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Original article
Outpatient intravenous multimodal elastomeric pump with methadone in ambulatory surgery
Analgesia multimodal domiciliaria con metadona en perfusión intravenosa mediante bomba elastomérica en cirugía mayor ambulatoria
L. Gómez-López
Corresponding author
LGOMEZ2@clinic.ub.es

Corresponding author.
, X. Sala-Blanch, P.L. Gambús Cerrillo, A. López Gutiérrez, M. Agustí Lasús, M.T. Anglada Casas
Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic de Barcelona, Barcelona, Spain
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is usually the route of choice&#46;<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 &#40;multimodal analgesia&#41;&#44; and are safe and easy to use in outpatients&#46; However&#44; optimal control of APP<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> is not always achieved&#44; perhaps due to the wide variety of interventions&#44; patients and postoperative management guidelines&#46; The use of non-steroidal anti-inflammatory drugs and minor opioids at variable doses in the outpatient setting is common practice&#46; Major&#44; particularly extended-release&#44; opioids are less common in MDS&#44; even though they are more effective and are often given to hospitalised patients&#46; Nevertheless&#44; they can cause undesirable effects&#44; such as postoperative nausea and vomiting &#40;PONV&#41;&#44; particularly after administration of intermittent boluses&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#8211;6</span></a> This is why analgesic strategies that can improve management of APP without increasing adverse effects must be found&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We designed this observational study in order to evaluate the analgesic efficacy&#44; safety and side effects of an intravenous&#44; low-dose infusion of methadone&#44; tramadol&#44; dexketoprofen and ondansetron delivered through an elastomeric infusion system for 48<span class="elsevierStyleHsp" style=""></span>h&#46; The analgesic combination was given to MDS patients undergoing interventions associated with moderate to severe postoperative pain&#46;</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 &#40;herniorrhaphy&#44; haemorrhoidectomy and perineal surgery&#41;&#46; The study was conducted in a tertiary level hospital catering for complex procedures and only adult patients&#44; and was approved by the Clinical Research Ethics Committee of the Hospital Cl&#237;nic of Barcelona&#46; All patients received detailed information about the study and its possible consequences&#44; and all were asked to give both oral and written informed consent&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was conducted over a period of 12 months&#44; during which we evaluated the analgesic quality&#44; side effects and quality and safety indicators of an intravenous multimodal analgesia combination of methadone&#44; dexketoprofen&#44; tramadol and ondansetron&#44; administered for 48<span class="elsevierStyleHsp" style=""></span>h by elastomeric pump&#46; The inclusion and exclusion criteria are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A portable&#44; non-electronic&#44; disposable low-flow continuous elastomeric infuser &#40;Infuser FOLFusor LV 5 Baxter<span class="elsevierStyleSup">&#174;</span>&#41; was used to deliver the study drug&#46; This device had a maximum capacity of 300<span class="elsevierStyleHsp" style=""></span>ml&#44; and the drugs were administered at a rate of 5<span class="elsevierStyleHsp" style=""></span>ml&#47;h for 48<span class="elsevierStyleHsp" style=""></span>h&#46; The pumps were prepared by an anaesthesia nurse&#44; and started immediately after the intervention&#46; The reservoir was loaded with 0&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg methadone &#40;0&#46;002<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;h&#41;&#44; 200<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen &#40;4<span class="elsevierStyleHsp" style=""></span>mg&#47;h&#41;&#44; 100<span class="elsevierStyleHsp" style=""></span>mg tramadol &#40;2<span class="elsevierStyleHsp" style=""></span>mg&#47;h&#41; and 8<span class="elsevierStyleHsp" style=""></span>mg ondansetron &#40;0&#46;16<span class="elsevierStyleHsp" style=""></span>mg&#47;h&#41;&#46; A solution of 0&#46;9&#37; saline was administered to bring the volume up to 250<span class="elsevierStyleHsp" style=""></span>ml&#46; Patients used the pump for 48<span class="elsevierStyleHsp" style=""></span>h&#44; and 1<span class="elsevierStyleHsp" style=""></span>g oral paracetamol every 8<span class="elsevierStyleHsp" style=""></span>h was prescribed for additional analgesia&#44; together with 2<span class="elsevierStyleHsp" style=""></span>g metamizol &#40;up to 2 doses per day&#41; as rescue analgesia&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">During the pre-surgery visit&#44; patients received information about the type of anaesthesia to be used&#44; the postoperative analgesic regimen&#44; and the home monitoring programme&#46; The usual preoperative workup was performed&#44; included kidney function tests to rule out delay in drug elimination&#46; A 12-lead ECG was performed to rule out pathologically prolonged QT interval&#46; All patients were asked to give their oral and written informed consent&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">On the day of the procedure&#44; patients were given 1&#8211;2<span class="elsevierStyleHsp" style=""></span>mg midazolam&#44; 50<span class="elsevierStyleHsp" style=""></span>mg ranitidine&#44; 4<span class="elsevierStyleHsp" style=""></span>mg dexamethasone&#44; and 50<span class="elsevierStyleHsp" style=""></span>mg intravenous dexketoprofen in the surgical prep room&#44; as per the protocol in force in the unit&#46; The intervention was carried out by the specialist surgical team&#44; following routing surgical and anaesthetic practice&#46; Immediately after surgery&#44; the elastomeric pump was started through a peripheral venous catheter located in an area of the patient&#39;s arm where it would not become kinked if the patient changed position&#46; This ensured continuous perfusion&#46; After transfer to the post-anaesthesia care unit&#44; 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 &#40;VAS&#41;&#44; after which they were transferred to the recovery unit &#40;RU&#41; A single bolus of ondansetron was administered in the case of PONV&#46; The usual discharge criteria were followed&#46; The RU nurse taught the patient and their carer care how to manage the catheter and pump&#44; described the possible side effects and their warning signs&#44; explained the postoperative monitoring protocol&#44; and gave them a 24-h telephone number to call if they had any questions related to the intervention and the treatment&#46; All phone calls were answered by an anaesthesiologist&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients received 2 home visits from study nurses&#44; at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#44; to monitor the quality and safety of the treatment&#46; During these visits&#44; the catheter and pump were checked to ensure they were working correctly&#44; and the infusion site was examined for abnormalities&#44; and the following variables were collected&#58; clinical status of the patient&#44; adverse effects&#44; the degree of pain at rest and on movement &#40;using the VAS&#44; Andersen scale&#44; and the Lattinen test&#41;&#44; the need for rescue analgesia&#44; the status of the surgical wound&#44; and finally&#44; the patient&#39;s performance status&#44; level of comfort and satisfaction&#46; In the 48-h visit&#44; in addition to the above&#44; the pump and catheter were removed and the puncture site was treated&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patients&#8217; received a follow-up phone call from the RU nurse 72<span class="elsevierStyleHsp" style=""></span>h after surgery &#40;24<span class="elsevierStyleHsp" style=""></span>h after completion of the infusion&#41; to enquire after the patient&#39;s pain status&#44; degree of recovery and physical and mental status&#46; Seven days after the intervention&#44; the RU nurse contacted the patient and the carer to conduct a telephone satisfaction survey&#46; Both were asked to rate the treatment and care received&#44; whether they would be willing to repeat the programme in the future&#44; and were invited to add any additional comments&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">This was an observational study&#46; Based on the annual case load of the MDS unit and the estimated time required to complete the study&#44; we calculated that a sample size of 100 patients would suffice&#44; taking into account that between 30&#37; and 40&#37; of patients would not satisfy the criteria established for postoperative home follow-up&#46; We considered that a sample of at least 60 patients would be representative of the population&#46; The data were presented as number and percentage of patients&#44; or as mean and standard deviation&#44; according to the characteristics of the variables analysed&#46; The nonparametric Kruskal&#8211;Wallis test was used to analyse the different surgical procedures&#44; and the Wilcoxon test was used to analyse VAS scores at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#46; In both tests&#44; significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</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&#44; 22 were immediately excluded because they lived too far from the hospital to receive home follow-up&#44; 1 was excluded due to technical contraindications&#44; 2 were excluded due to the impossibility of receiving home visits&#44; and 4 due to biological risk&#46; Two of the remaining 75 cases were also excluded&#58; 1 due to refusal to take part&#44; and the other due to a psychiatric disorder that was not detected during the initial interview &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The analysis was performed on the remaining 73 patients&#46; All patients&#44; 42 men and 31 women&#44; finished the study&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">With respect to surgery&#44; 27 patients &#40;37&#37;&#41; underwent inguinal herniorrhaphy surgery&#44; 22 &#40;30&#37;&#41; proctologic surgery &#40;haemorrhoidectomy&#41;&#44; and the remaining 24 &#40;33&#37;&#41; underwent minor perineal surgery&#46; The mean age was 55 years in the herniorrhaphy group&#44; 46 years in the haemorrhoidectomy group&#44; and 38 years in the perineal surgery group&#46; The body mass index was similar in all 3 groups &#40;herniorrhaphy<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#46;18<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; haemorrhoidectomy<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#46;62<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#59; perineal surgery<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#46;03<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; The predominant anaesthetic technique used was balanced general anaesthesia with inhalational agents&#44; used in 71 patients &#40;97&#37;&#41;&#59; general intravenous anaesthesia was used in 2 patients &#40;3&#37;&#41;&#46; All study patients were discharged home with good pain control and no PONV&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">At 24<span class="elsevierStyleHsp" style=""></span>h&#44; 86&#37; reported mild pain at rest &#40;VAS<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>3&#41; and 62&#37; reported mild pain on movement &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#59; at 48<span class="elsevierStyleHsp" style=""></span>h&#44; 90&#37; reported mild pain at rest and 77&#37; on movement&#46; Around 30&#37; required rescue analgesia&#46; On the Andersen scale at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; 89&#37; presented a score of &#8804;1&#59; none reported a high score&#46; In the Lattinen test &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; most &#40;more than 90&#37;&#41; reported low scores &#40;&#8804;6&#41; in all items&#46;</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&#46; Pain at rest appeared to be slightly more intense in the haemorrhoidectomy group&#44; although the herniorrhaphy and perineal surgery groups reported greater pain on movement &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding adverse effects &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; 2&#46;7&#37; presented vomiting at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#44; 4&#46;1&#37; had problems with venous access and with the pump at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#46; There was 1 case of accidental catheter removal&#44; 2 of extravasation&#44; 2 of localised phlebitis&#44; and 1 unspecified problem with the catheter in a patient who underwent perianal polypectomy&#59; VAS&#58; at rest<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#59; on movement<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#46; There was 1 case of minor skin reaction at 72<span class="elsevierStyleHsp" style=""></span>h &#40;1 day after removal of the pump&#41;&#46; In 1 patient&#44; the pump reservoir had not emptied completely by the 48-h visit &#40;haemorrhoidectomy&#59; VAS&#58; at rest<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#59; on movement<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; and in another&#44; the visiting nurse found that the valve was closed&#46; In 1 case&#44; premature emptying of the pump was discovered during the 48-h visit &#40;haemorrhoidectomy&#59; VAS&#58; at rest<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#59; on movement<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&#44; albeit with no side effects&#46; None of the study patients presented serious problems&#46;</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&#46; All &#40;100&#37;&#41; considered the treatment received to be good&#47;very good&#44; and the medical team to have been supportive&#46; All &#40;100&#37;&#41; carers and 85&#37; of the patients would repeat the programme without any changes&#59; 14&#37; would do so under certain conditions&#46;</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&#44; affect the patient&#39;s perception of the quality of care received&#44; and lead to long-term complications&#44; such as chronic pain syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#8211;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&#46; The addition of low-dose intravenous methadone does not increase the incidence of side effects&#46; However&#44; despite the good pain management results&#44; catheter-related complications &#40;phlebitis&#44; extravasation&#44; device dysfunction&#44; etc&#46;&#41; can put the patient at risk&#46; This is why&#44; although complications are rare&#44; patients receiving this therapy must be monitored by a healthcare professional&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In our study&#44; VAS scores are slightly lower than those observed in similar studies&#44; even though our analgesia combination contained lower doses of tramadol and dexketoprofen&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> For example&#44; Rodr&#237;guez de la Torre et al&#46; reported a mean at-rest VAS score of 2&#46;13 at the 24-h telephone follow-up&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> while Serra et al&#46; reported a mean VAS of 1&#46;35&#44; and 1&#46;28 at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> In our study&#44; mean VAS scores were 1&#46;21 at 24<span class="elsevierStyleHsp" style=""></span>h and 0&#46;57 at 48<span class="elsevierStyleHsp" style=""></span>h&#46; On the second postoperative day&#44; all our patients reported a VAS of &#8804;3&#46; An interesting feature of our study is the inclusion of APP variables both at rest and on movement&#44; since the latter is a key factor in indicating early recovery of mobility&#46;<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&#44; an observational test that assesses both static and dynamic pain&#44; and which has a good correlation with other APP scales&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> In our case&#44; 84&#37; of patients reported a score of 0&#8211;1&#44; which indicate good pain management both at rest and on movement&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The other scale used was the Lattinen test&#44; a multidimensional scale that evaluates several parameters that measure not only the degree of pain&#44; but also its emotional component and effect on the patient&#39;s well-being&#46; Although it is more often used in chronic pain&#44; we believed this scale would also provide important information in acute processes&#46; More than 90&#37; of our patients had a score of &#8804;6 &#40;4 being the minimum and 20 the maximum&#41;&#44; indicating minimal pain with little impact on well-being&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">No statistically significant differences in the degree of postoperative pain were found when comparing surgical procedures&#46; However&#44; pain at rest appears to be slightly more intense in the haemorrhoidectomy group&#44; while patients in the herniorrhaphy and perineal group reported greater pain on movement&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Pain at rest was well controlled in all groups overall&#59; it was slightly greater in the haemorrhoidectomy group&#44; but without reaching the level of severe pain &#40;median VAS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#59; 75th percentile<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3 in the haemorrhoidectomy group at 24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Pain on movement was greater in the herniorrhaphy and perineal surgery groups vs the haemorrhoidectomy group&#44; particularly at 24<span class="elsevierStyleHsp" style=""></span>h &#40;median 24-h VAS score<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2 and 75th percentile<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3 in haemorrhoidectomies&#59; median 24-h VAS score<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3 and 75th percentile<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5 in herniorrhaphy and perineal surgery&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">On-movement pain scores were similar in all groups at the 48-h follow-up&#46; However&#44; in the perineal surgery group&#44; outlying on-movement VAS scores were higher&#46; The male&#58;female ratio of this group was 3&#58;7&#44; inverse to that of the other groups&#44; and the average age &#40;38 years&#41; is lower&#46; This suggests that the higher pain scores could be due to either a predominantly lower pain threshold&#44; or to a trend towards greater activity in younger patients&#46; If the latter hypothesis is true&#44; it would explain why at-rest pain scores were similar in all 3 groups&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The side effects observed were similar to those reported in comparable studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;5</span></a> The addition of low-dose methadone to the elastomeric pump did not increase the incidence of side effects&#44; and none were serious&#46; Although some catheter-related complications arose&#44; these were infrequent and did not cause serious problems&#59; however&#44; we believe they require professional monitoring&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Elastomeric pumps can deliver continuous intravenous infusion of multimodal analgesia regimens&#44; and are therefore ideally suited for APP management&#46; These devices can deliver combinations of drugs with different mechanisms of action&#44; thus increasing the analgesic effect while minimising the risk of side effects by reducing the dose required of each drug&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;8&#44;9</span></a> The intravenous route delivers the analgesics directly into the systemic circulation&#46; This facilitates titration&#44; particularly in intravenous infusion where plasma levels remain stable over time&#46;<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&#44; respectively&#46; However&#44; there is always the danger of pump malfunction leading to premature emptying of the reservoir&#44; and with it&#44; extremely high plasma levels of the drug combination&#46; For this reason&#44; it is important to keep the total dose of all drugs in the pump reservoir below toxic levels&#44; particularly in view of the effects of methadone&#46; Problems such as extravasation or phlebitis should also be treated professionally&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding satisfaction&#44; 100&#37; of patients and carers interviewed considered the treatment received to be good&#47;very good&#44; and the great majority would repeat the experience&#46; 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&#44; which will in turn optimise resources and reduce waiting lists&#46;<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&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Several different analgesic regimens for intravenous elastomeric pumps have been described in the MDS setting&#46; These usually include non-steroidal anti-inflammatory drugs and minor opioids&#44; such as tramadol in variable doses&#44; and sometimes antiemetics&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> However&#44; these do not always provide sufficient relief of APP&#46; In the case of moderate to severe pain&#44; adequate analgesia may only be possible with major opioids&#46; Long-acting opioids are usually the treatment of choice for oncological and chronic pain because of their stability and duration of effect&#46; However&#44; despite their many advantages&#44; they are not often used to treat APP&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;11</span></a> Long-acting opioids provide a continuous level of analgesia and are as potent as shorter-acting drugs&#44; such as morphine&#44; at far lower doses&#44; thus reducing daily drug consumption<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> and opioid-related side effects&#44; and improving the quality of the analgesia&#46; Despite the scarcity of studies in methadone for postoperative pain management&#44; some groups&#44; such as Miranda et al&#46;&#44; have shown the synergistic effect of the methadone-morphine&#44; methadone-fentanyl and methadone-tramadol combination in a model of visceral pain in mice&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> For all the above&#44; methadone has been the major opioid of choice for parenteral treatment of moderate to severe APP in our hospital for over 30 years&#44; and has achieved good results&#46; This is why we believe it could be effective in MDS patients undergoing procedures associated with severe APP&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Methadone is a synthetic opioid equipotent to morphine&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;13</span></a> It acts on &#956; and &#948; 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&#46; This is why it useful in the treatment and prevention of neuropathic pain&#44; chronic pain&#44; opioid tolerance and hyperalgesia&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;11&#44;13&#44;14</span></a> Other advantages are its haemodynamic stability at therapeutic doses&#44; absence of euphoria&#44; milder withdrawal syndrome than morphine&#44; and low cost&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Although it can be cardio toxic &#40;causing pathological lengthening of the QT interval and severe ventricular arrhythmias&#41;&#44; 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&#44; or in cases of methadone overdose and association with other drugs or narcotics that also lengthen the QT interval&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> Studies such as those published by Anderson or Alvarado&#44; for example&#44; do not report haemodynamic changes in cardiac surgery patients receiving methadone at therapeutic doses&#46; Nevertheless&#44; it is advisable not to administer methadone when the QTc interval is &#8805;450<span class="elsevierStyleHsp" style=""></span>ms&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;15&#44;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&#46; Tramadol is a &#956;&#44; &#948; and &#954; agonist&#44; and acts on neuropathic pain by inhibiting the reuptake of noradrenaline and serotonin&#46; It does not create tolerance or dependence&#44; and causes few cardiovascular or respiratory side effects&#46; Theoretically&#44; both tramadol and methadone act on opioid receptors&#46; However&#44; studies have shown the existence of several &#956;&#44; &#948; and &#954; receptor subtypes unevenly distributed across the nervous system&#46; The simultaneous activation of certain combinations of receptors at different sites can cause very different analgesic effects&#44; and therefore the association of several opioids can enhance the antinociceptive effect&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12&#44;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&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> although this is highly unlikely&#46; Onset of this syndrome is typically dose-dependent&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18&#44;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&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> Severe cases are usually associated with use of a high-risk drug &#40;such as monoamine oxidase inhibitors &#91;MAOI&#93; antidepressants or serotonin reuptake inhibitors &#91;SRI&#93;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18&#44;20</span></a> although they can also be caused by high-dose combinations of several low to intermediate risk drugs&#46; It is important to bear in mind that drugs such as linezolid are MAOIs&#46; In these cases&#44; alternative treatment with non-serotonergic drugs such as morphine should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18&#44;19</span></a> Symptoms are mild in most documented cases&#44; although the syndrome can be fatal&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Both tramadol and methadone are weak SRIs&#46; Tramadol also slightly increases serotonin release at the synaptic level&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> We debated the interaction of these drugs before starting the study&#44; but decided to include them because their use in combination they allowed us to significantly reduce the total dose&#44; thus considerably reducing the risk of side effects&#46; According to authors such as Hillman et al&#46;&#44; the association of several morphine-based drugs is a common clinical practice that&#44; under normal conditions&#44; does not usually cause serotonin syndrome&#46; These authors associated the onset of symptoms to the simultaneous use of drugs with more serotonergic activity than opiates&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> In the studies consulted&#44; daily doses of methadone 90&#8211;120<span class="elsevierStyleHsp" style=""></span>mg were used&#44; whereas in our study only 3&#8211;4<span class="elsevierStyleHsp" style=""></span>mg per day were administered&#46; However&#44; patients under psychiatric treatment were excluded from the study&#44; 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&#46; Neither were any incidences reported on the 24-h emergency phone&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">One of the most frequent side effects of tramadol is nausea and vomiting&#46; This&#44; however&#44; is dose-dependent&#44; and the risk can therefore be reduced in MDS patients&#46; In our case&#44; in addition to reducing tramadol dose to 2<span class="elsevierStyleHsp" style=""></span>mg&#47;h &#40;56&#37; less than that used by Rodr&#237;guez de la Torre et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> 75&#37; less than in Serra et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> and 78&#37; less than in Recasens et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a>&#41;&#44; we also added ondansetron to the multimodal regimen&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Ondansetron is a 5-HT<span class="elsevierStyleInf">3</span> antagonist which&#44; when mixed with tramadol in 0&#46;9&#37; saline&#44; remains stable for up to 14 days when stored at both 4<span class="elsevierStyleHsp" style=""></span>&#176;C and 25<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> However&#44; some authors&#44; such as Stevens&#44; Woodman and Owen&#44; concluded that the ondansetron diminishes the analgesic effect of tramadol in the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; Despite this&#44; we decided to use it because it does not inhibit serotonergic pathways and is effective &#40;level of evidence 1A&#41; in the prevention and treatment of PONV at low doses&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> On this premise&#44; and bearing in mind that PONV risk scales&#44; such as Apfel&#44; are poor predictors of late PONV&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> all participants were given ondansetron at a dose of 0&#46;16<span class="elsevierStyleHsp" style=""></span>mg&#47;h&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Our study is limited by the absence of a control group and its small sample size&#46; Furthermore&#44; given the wide range of interventions and pharmacological regimens&#44; it is difficult to compare it with other studies&#46; It is also important to note that the same drug combination &#40;except for methadone&#41; was used in all patients&#44; irrespective of their surgical group and their anthropometric characteristics&#46; This could have led to under- or over-dosing in patients at either end of the weight scale&#46; Comparable studies are needed to enable us to define the most effective analgesia regimens for each intervention and type of patient&#46;</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&#44; we can conclude that analgesic regimens with methadone in continuous infusion through an elastomeric pump are effective and safe&#46; However&#44; due to the risk of adverse effects and catheter-related complications &#40;phlebitis&#44; extravasation&#44; device dysfunction&#44; etc&#46;&#41;&#44; these treatments require supervision over time&#46; In these patients&#44; home nursing care in the immediate postoperative period should be part of routine practice&#46;</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&#44; 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&#46;</p></span></span>"
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          "identificador" => "xres1042011"
          "titulo" => "Abstract"
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            0 => array:2 [
              "identificador" => "abst0005"
              "titulo" => "Background and objective"
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          "titulo" => "Resumen"
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              "titulo" => "Antecedentes y objetivo"
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              "titulo" => "Pacientes y m&#233;todos"
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          "titulo" => "Introduction"
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          "titulo" => "References"
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    "fechaRecibido" => "2017-10-09"
    "fechaAceptado" => "2018-01-19"
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        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 elastom&#233;rica"
            2 => "Dolor postoperatorio"
            3 => "Cirug&#237;a mayor ambulatoria"
          ]
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        "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 &#40;AS&#41; needs to evolve in parallel with surgical complexity&#46; We designed a study to try to improve analgesia in painful surgery using an intravenous elastomeric pump&#46; As a novelty&#44; methadone was included&#46;</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&#44; physical status ASA I&#8211;II&#44; underwent ambulatory surgeries with moderate-severe postoperative pain&#46; Analgesia was administered for 48<span class="elsevierStyleHsp" style=""></span>h by an intravenous multimodal elastomeric pump &#40;methadone&#44; tramadol&#44; dexketoprofen and ondansetron at low doses&#41;&#46; Visual analogue scale &#40;VAS&#41; at rest and movement were evaluated at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#46; Andersen scale&#44; Lattinen test&#44; rescue analgesia and side-effects were recorded at 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46;</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&#58; 37&#37; abdominal wall surgery&#44; 30&#37; hemorrhoidectomies and 33&#37; perineal surgery&#46; Median VAS score at rest and movement were 0 and 3 at 24<span class="elsevierStyleHsp" style=""></span>h&#44; and 0 and 2 at 48<span class="elsevierStyleHsp" style=""></span>h&#46; At 24<span class="elsevierStyleHsp" style=""></span>h&#44; Andersen&#39;s Scale score was &#8804;1 in 89&#37;&#44; and Lattinen test &#8804;6 in 90&#37; of patients&#46; Rescue medication was administered in 30&#37; of patients&#46; Two patients had vomiting at 24 and 48<span class="elsevierStyleHsp" style=""></span>h&#46; Minor catheter and pump dysfunctions were observed in 8&#37; of patients&#46;</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&#46; However&#44; monitoring is needed to diagnosis dysfunction of devices&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Background and objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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          2 => array:2 [
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            "titulo" => "Results"
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        "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 cirug&#237;a mayor ambulatoria &#40;CMA&#41; necesita evolucionar paralelamente a la complejidad quir&#250;rgica&#46; Dise&#241;amos un estudio para intentar mejorar la analgesia en cirug&#237;a dolorosa mediante elast&#243;mera intravenosa&#46; Como novedad&#44; se incluy&#243; metadona&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional en pacientes ASA I-II&#44; intervenidos en CMA de cirug&#237;as con dolor postoperatorio moderado-severo&#46; Se administr&#243; analgesia durante 48<span class="elsevierStyleHsp" style=""></span>h mediante elast&#243;mera intravenosa de metadona&#44; tramadol&#44; dexketoprofeno y ondansetr&#243;n a dosis bajas&#44; y paracetamol oral&#46; A las 24 y 48<span class="elsevierStyleHsp" style=""></span>h se evalu&#243; la eficacia analg&#233;sica en reposo y en movimiento &#40;Escala Visual Anal&#243;gica &#91;EVA&#93;&#44; Escala de Andersen y Test de Lattinen&#41;&#44; la necesidad de analgesia de rescate y los efectos adversos&#46;</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&#58; un 37&#37; de ellos intervenidos de cirug&#237;a de pared abdominal&#44; un 30&#37; de hemorroidectom&#237;as y un 33&#37; de cirug&#237;a del perin&#233;&#46; La mediana en reposo a las 24 y 48<span class="elsevierStyleHsp" style=""></span>h fue EVA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44; y en movimiento&#44; fue de 3 a las 24<span class="elsevierStyleHsp" style=""></span>h y de 2 a las 48<span class="elsevierStyleHsp" style=""></span>h&#46; En la Escala de Andersen&#44; a las 24<span class="elsevierStyleHsp" style=""></span>h el 89&#37; present&#243; puntuaci&#243;n &#8804;1&#46; En el Test de Lattinen&#44; el 90&#37; present&#243; una puntuaci&#243;n &#8804;6&#46; Precis&#243; rescate el 30&#37;&#46; Dos pacientes presentaron v&#243;mitos a las 24 y 48<span class="elsevierStyleHsp" style=""></span>h&#46; Se observaron problemas menores con el cat&#233;ter y la elast&#243;mera en el 8&#37; de los pacientes&#46;</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 elast&#243;mera para cirug&#237;a ambulatoria dolorosa es eficaz y segura&#46; Sin embargo&#44; es necesaria vigilancia para identificar disfunciones del dispositivo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; G&#243;mez-L&#243;pez L&#44; Sala-Blanch X&#44; Gamb&#250;s Cerrillo PL&#44; L&#243;pez Guti&#233;rrez A&#44; Agust&#237; Las&#250;s M&#44; Anglada Casas MT&#46; Analgesia multimodal domiciliaria con metadona en perfusi&#243;n intravenosa mediante bomba elastom&#233;rica en cirug&#237;a mayor ambulatoria&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;306&#8211;313&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Andersen Pain Scale at 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Score&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no pain at rest&#44; on movement&#44; or coughing&#59; 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no pain at rest&#44; slight pain on movement or coughing&#59; 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>slight pain at rest or moderate pain on movement or coughing&#59; 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>moderate pain at rest or severe pain on movement or coughing&#59; 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>intense pain at rest or unbearable pain on movement or coughing&#59; 5<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very intense pain at rest&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">PCA&#58; primary care area&#46;</p>"
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                  <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&nbsp;\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&nbsp;\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&#8211;II&nbsp;\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 &#40;1&#41;&nbsp;\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&nbsp;\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 &#40;1&#41;&nbsp;\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&nbsp;\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&#39;s PCA &#40;22&#41;<br>Biological risk &#40;4&#41;&nbsp;\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&#58;<br>&#8226;<span class="elsevierStyleHsp" style=""></span>Haemorrhoidectomy<br>&#8226;<span class="elsevierStyleHsp" style=""></span>Herniorrhaphy<br>&#8226;<span class="elsevierStyleHsp" style=""></span>Perineal diseases &#40;vulvar cysts&#44; labiaplasty&#44; condylomata&#44; cystocele&#44; fistulectomy&#44; pilonidal cyst&#41;&nbsp;\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 &#40;1&#41;&#58;<br>&#8226; Allergy or intolerance<br>&#8226; Severe kidney or liver disease<br>&#8226; Serious arrhythmias&#44; QT alterations<br>&#8226; Inflammatory bowel disease<br><br>Home hospitalisation team unable to take on the patient &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1770309.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Inclusion and exclusion criteria&#46;</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"
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        ]
        "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 &#40;visual analogue scale&#41;&nbsp;\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">&nbsp;\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 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&nbsp;\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 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&nbsp;\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 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&nbsp;\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 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&nbsp;\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 &#40;0&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;86&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45 &#40;61&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;90&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;76&#46;7&#37;&#41;&nbsp;\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 &#40;4&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;12&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;32&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;15&#46;1&#37;&#41;&nbsp;\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 &#40;8&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;6&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;8&#46;2&#37;&#41;&nbsp;\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&nbsp;\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 &#40;31&#46;5&#37;&#41;</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">21 &#40;28&#46;8&#37;&#41;</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1770307.png"
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          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Problems with venous catheter&#44; elastomeric pump or incomplete data&#46;</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&#46;</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&nbsp;\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 &#40;score&#41;&nbsp;\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> &#40;&#37;&#41;&nbsp;\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 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62 &#40;84&#46;9&#41;&nbsp;\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 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;13&#46;7&#41;&nbsp;\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 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#41;&nbsp;\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 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;86&#46;3&#41;&nbsp;\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 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;9&#46;6&#41;&nbsp;\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 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#46;1&#41;&nbsp;\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 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;80&#46;8&#41;&nbsp;\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&#44; few &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;17&#46;8&#41;&nbsp;\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&#44; many &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#41;&nbsp;\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 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;100&#41;&nbsp;\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 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;83&#46;6&#41;&nbsp;\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 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;9&#46;6&#41;&nbsp;\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 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;7&#41;&nbsp;\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 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\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 &#40;&#43;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Lattinen test at 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p>"
        ]
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      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"
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        "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&nbsp;\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 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&nbsp;\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 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;5&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;6&#46;8&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;7&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#46;1&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\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&#58; allergy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;6&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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