Brief Report
Pulsed-Doppler evaluation of renal perfusion during pulsatile extracorporeal circulation. A pilot study
Evaluación del flujo renal con Doppler pulsado durante la circulación extracorpórea pulsátil. Estudio piloto
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A pilot study" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1760 "Ancho" => 2545 "Tamanyo" => 159939 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Box plot del índice de resistencia medido según la modalidad ecográfica.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A: amplitud; CEC: circulación extracorpórea; F: flujo base.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Carretero de la Encarnación, E. Mateo Rodríguez, C.S. 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A pilot study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "380" "paginaFinal" => "384" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B. Carretero de la Encarnación, E. Mateo Rodríguez, C.S. Romero García, M.A. Revert Ros" "autores" => array:4 [ 0 => array:3 [ "nombre" => "B." "apellidos" => "Carretero de la Encarnación" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "E." "apellidos" => "Mateo Rodríguez" "email" => array:1 [ 0 => "evamateo63@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "C.S." "apellidos" => "Romero García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M.A." "apellidos" => "Revert Ros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital General Universitario de Albacete, Albacete, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital General Universitari de València, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Hospital General Universitari de València, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación del flujo renal con Doppler pulsado durante la circulación extracorpórea pulsátil. Estudio piloto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 435 "Ancho" => 2000 "Tamanyo" => 121296 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A) Renal Doppler T1 (pre-ECC). (B) Renal Doppler T2 ECC A50F50. (C) Renal Doppler T4 A30F30.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A: amplitude; ECC: extracorporeal circulation; F: base flow.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Approximately 2 million cardiac surgeries are performed each year, and acute renal failure is the major risk factor associated with mortality, longer hospital stay, and higher costs. The development of extracorporeal circulation (ECC) and technological advances over the past 30 years have enabled clinicians to deliver high amplitude intermittent flow using pulsatile pumps. In theory, pulsed flow mimics the normal haemodynamic state. For this reason, several researchers have suggested that pulsatile flow in ECC is superior to non-pulsatile flow,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1–8</span></a> while others find no differences between these techniques.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9–12</span></a> Intrarenal arterial waveforms observed on Doppler ultrasound have been widely used to evaluate renal dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13–15</span></a> The aim of this study is to describe the changes in renal flow waveforms caused by modifying the characteristics of pulsatile flow (amplitude and base flow) during pulsatile ECC.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0010" class="elsevierStylePara elsevierViewall">Data were collected from 10 patients who underwent on-pump cardiac surgery. The study was approved by the Ethics Committee. Patients aged under 18 years and those with a history of glomerular filtration rate of less than 60<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> determined using the corrected Cockcroft-Gault were excluded. Demographic variables, comorbidity, characteristics of the ECC, and postoperative renal function were collected. Left-sided, subdiaphragmatic kidney ultrasound (Phillips HD11 ultrasound system<span class="elsevierStyleSup">®</span>, Bothell, WA, USA) was performed with the patient in the supine position (below the surgical drapes, without interrupting surgery), and pulsed Doppler views of intrarenal arteries of the left kidney, using 3 representative proximal segmental arteries (located with colour Doppler), were viewed and recorded. The peak systolic velocity (PSV) and the minimum diastolic velocity (MDV) were determined, together with the resistance index (RI), which was defined as RI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span> (PSV<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>MDV)/PSV, and acceleration time (time to PSV, in milliseconds) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). All values were measured at least 3 times for each segmental artery and averaged to obtain the mean value. All measurements were made by a trained researcher who was blinded to the subjects’ clinical data. PSV, MDV, RI and acceleration time were measured at the following time points: pre-ECC T1: before the surgical incision, after induction, with the patient anaesthetised, T2 ECC: standard pulsatile ECC with base flow 50%, amplitude 50% and 60<span class="elsevierStyleHsp" style=""></span>bpm; T3 A60: pulsatile ECC with base flow 50%, amplitude 60% and 60<span class="elsevierStyleHsp" style=""></span>bpm; T4 F30: pulsatile ECC with base flow 30%, amplitude 50% and 60<span class="elsevierStyleHsp" style=""></span>bpm; T5 A30F30: pulsatile ECC with base flow 30%, amplitude 30% and 60<span class="elsevierStyleHsp" style=""></span>bpm; and T6 24<span class="elsevierStyleHsp" style=""></span>h, with the patient extubated, 24<span class="elsevierStyleHsp" style=""></span>h after the end of surgery. Measurements were taken during ECC by asking the perfusionist to start pulsatile perfusion and maintain it for 5<span class="elsevierStyleHsp" style=""></span>min. Pulsatile ECC was delivered using a Stockert S5<span class="elsevierStyleSup">®</span> roller pump (SorinGroup, Munich, Germany) that permits pulsatile flow (<a class="elsevierStyleCrossRef" href="#sec0035">Appendix A</a>). The statistical analysis was performed on R. After a descriptive analysis of the data, normality was tested with the Saphiro–Wilk test. Normally distributed data are expressed as mean and standard deviation, while non-normal data are expressed as median and interquartile range. The Wilcoxon signed-rank test was used to find significant differences between the variables of interest, RI and acceleration time, obtained during the renal ultrasound. In addition to the frequentist analysis, a graphic diagnosis was made using R's <span class="elsevierStyleItalic">ggplot2 library</span>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">The descriptive analysis of the data shows that the mean age of the series was 67 years (SD 10) with a mean body mass index of 28 (SD 4). Seven patients were men, 80% presented arterial hypertension, 60% presented type 2 diabetes mellitus, and 60% dyslipidaemia. Mean Euroscore II score was 2.7 (SD 1.8). Mean time on pump was 134<span class="elsevierStyleHsp" style=""></span>min (SD 41<span class="elsevierStyleHsp" style=""></span>min), and mean duration of aortic clamping was 102<span class="elsevierStyleHsp" style=""></span>min (SD 40<span class="elsevierStyleHsp" style=""></span>min). The median minimum temperature reached was 33<span class="elsevierStyleHsp" style=""></span>°C (IQR 33.34). Mean arterial pressure during ECC was 70<span class="elsevierStyleHsp" style=""></span>mmHg (SD 7<span class="elsevierStyleHsp" style=""></span>mmHg) and 70<span class="elsevierStyleHsp" style=""></span>mmHg (8<span class="elsevierStyleHsp" style=""></span>mmHg) in the ICU. Mean urine output at 24<span class="elsevierStyleHsp" style=""></span>h was 2360<span class="elsevierStyleHsp" style=""></span>ml (940<span class="elsevierStyleHsp" style=""></span>ml). Four patients were given diuretics (furosemide 10 or 20<span class="elsevierStyleHsp" style=""></span>mg) and 7 were given nephrotoxic antibiotics (vancomycin). Eight patients required vasoactive drugs, predominantly nitroglycerin (30%).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The results of the comparative analysis are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the renal pulsed Doppler waveforms observed at T1 pre-ECC, T2 ECC A50F50 and T5 A30F30. Significant differences were observed between the T1 pre-ECC ultrasound and the values obtained at T2 A50F50 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013), T3 A60F50 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003) and T4 A5030 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013). At T5 A30F30, no significant differences were found in comparison with the previous ultrasound (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.125): in this modality, the RI was closer to the pre-ECC value (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pulsatile ECC with lower amplitude and base flow gives a renal ultrasound image that is more similar to pre-ECC morphology.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This is the first time the effect of changes in amplitude or base flow on the renal artery waveform using pulsed Doppler ultrasound have been described. Intrarenal arterial waveforms observed on Doppler ultrasound are widely used to evaluate renal dysfunction. The RI correlates with renal vascular resistance, the filtration rate, and the effective renal plasma flow.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13–15</span></a> It also establishes the severity of tubular necrosis and evaluates renal functional recovery, since reduced RI precedes a reduction in plasma urea and creatinine levels by 24–48<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> The normal acceleration time is <70<span class="elsevierStyleHsp" style=""></span>ms. Longer acceleration time is indicative of renal hypoperfusion. In our patients, the average pre-ECC acceleration time was higher than normal ranges. Performing the pre-ECC (T1) ultrasound with the patient under general anaesthesia before the surgical incision, the patient's comorbidity (arterial hypertension and diabetes mellitus), and the abnormal renal flow during ECC could explain this finding.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The lack pulsatile flow settings could have biased the results of both studies that support the use of this technique to improve renal perfusion during ECC<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4–8</span></a> and those that find no differences with respect to continuous flow.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9–11</span></a> Studies investigating changes in amplitude and base flow (or other characteristics, such as rate) in pulsatile ECC in larger patient series could show the potential benefits of different settings on perioperative renal function. Elevated postoperative RI could show whether a particular type of ECC produces more acute renal failure than others. In our study, we show that the A30F30 mode is numerically equivalent to pre-CEC ultrasound data; however, the implications of this are unclear, since there are no studies that correlate postoperative clinical outcomes with the presence of postoperative complications. Furthermore, given the small number of patients, our results should be viewed with caution.</p><p id="par0040" class="elsevierStylePara elsevierViewall">This study is limited by its sample size which, being a pilot study, is low. Further studies in larger series are needed to confirm our preliminary results. We did not evaluate the incidence of haemolysis, ventilator-induced injury, or safety of ECC connections: further studies should take into account these side effects that increase bpm in pulsatile ECC.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Reducing amplitude and base flow during ECC gives an ultrasound image that is more similar to pre-ECC morphology. Further studies with a larger number of patients using these characteristics during pulsatile ECC could show the effect of this perfusion mode on the incidence of acute renal failure after cardiac surgery.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1065090" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1013105" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1065089" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1013104" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-28" "fechaAceptado" => "2018-01-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1013105" "palabras" => array:3 [ 0 => "Renal perfusion" 1 => "Pulsed wave Doppler" 2 => "Extracorporeal circulation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1013104" "palabras" => array:3 [ 0 => "Perfusión renal" 1 => "Eco-Doppler pulsado" 2 => "Circulación extracorpórea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute renal failure (ARF) after cardiac surgery is a risk factor associated with mortality and use of resources. Some studies have reported beneficial effects of pulsatile flow on cardiopulmonary bypass (CPB) on renal function. The aim of this study is to describe the echographic morphology of the renal arterial wave modifying the parameters of pulsatile CPB.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descriptive study was performed on 10 patients without previous AFR and undergoing cardiac surgery with CPB. Pre-, intra- and post-surgery renal ultrasound was performed. During pulsatile CPB, the amplitude and the baseline flow were modified. Recordings of pulsed Doppler in intrarenal arteries were obtained by measuring maximum systolic velocity, minimum diastolic velocity, resistance index (RI) and acceleration time (AT).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Statistical differences were found in ultrasounds pre-CPB between A50F50 modality (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013), A50F30 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013) and A60F50 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003). No statistically significance was found with A30F30 modality (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.125).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The decrease in the amplitude and the baseline flow of pulsatility during CPB shows a renal ultrasound morphology that is more similar to the physiological one. Subsequent studies using these characteristics during pulsatile CPB could thus show perfusion over the ARF that occurs after cardiac surgery.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El fracaso renal agudo (FRA) tras la cirugía cardiaca es un factor de riesgo asociado a mortalidad y consumo de recursos. Algunos estudios encuentran efectos beneficiosos del flujo pulsátil en la circulación extracorpórea (CEC) sobre la función renal. El objetivo de este estudio es describir la morfología ecográfica de la onda arterial renal modificando los parámetros de la CEC pulsátil.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo de 10 pacientes intervenidos mediante cirugía cardiaca con CEC sin FRA previo. Se realizó ecografía renal pre-, intra- y poscirugía. Durante la CEC pulsátil se modificaron la amplitud y el flujo base. Se obtuvieron registros de Doppler pulsado en arterias intrarrenales, se midió la velocidad máxima sistólica y la velocidad mínima diastólica, el índice de resistencia (IR) y el tiempo de aceleración (TAcel).</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La ecografía previa a la CEC (pre-CEC) muestra que hay diferencias significativas cuando se compara con los valores obtenidos en la modalidad A50F50 (p = 0,013), A50F30 (p = 0,013) y A60F50 (p = 0,003). No las hay para la modalidad A30F30 (p = 0,125).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La disminución de la amplitud y del flujo base de la pulsatilidad durante la CEC permite obtener una morfología ecográfica renal más parecida a la fisiológica. Estudios posteriores utilizando estas características durante la CEC pulsátil podrían mostrar la repercusión de este modo de perfusión sobre el FRA que se produce tras la cirugía cardiaca.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Carretero de la Encarnación B, Mateo Rodríguez E, Romero García CS, Revert Ros MA. Evaluación del flujo renal con Doppler pulsado durante la circulación extracorpórea pulsátil. Estudio piloto. Rev Esp Anestesiol Reanim. 2018;65:380–384.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="http://www.elsevier.es/redar">www.elsevier.es/redar</a></p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0060" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1226 "Ancho" => 1413 "Tamanyo" => 72516 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Measurement of the resistance index (RI) and acceleration time. Normal values: Acceleration time <70<span class="elsevierStyleHsp" style=""></span>ms, resistance index ≤0.7.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 435 "Ancho" => 2000 "Tamanyo" => 121296 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A) Renal Doppler T1 (pre-ECC). (B) Renal Doppler T2 ECC A50F50. (C) Renal Doppler T4 A30F30.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A: amplitude; ECC: extracorporeal circulation; F: base flow.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1740 "Ancho" => 2538 "Tamanyo" => 168250 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Box plot of the resistance index according to ultrasound modality.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A: amplitude; ECC: extracorporeal circulation; F: base flow.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ECC: extracorporeal circulation; RI: resistance index; MDV: minimum diastolic velocity; PSV: maximum systolic velocity.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Data shown as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation.</p>" "tablatextoimagen" => array:2 [ 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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PSV (cm/s) \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">MDV (cm/s) \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">RI \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">Acceleration time (ms) \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">Normal range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><70 \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">(T1) Pre-ECC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.62<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1816158.png" ] ] 1 => 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 " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pulsatile ECC</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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 " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amplitude \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Base flow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">T2 A50F50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.49<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">253<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11 \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">T3 A60F50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.43<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">260<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15 \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">T4 A50F30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.50<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 \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">T5 A30F30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">150<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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