emergency phone.</p><p id="par0190" class="elsevierStylePara elsevierViewall">One of the most frequent side effects of tramadol is nausea and vomiting. This, however, is dose-dependent, and the risk can therefore be reduced in MDS patients. In our case, in addition to reducing tramadol dose to 2<span class="elsevierStyleHsp" style=""></span>mg/h (56% less than that used by Rodríguez de la Torre et al.,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> 75% less than in Serra et al.,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> and 78% less than in Recasens et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a>), we also added ondansetron to the multimodal regimen.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Ondansetron is a 5-HT<span class="elsevierStyleInf">3</span> antagonist which, when mixed with tramadol in 0.9% saline, remains stable for up to 14 days when stored at both 4<span class="elsevierStyleHsp" style=""></span>°C and 25<span class="elsevierStyleHsp" style=""></span>°C.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> However, some authors, such as Stevens, Woodman and Owen, concluded that the ondansetron diminishes the analgesic effect of tramadol in the first 24<span class="elsevierStyleHsp" style=""></span>h. Despite this, we decided to use it because it does not inhibit serotonergic pathways and is effective (level of evidence 1A) in the prevention and treatment of PONV at low doses.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> On this premise, and bearing in mind that PONV risk scales, such as Apfel, are poor predictors of late PONV,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> all participants were given ondansetron at a dose of 0.16<span class="elsevierStyleHsp" style=""></span>mg/h.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Our study is limited by the absence of a control group and its small sample size. Furthermore, given the wide range of interventions and pharmacological regimens, it is difficult to compare it with other studies. It is also important to note that the same drug combination (except for methadone) was used in all patients, irrespective of their surgical group and their anthropometric characteristics. This could have led to under- or over-dosing in patients at either end of the weight scale. Comparable studies are needed to enable us to define the most effective analgesia regimens for each intervention and type of patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">Based on our observational study, we can conclude that analgesic regimens with methadone in continuous infusion through an elastomeric pump are effective and safe. However, due to the risk of adverse effects and catheter-related complications (phlebitis, extravasation, device dysfunction, etc.), these treatments require supervision over time. In these patients, home nursing care in the immediate postoperative period should be part of routine practice.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">This study has been funded by Baxter Spain, who donated the elastomeric pumps used</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1042011" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec994783" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1042012" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec994782" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack351447" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-09" "fechaAceptado" => "2018-01-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec994783" "palabras" => array:4 [ 0 => "Methadone" 1 => "Infusion pumps" 2 => "Postoperative pain" 3 => "Outpatient surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec994782" "palabras" => array:4 [ 0 => "Metadona" 1 => "Bomba elastomérica" 2 => "Dolor postoperatorio" 3 => "Cirugía mayor ambulatoria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analgesia in ambulatory surgery (AS) needs to evolve in parallel with surgical complexity. We designed a study to try to improve analgesia in painful surgery using an intravenous elastomeric pump. As a novelty, methadone was included.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An observational study, physical status ASA I–II, underwent ambulatory surgeries with moderate-severe postoperative pain. Analgesia was administered for 48<span class="elsevierStyleHsp" style=""></span>h by an intravenous multimodal elastomeric pump (methadone, tramadol, dexketoprofen and ondansetron at low doses). Visual analogue scale (VAS) at rest and movement were evaluated at 24 and 48<span class="elsevierStyleHsp" style=""></span>h. Andersen scale, Lattinen test, rescue analgesia and side-effects were recorded at 24<span class="elsevierStyleHsp" style=""></span>h after surgery.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We included 73 patients: 37% abdominal wall surgery, 30% hemorrhoidectomies and 33% perineal surgery. Median VAS score at rest and movement were 0 and 3 at 24<span class="elsevierStyleHsp" style=""></span>h, and 0 and 2 at 48<span class="elsevierStyleHsp" style=""></span>h. At 24<span class="elsevierStyleHsp" style=""></span>h, Andersen's Scale score was ≤1 in 89%, and Lattinen test ≤6 in 90% of patients. Rescue medication was administered in 30% of patients. Two patients had vomiting at 24 and 48<span class="elsevierStyleHsp" style=""></span>h. Minor catheter and pump dysfunctions were observed in 8% of patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Multimodal analgesia with intravenous methadone administered by elastomeric perfusion at home is effective and safe. However, monitoring is needed to diagnosis dysfunction of devices.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La analgesia en cirugía mayor ambulatoria (CMA) necesita evolucionar paralelamente a la complejidad quirúrgica. Diseñamos un estudio para intentar mejorar la analgesia en cirugía dolorosa mediante elastómera intravenosa. Como novedad, se incluyó metadona.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional en pacientes ASA I-II, intervenidos en CMA de cirugías con dolor postoperatorio moderado-severo. Se administró analgesia durante 48<span class="elsevierStyleHsp" style=""></span>h mediante elastómera intravenosa de metadona, tramadol, dexketoprofeno y ondansetrón a dosis bajas, y paracetamol oral. A las 24 y 48<span class="elsevierStyleHsp" style=""></span>h se evaluó la eficacia analgésica en reposo y en movimiento (Escala Visual Analógica [EVA], Escala de Andersen y Test de Lattinen), la necesidad de analgesia de rescate y los efectos adversos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 73 pacientes: un 37% de ellos intervenidos de cirugía de pared abdominal, un 30% de hemorroidectomías y un 33% de cirugía del periné. La mediana en reposo a las 24 y 48<span class="elsevierStyleHsp" style=""></span>h fue EVA<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0, y en movimiento, fue de 3 a las 24<span class="elsevierStyleHsp" style=""></span>h y de 2 a las 48<span class="elsevierStyleHsp" style=""></span>h. En la Escala de Andersen, a las 24<span class="elsevierStyleHsp" style=""></span>h el 89% presentó puntuación ≤1. En el Test de Lattinen, el 90% presentó una puntuación ≤6. Precisó rescate el 30%. Dos pacientes presentaron vómitos a las 24 y 48<span class="elsevierStyleHsp" style=""></span>h. Se observaron problemas menores con el catéter y la elastómera en el 8% de los pacientes.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La analgesia multimodal con metadona intravenosa administrada mediante bomba elastómera para cirugía ambulatoria dolorosa es eficaz y segura. Sin embargo, es necesaria vigilancia para identificar disfunciones del dispositivo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Gómez-López L, Sala-Blanch X, Gambús Cerrillo PL, López Gutiérrez A, Agustí Lasús M, Anglada Casas MT. Analgesia multimodal domiciliaria con metadona en perfusión intravenosa mediante bomba elastomérica en cirugía mayor ambulatoria. Rev Esp Anestesiol Reanim. 2018;65:306–313.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 832 "Ancho" => 1570 "Tamanyo" => 64976 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Andersen Pain Scale at 24<span class="elsevierStyleHsp" style=""></span>h.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Score: 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>no pain at rest, on movement, or coughing; 1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>no pain at rest, slight pain on movement or coughing; 2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>slight pain at rest or moderate pain on movement or coughing; 3<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>moderate pain at rest or severe pain on movement or coughing; 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>intense pain at rest or unbearable pain on movement or coughing; 5<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>very intense pain at rest.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2405 "Ancho" => 1583 "Tamanyo" => 127281 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing VAS scores at 24 and 48<span class="elsevierStyleHsp" style=""></span>h in the different surgical groups analysed. Variables were measured at rest and on movement.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">PCA: primary care area.</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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inclusion criteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Exclusion criteria \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA class I–II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Refusal to participate (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical and anaesthetic criteria for MDS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Relevant physical or mental disability (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Accompanied by a capable carer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Outside the hospital's PCA (22)<br>Biological risk (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interventions with moderate to severe pain:<br>•<span class="elsevierStyleHsp" style=""></span>Haemorrhoidectomy<br>•<span class="elsevierStyleHsp" style=""></span>Herniorrhaphy<br>•<span class="elsevierStyleHsp" style=""></span>Perineal diseases (vulvar cysts, labiaplasty, condylomata, cystocele, fistulectomy, pilonidal cyst) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contraindication for surgical technique or drugs (1):<br>• Allergy or intolerance<br>• Severe kidney or liver disease<br>• Serious arrhythmias, QT alterations<br>• Inflammatory bowel disease<br><br>Home hospitalisation team unable to take on the patient (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1770309.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Inclusion and exclusion criteria.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Intensity of pain (visual analogue scale) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">24<span class="elsevierStyleHsp" style=""></span>h</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">48<span class="elsevierStyleHsp" style=""></span>h</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At rest (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">On movement (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At rest (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">On movement (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild (0–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (86.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (61.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (90.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (76.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate (4–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (12.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (32.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (15.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe (8–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Not assessable<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (8.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rescue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">23 (31.5%)</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">21 (28.8%)</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1770307.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Problems with venous catheter, elastomeric pump or incomplete data.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Intensity of pain and need for rescue analgesia at 24 and 48<span class="elsevierStyleHsp" style=""></span>h.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade (score) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Pain intensity</td><td class="td" title="table-entry " align="left" valign="top">Mild (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (84.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (13.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intense (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unbearable (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Pain frequency</td><td class="td" title="table-entry " align="left" valign="top">Rarely (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (86.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frequently (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (9.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Very frequently (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Continuously (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Use of analgesics</td><td class="td" title="table-entry " align="left" valign="top">Occasionally (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (80.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regularly, few (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (17.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regularly, many (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Very many (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Incapacity</td><td class="td" title="table-entry " align="left" valign="top">Slight (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate (42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Needs help (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total incapacity (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Hours of sleep</td><td class="td" title="table-entry " align="left" valign="top">Normal (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (83.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wakes occasionally (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (9.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wakes often (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insomnia (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sedatives (+1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1770308.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Lattinen test at 24<span class="elsevierStyleHsp" style=""></span>h.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Side effects \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">24<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">48<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>73) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nausea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (5.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Catheter-related problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pump-related problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptomatic hypotension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other: allergy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incomplete data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1770306.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Side effects at 24 and 48<span class="elsevierStyleHsp" style=""></span>h.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolución de la cirugía mayor ambulatoria en Cataluña, 2001-2011" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. 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