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The photo shows the approach with arm in abduction (A) and with the arm in adduction when abduction is impossible due to pain or mobilisation of the fracture site (B); ultrasound images obtained with the approach, in-plane needle over the third costal arch (C) and in-plane needle in the interpectoral space (D); schematic representation of the block (E).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.B. Schuitemaker R., X. Sala-Blanch, C.L. Rodriguez-Pérez, J.T. Mayoral R., L.A. López-Pantaleon, A.P. Sánchez-Cohen" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J.B." "apellidos" => "Schuitemaker R." ] 1 => array:2 [ "nombre" => "X." "apellidos" => "Sala-Blanch" ] 2 => array:2 [ "nombre" => "C.L." "apellidos" => "Rodriguez-Pérez" ] 3 => array:2 [ "nombre" => "J.T." "apellidos" => "Mayoral R." ] 4 => array:2 [ "nombre" => "L.A." "apellidos" => "López-Pantaleon" ] 5 => array:2 [ "nombre" => "A.P." "apellidos" => "Sánchez-Cohen" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301160" "doi" => "10.1016/j.redar.2017.04.005" "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/S0034935617301160?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301774?idApp=UINPBA00004N" "url" => "/23411929/0000006500000001/v1_201802080003/S2341192917301774/v1_201802080003/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192917301841" "issn" => "23411929" "doi" => "10.1016/j.redare.2017.11.010" "estado" => "S300" "fechaPublicacion" => "2018-01-01" "aid" => "853" "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;65:41-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 11 "formatos" => array:2 [ "HTML" => 6 "PDF" => 5 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Continuing education</span>" "titulo" => "Guidelines and algorithms for managing the difficult airway" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "41" "paginaFinal" => "48" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guías y algoritmos para el manejo de la vía aérea difícil" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.A. Gómez-Ríos, L. Gaitini, I. Matter, M. Somri" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M.A." "apellidos" => "Gómez-Ríos" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Gaitini" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Matter" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Somri" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301998" "doi" => "10.1016/j.redar.2017.07.009" "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/S0034935617301998?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301841?idApp=UINPBA00004N" "url" => "/23411929/0000006500000001/v1_201802080003/S2341192917301841/v1_201802080003/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Sevoflurane anaesthesia for nasal surgery in a patient with multiple chemical sensitivity" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "49" "paginaFinal" => "52" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.T. Fernández Martín, J.C. Álvarez López" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M.T." "apellidos" => "Fernández Martín" "email" => array:1 [ 0 => "maitefm70@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.C." "apellidos" => "Álvarez López" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de Medina del Campo, Medina del Campo, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anestesia con sevoflurano para cirugía de senos paranasales en un paciente con sensibilidad química múltiple" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Multiple chemical sensitivity (MCS), also known as multiple allergy or idiopathic environmental intolerance, is a chronic complex disorder that was first described in 1940. Incidence of MCS has increased in recent years, and prevalence is now estimated at between 75 and 267 per 100,000 inhabitants, predominantly women.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> This syndrome encompasses a set of symptoms that appear repeatedly after exposure to different stimuli (cleaning products, dyes, colognes, etc.).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Symptoms vary from respiratory or digestive signs to general symptoms (fatigue, irritability, etc.).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sevoflurane is an inhalational anaesthetic agent used for the induction and maintenance of general anaesthesia in adult and paediatric patients. Because of its pharmacological characteristics, this drug is almost the “ideal anaesthetic”: its low blood/gas solubility coefficient (0.63–0.69), pleasant odour and low pungency (unlike desflurane) permit rapid induction of general anaesthesia, less than 5% of the drug is metabolised, and it is rapidly eliminated (95% through the lungs) when administration ceases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a patient with MCS undergoing paranasal sinus surgery, who was anaesthetised with sevoflurane without the use of neuromuscular relaxants.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case study</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 36 year-old woman scheduled for endoscopic sinus surgery. Her medical history included hypersensitivity to latex, non-steroidal anti-inflammatory drugs and pyrazolones, and recurrent bronchitis and asthma related to exposure to chemical agents, which led to the diagnosis of MCS 2 years previously and required her to wear a facial mask. She presented us with a document from the Institut Ferran de Rheumatology giving a list of drugs to be avoided when anaesthetising MCS patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Her surgical history included knee arthroscopy and septoplasty, performed prior to the diagnosis of MCS. Examination of the airway revealed no predictors of difficult airway.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was admitted 1 day before surgery, and all the necessary environmental measures required for this type of patient were taken, she was given a private room and was allowed to use her own, allergen-free sheets. The medical staff avoided the use of latex and perfumed products (gel, deodorants, cologne, etc.). Despite these precautions, the patient, who kept her face mask on at all times, showed signs of dyspnoea, so she asked to be discharged voluntarily and return the next morning for surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The hospital's latex allergy protocol was applied and the patient was prepared for the first part of her surgery. After placing a central line, she was premedicated with 2<span class="elsevierStyleHsp" style=""></span>mg midazolam and “generous” (850<span class="elsevierStyleHsp" style=""></span>ml) administration of lactated Ringer's solution (weight 58<span class="elsevierStyleHsp" style=""></span>kg) was started, in accordance with the recommendations for patients with MCS. Once in the operating room, standard monitoring (electrocardiogram, pulse oximetry and non-invasive blood pressure) was performed. The patient was pre-oxygenated with 100% O<span class="elsevierStyleInf">2</span> for 3<span class="elsevierStyleHsp" style=""></span>min, after which 150<span class="elsevierStyleHsp" style=""></span>μg fentanyl was administered prior to induction with 8% sevoflurane. After confirming absence of eyelid reflex and mandibular relaxation, an anaesthesia depth of 40 on a SEDLine<span class="elsevierStyleSup">®</span> monitor and an end tidal concentration of sevoflurane >4%, the airway was secured with a number 7 orotrachael tube placed under direct laryngoscopy, without incident. The entire process was performed with the patient under spontaneous ventilation, maintaining normocapnia. The nostrils were not infiltrated with adrenaline for the procedure. During the 2<span class="elsevierStyleHsp" style=""></span>h of surgery, anaesthesia was maintained with fentanyl boluses (450<span class="elsevierStyleHsp" style=""></span>μg in total) and sevoflurane at 1.5–2 MAC, without the need for muscle relaxants. Extubation was uneventful and the patient was transferred to the post-anaesthesia care unit. In the postoperative period, 1<span class="elsevierStyleHsp" style=""></span>g of IV paracetamol was administered every 8<span class="elsevierStyleHsp" style=""></span>h for pain management, and the patient was discharged home at 24<span class="elsevierStyleHsp" style=""></span>h without complications.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">MCS or idiopathic environmental intolerance was defined in 1987<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> as “an acquired disorder characterised by recurrent symptoms, referable to multiple organ systems, occurring in response to demonstrable exposure to many chemically unrelated compounds at doses below those established in the general population to cause harmful effects”. It can no longer be considered a rare disease, since it affects around 2% of the general population. In September 2014, the Spanish Ministry of Health included the disease among “non-specific allergies” (code 995.3) of the Spanish version of the International Classification of Diseases, Ninth Revision, Clinical Modification.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The syndrome manifests with diverse central nervous system (dizziness, paraesthesias), respiratory (cough, dyspnoea) and circulatory (palpitations, chest pain) symptoms.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> It is also important to bear in mind that MCS has a major psychological component of anxiety and depression,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> and that the symptoms sometimes have no medical explanation. Our patient was diagnosed after 2 years of repeated hospital admissions due to increasingly intense asthmatic attacks combined with malaise. A comprehensive allergy study led to the diagnosis of MCS.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the situation, and after a review of the literature failed to uncover sufficient data or specific guidelines for these patients, the most reasonable approach appeared to consist of limiting the number of drugs administered and avoiding any drugs that would have caused an adverse reaction, and accordingly tackled the delicate task of anaesthetising our patient following the recommendations of the Institut Ferran de Rheumatology,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> which includes the Catalan Health Service's anaesthesia management protocol for MCS patients, the only document of its kind in Spain, together with a list of drugs to avoid (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). We presume that the drugs listed in this document are contraindicated due to various mechanisms of action: their possible adverse effects, such as bronchoconstriction (neostigmine, atropine or succinylcholine), their release of histamine (pentothal, morphine and most neuromuscular relaxants), or their allergenic potential (para-aminobenzoic acid, the inactive metabolite of local ester-type anaesthetics). For this reason, we considered the best anaesthesia strategy in this patient to be induction with propofol or sevoflurane, with fentanyl for analgesia (instead of remifentanil and alfentanil analogues, which cause greater hypotension and bradycardia due to medullary vagal stimulation as opposed to histamine release). If muscle relaxants were required, vecuronium would have been our agent of choice, monitoring relaxation to avoid overdosing. Cisatracurium does not release histamine, but it is contraindicated in patients with hypersensitivity to benzenesulfuric acid (present in some dyes), although it has occasionally been used<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> without incident. For local anaesthesia, adrenaline-free amide-type anaesthetics would be our choice.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our anaesthesia management included premedication with midazolam, which, although disadvised in some studies, was uneventful.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> We administered plenty of fluids, since some studies have reported abnormal cardiovascular response and orthostatic hypotension related to autonomic dysfunction in patients with multiple chemical sensitivity.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> We chose an inhalational agent for induction and maintenance of anaesthesia. Although propofol would have been safe, it can cause coughing or laryngo- or bronchospasm, which would have been inadvisable in our patient. Instead, we chose sevoflurane, which has the added advantage of producing relaxation, thus avoiding the use of neuromuscular relaxants.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Sevoflurane has a MAC of 2.07, but an 8% concentration is usually used for anaesthesia induction. Unlike desflurane, sevoflurane produces practically no airway irritation and decreases airway resistance. A sevoflurane concentration of 8% in the vaporiser permits rapid increase in alveolar concentration and enables a laryngeal mask airway to be placed or a laryngoscope to be inserted 90<span class="elsevierStyleHsp" style=""></span>s after induction, and also permits intubation without muscle relaxants between 3.6 and 5.7<span class="elsevierStyleHsp" style=""></span>min after induction.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9,10</span></a> For maintenance, the synergistic effect of the combination of sevoflurane and fentanyl<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> allow the end-tidal concentration of sevoflurane to be adjusted to suppress the motor response and maintain haemodynamic stability.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> Intravenous paracetamol was given for postoperative analgesia, which proved sufficient for pain control.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was hospitalised for 24<span class="elsevierStyleHsp" style=""></span>h to monitor for surgery- or anaesthesia-related complications. Fortunately, none were observed, and she was discharged home without incident.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">MCS is a challenge for anaesthesiologists due to the absence of clear guidelines on the correct approach in these patients. In our case, induction and maintenance with sevoflurane and fentanyl, without muscle relaxants, was successful, and is an strategy to be considered in future cases.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have adhered to the protocols of their centre of work on patient data publication.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres978763" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec947851" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres978764" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec947852" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case study" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-13" "fechaAceptado" => "2017-03-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec947851" "palabras" => array:5 [ 0 => "Environmental allergy" 1 => "Nasal surgery" 2 => "Sevoflurane" 3 => "Fentanyl" 4 => "Multiple chemical sensitivity" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec947852" "palabras" => array:5 [ 0 => "Alergia ambiental" 1 => "Cirugía otorrinolaringológica" 2 => "Sevoflurano" 3 => "Fentanilo" 4 => "Sensibilidad química múltiple" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple chemical sensitivity syndrome is a group of complex disorders that include psychiatric disorders, chronic fatigue and/or respiratory problems. This syndrome could be triggered by specific allergens and toxins that cause neurophysiological sensitisation and the appearance of the clinical symptomatology. Anaesthesia for these patients always poses a challenge for the anaesthetist, because they need to find and use drugs that do not trigger or aggravate the symptoms of the disease. Therefore, sevoflurane in these circumstances might be “the ideal anaesthetic”. Performing general anaesthesia with sevoflurane as the sole anaesthetic agent, together with a series of environmental measures formed the basis for successful anaesthesia and surgery in our patient with a multiple chemical sensitivity syndrome.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El síndrome se sensibilidad química múltiple supone un conjunto de desórdenes complejos que incluyen, entre otros, una serie de trastornos psiquiátricos, síntomas de fatiga crónica y/o trastornos respiratorios. Los desencadenantes del cuadro serían alergenos inespecíficos o tóxicos que provocan una sensibilización neurofisiológica y la aparición de la sintomatología clínica. El tratamiento anestésico de estos pacientes supone siempre un reto para el anestesiólogo por la búsqueda y utilización de fármacos que no desencadenen o agraven los síntomas de dicha enfermedad. Así, el sevoflurano en estas circunstancias podría acercarse al «anestésico ideal». La realización de anestesia general con sevoflurano como agente anestésico único, junto con una serie de medidas ambientales, fueron la base para la realización exitosa de la cirugía en una paciente afecta de síndrome se sensibilidad química múltiple.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Martín MT, Álvarez López JC. Anestesia con sevoflurano para cirugía de senos paranasales en un paciente con sensibilidad química múltiple. Rev Esp Anestesiol Reanim. 2018;65:49–52.</p>" ] ] "multimedia" => array:1 [ 0 => 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: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">Adrenaline and other adrenergic amines \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">Morphine and derivatives (except fentanyl) \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">Aminophylline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Muscle relaxants \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">Local anaesthetics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Succinylcholine \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">Cholinergic drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neostigmine \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">Anticholinesterase drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Furosemide \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658235.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Drugs to be avoided in patients with multiple chemical sensitivity syndrome.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cesárea electiva en una paciente con síndrome de sensibilidad química múltiple" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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