Case report
The value of hypotensive prediction index and dP/dtmax to predict and treat hypotension in a patient with a dilated cardiomyopathy
Valor del índice de predicción de la hipotensión y el dP/dtmax para predecir y tratar la hipotensión en un paciente con miocardiopatía dilatada
Read
3
Timeswas read the article
0
Total PDF
3
Total HTML
Share statistics
array:24 [ "pii" => "S2341192920301554" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.02.004" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1137" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:563-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935620300748" "issn" => "00349356" "doi" => "10.1016/j.redar.2020.02.011" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1137" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2020;67:563-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Valor del índice de predicción de la hipotensión y el dP/dt<span class="elsevierStyleInf">max</span> para predecir y tratar la hipotensión en un paciente con miocardiopatía dilatada" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "563" "paginaFinal" => "567" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The value of hypotensive prediction index and dP/dt<span class="elsevierStyleInf">max</span> to predict and treat hypotension in a patient with a dilated cardiomyopathy" ] ] "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" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1116 "Ancho" => 1508 "Tamanyo" => 150218 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pantalla secundaria después de la administración del propofol.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">dP/dt: dP/dt<span class="elsevierStyleInf">max</span>; Ea<span class="elsevierStyleInf">dyn</span>: elastancia arterial; FP: frecuencia de pulso; GC: gasto cardiaco; PAM: presión arterial media; P(↓BP): índice de predicción de la hipotensión; RVS: resistencias vasculares sistémicas; VS: volumen sistólico; VVS: volumen de variación sistólico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Solares, F. Barredo, M.I. Monge García" "autores" => array:3 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Solares" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Barredo" ] 2 => array:2 [ "nombre" => "M.I." "apellidos" => "Monge García" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192920301554" "doi" => "10.1016/j.redare.2020.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301554?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620300748?idApp=UINPBA00004N" "url" => "/00349356/0000006700000010/v1_202011270856/S0034935620300748/v1_202011270856/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192920301645" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.04.006" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1161" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:568-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image of the month</span>" "titulo" => "Jugular venous catheter lodged in intercostal vein" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "568" "paginaFinal" => "569" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Catéter venoso de acceso yugular alojado en vena intercostal" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 872 "Ancho" => 750 "Tamanyo" => 124356 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Non-contrast-enhanced chest computed tomography. Multi-plane reconstruction of soft tissue, vascular technique, axial view with 30º anti-clockwise rotation, showing the path of the catheter over the aortic arch.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. López-Millán, C. Coca Gamito" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "López-Millán" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Coca Gamito" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493562030133X" "doi" => "10.1016/j.redar.2020.04.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493562030133X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301645?idApp=UINPBA00004N" "url" => "/23411929/0000006700000010/v1_202012131408/S2341192920301645/v1_202012131408/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192920300937" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.01.012" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1115" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2020;67:559-62" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Cardiac arrest after a cerebral gas embolism. Case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "559" "paginaFinal" => "562" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paro cardiaco tras embolia gaseosa cerebral. Caso clínico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1032 "Ancho" => 855 "Tamanyo" => 63231 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT-scan of the brain showing no cerebral gas embolism after an HBOT.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Ferreira, E. Francisco, S. Ferraz, A. Panzina, A.I. Pereira, R. Teixeira" "autores" => array:6 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Ferreira" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Francisco" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Ferraz" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Panzina" ] 4 => array:2 [ "nombre" => "A.I." "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Teixeira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620300244" "doi" => "10.1016/j.redar.2020.01.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620300244?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920300937?idApp=UINPBA00004N" "url" => "/23411929/0000006700000010/v1_202012131408/S2341192920300937/v1_202012131408/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "The value of hypotensive prediction index and dP/dt<span class="elsevierStyleInf">max</span> to predict and treat hypotension in a patient with a dilated cardiomyopathy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "563" "paginaFinal" => "567" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Solares, F. Barredo, M.I. Monge García" "autores" => array:3 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Solares" "email" => array:1 [ 0 => "gumersindojavier.solares@scsalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Barredo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.I." "apellidos" => "Monge García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Área de Anestesiología y Reanimación, Servicio de Anestesia, Hospital Universitario Marqués de Valdecílla, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Área de Cuidados Intensivos, Departamento de Cuidados Críticos, Hospital SAS de Jerez, Jerez de la Frontera, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valor del índice de predicción de la hipotensión y el dP/dt<span class="elsevierStyleInf">max</span> para predecir y tratar la hipotensión en un paciente con miocardiopatía dilatada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1116 "Ancho" => 1508 "Tamanyo" => 150218 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Secondary screen after propofol administration.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">dP/dt: dP/dt<span class="elsevierStyleInf">max</span>; Ea<span class="elsevierStyleInf">dyn</span>: arterial elastance; FP: pulse rate; GC: cardiac output; PAM: mean arterial pressure; P (↓ BP): hypotension prediction index; RVSI: systemic vascular resistance index; RVS: systemic vascular resistance; VS: stroke volume; VVS: systolic variation volume.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Dilated cardiomyopathy (DCM) is a rare disease characterized by progressive ventricular dilation and significant loss of cardiac contractility, and is associated with a high rate of intraoperative morbidity due to the appearance of hypotension and/or malignant arrhythmias. Anaesthesia management in these patients is usually challenging for the anaesthesiologist, and is based on maintaining normovolaemia, avoiding drugs that significantly affect myocardial function, preventing increased cardiac afterload, and appropriate cardiovascular monitoring.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The hypotension prediction index (HPI) is a recently developed tool that indicates the likelihood of a patient developing a hypotensive episode, defined as a drop in mean arterial pressure (MAP) below 65 mmHg.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This parameter is based on the multivariate analysis of the different characteristics of the mean arterial pressure (MAP) waveform that were selected by a mathematical model developed using machine learning.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this case report, we describe the appearance of several episodes of arterial hypotension immediately after anaesthesia induction in a patient with mild/moderate DCM, and how this new tool, the HPI, facilitated early detection of the event and helped us choose the best therapeutic approach.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 54 year-old man, obese (99 kg) and 171 cm in height, was admitted to our hospital for resection of a hepatic cholangiocarcinoma. The patient presented high blood pressure and had been diagnosed with mild to moderate DCM. Echocardiography showed mild ventricular dilatation, a moderate degree of mitral regurgitation, and a left ventricular ejection fraction of 50%. The patient was under treatment with valsartan, hydrochlorothiazide, and carvedilol. Preoperative serum creatinine (Cr) was 0.79 mg dl<span class="elsevierStyleSup">↓</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and troponin (Tpn) was 0.01 ng/ml. After arriving in the operating room, the radial artery was canalized under local anaesthesia with lidocaine 20 mg. The arterial line was connected to an AP transducer (Acumen IQ sensor®, Edwards Lifescience, Irvine, CA, USA), which was in turn connected to a HemoSphere monitor (Edwards Lifescience, Irvine, CA, USA). Before induction, BP was 121/60 (MAP 83) mmHg, cardiac index (CI) was 2.66 l/mm<span class="elsevierStyleSup">1</span> m<span class="elsevierStyleSup">2</span>, the systemic vascular resistance index (SVRI, calculated on the basis of an estimated CVP of 0 mmHg) was 2,356 dyn/s/cm<span class="elsevierStyleSup">5</span>/m<span class="elsevierStyleSup">2</span>, arterial dynamic elastance (Ea<span class="elsevierStyleInf">dyn</span>) was 0.95, and dP/dt<span class="elsevierStyleInf">max</span> was 670 mmHg/s. Anaesthesia was induced with 15 µg of fentanyl and propofol up to 2 mg/kg administered for 30 s. Immediately after induction, AP fell to 70/45 (MAP 54) mmHg, while the HPI value increased from 12 to 100 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The secondary screen showed a stroke volume variation (SVV) of 11%, a dP/dt<span class="elsevierStyleInf">max</span> of 294 mmHg/s, and an Ea<span class="elsevierStyleInf">dyn</span> of 1.0 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). CI fell to 1.62 l/min<span class="elsevierStyleSup">1</span>m<span class="elsevierStyleSup">2</span>, while the SVRI remained at 2,406 dyn/s/cm<span class="elsevierStyleSup">5</span>/m<span class="elsevierStyleSup">2</span>. Since a central venous catheter (CVC) had not yet been placed, a 15 mg ephedrine bolus was administered to correct AP, which increased to 129/76 (MAP 95) mmHg, with SVRI increasing to 3,556 dyn/s/cm<span class="elsevierStyleSup">5</span>/m<span class="elsevierStyleSup">2</span> and dP/dt<span class="elsevierStyleInf">max</span> to 603 mmHg/s; however, CI only reached 1.9 l/min/m<span class="elsevierStyleSup">2</span>. After tracheal intubation with 1.0 mg kg of rocuronium, anaesthesia was maintained with desflurane at 0.8 MAC. During CVC placement, another 5 hypotensive episodes occurred in which systolic blood pressure (SBP) fell below 100 mmHg; these were predicted by HPI > 85. MAP fell below 65 mmHg in only 1 episode. The first 4 episodes were of short duration and AP was adequately controlled with ephedrine boluses (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The last episode lasted almost 5 min and occurred at the end of CVC placement. In this case, MAP fell to 64 mmHg and the secondary screen again showed low dP/d<span class="elsevierStyleInf">max</span> values of 443 mmHg/s, while Ea<span class="elsevierStyleInf">dyn</span> was 1.0 and SVV was 9%. An infusion of dobutamine 4 µg/kg/min was started and then tapered to 2 µg/kg/min. This restored all the cardiovascular parameters to pre-induction values. Dobutamine was maintained for the duration of the intervention, until the patient was finally extubated. Once awake in the operating room and without any inotropic support, the AP remained stable at 112/59 (MAP 77) mmHg, CI at 2.40 l/min/m<span class="elsevierStyleSup">2</span>, SVRI at 2,549 dyn/s/cm<span class="elsevierStyleSup">5</span>/m<span class="elsevierStyleSup">2</span>, Ea<span class="elsevierStyleInf">dyn</span> at 1.0, and dP/dt<span class="elsevierStyleInf">max</span> at 620 mmHg/s. At the end of the procedure, haemodynamic data was downloaded from the monitor and analysed off-line. The total time of anaesthesia and the accumulated time of MAP < 65 mmHg was 115 min, 2 min and 40 s (2.6%), respectively. Serum Cr levels at 24 postoperative hours were 0.73 mg/dl with a Tpn of 0.0 ng/ml.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The choice of monitoring strategy for the perioperative management of patients with mild/moderate DCM can be controversial. Some experts recommend using a pulmonary artery catheter (PAC) to monitor these patients with compromised cardiac function.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, this type of monitoring is not without risks: catheter placement can induce malignant arrhythmias,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and has been associated with increased mortality in patients with less severe diseases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For this reason, the use of this type of catheter should be restricted to critically ill patients and specific high-risk interventions.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In addition, it does not measure left ventricular contractility, and this could limit its use in patients with heart disease with left heart involvement.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The HPI is obtained from the analysis of the AP waveform, and is based on a proprietary algorithm.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The HPI value is displayed on a monitor as a number ranging 1 to 100; the first warning of hypotensive episode occurs when the HPI value is greater than 85. This algorithm estimates different haemodynamic parameters, such as cardiac output, stroke volume, heart rate, dP/dt<span class="elsevierStyleInf">max</span>, Ea<span class="elsevierStyleInf">dyn</span>, and SVRI.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> HPI technology includes a secondary screen on the monitor that shows when the HPI value exceeds 85. This screen simultaneously shows SVV, Ea<span class="elsevierStyleInf">dyn</span> and dP/dt<span class="elsevierStyleInf">max</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). SVV is a sensitive marker of cardiac preload dependence, and is known to be superior to static haemodynamic parameters in indicating fluid responsiveness. Values above 13%-15% indicate that the heart will respond to volume expansion therapy and values ≤ 10% indicate that it will not. Ea<span class="elsevierStyleInf">dyn</span> is the ratio between pulse pressure variation (PPV) and SVV, and has been postponed as a functional assessment of arterial load.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This index has been shown to predict AP response after volume expansion in hypotensive and preload dependent patients. Ea<span class="elsevierStyleInf">dyn</span> > 1 is usually associated with significant increases in AP when cardiac output increases with fluid overload. In contrast, Ea<span class="elsevierStyleInf">dyn</span> < 1 normally corresponds to patients whose AP does not change, despite significant increases in cardiac output.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In a recent experimental study under different load and contractility conditions, the value of peripheral dP/dt<span class="elsevierStyleInf">max</span> obtained from a radial or femoral catheter was compared with that of left ventricular end systolic elastance (Ees), a measure of cardiac contractility independent of preload and afterload conditions.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In this study, peripheral dP/dt<span class="elsevierStyleInf">max</span> allowed good follow-up of contractility changes when compared with Ees values.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Furthermore, dP/dt<span class="elsevierStyleInf">max</span> obtained from a peripheral artery has the advantage of measuring cardiac contractility using easily accessible monitoring techniques.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore, the secondary screen gives information that can help pinpoint the underlying mechanism of hypotension. Davies et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> have recently shown that the HPI is superior to the haemodynamic parameters commonly used to predict intraoperative hypotension at 15 min. We have also found that HPI > 85 predicted in less than 5 min the treatment of spinal anaesthesia-induced hypotension, although in our case we defined hypotension as SAP < 100 mmH.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, like any other AP-derived parameter, the HPI depends on the quality of the waveform; therefore, artifacts such as the height at which the transducer is placed or under- or over-damping phenomena can affect the reliability of the HPI values and the prediction of arterial hypotension.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The frequency of hypotension during anaesthesia induction can be as high as 1 in every 3 cases, and is primarily the result of the negative side effects of anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This hypotension must be corrected promptly; if it persists, it can lead to cardiovascular collapse and/or postoperative organ damage.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> We chose propofol for induction and desflurane for anaesthesia maintenance because these drugs inhibit vasoconstrictor sympathetic activity by inducing a slight arterial vasodilation that has little depressant effect on cardiac contractility.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, the use of either of these drugs could explain the significant drop in BP and dP/dt<span class="elsevierStyleInf">max</span> observed. Meanwhile, the preload and afterload dependence indices, the SVV, SVRI and Ea<span class="elsevierStyleInf">dyn</span> remained in normal ranges or similar to pre-induction values. These data suggest that haemodynamic instability was the result of an acute loss of myocardial contractility rather than a sympathetic blockade. There are different possible explanations for this response. Mulier et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> have suggested that propofol reduces AP primarily because of its negative inotropic properties, which could have occurred in our case. The patient was under treatment with beta-blockers, which could have potentiated the depressant effects of these drugs on the myocardium. On the other hand, contractility in patients with DCM, even to a mild/moderate degree, is more sensitive to the adverse effects of anaesthetic drugs.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The utility of the HPI in treating hypotension proactively remains unclear.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We used the HPI to manage hypotension in two ways: during propofol- and desflurane-induced hypotensive episodes it was used as a diagnostic tool to clarify the underlying cause; and high HPI values alerted us of the need to take therapeutic measures to reduce the severity and duration of this condition, thereby avoiding postoperative organ damage. Estimates suggests that a cumulative period of at least 4-5 min with MAP < 65 mmHg is needed, even before the surgical incision, for the development of postoperative kidney injury.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In our case, the total accumulated time with MAP < 65 mmHg was below this limit, and the levels of postoperative organ damage, renal and/or cardiac markers were found to be within normal ranges.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In summary, we consider that HPI technology can be a valid alternative for the intraoperative management of patients with mild/moderate DCM. We recommend using HPI > 85 as a warning for intervention in the event of a predicted episode of hypotension, and using the secondary screen to determine the cause and guide the treatment. We also believe that peripheral dP/dt<span class="elsevierStyleInf">max</span> can be a useful tool for continuous monitoring of cardiac systolic function.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical responsibilities</span><p id="par0055" class="elsevierStylePara elsevierViewall">This case is published with the written consent of the patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This case has not received specific funding from the public, commercial or non-profit sectors.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Authorship</span><p id="par0065" class="elsevierStylePara elsevierViewall">Francisco Barredo administered anaesthesia, collected the data, and reviewed the final version of the manuscript. Gumersindo Solares and Ignacio Monge García wrote the article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">Gumersindo Solares and Ignacio Monge are medical consultants and give lectures at different institutions funded by Edwards Lifesciences Ltd.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1432413" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1307567" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1432412" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1307566" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical responsibilities" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Authorship" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-02-17" "fechaAceptado" => "2020-02-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1307567" "palabras" => array:4 [ 0 => "Dilated cardiomyopathy" 1 => "Hypotension" 2 => "Hypotension Prediction Index" 3 => "dP/dt<span class="elsevierStyleInf">max</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1307566" "palabras" => array:4 [ 0 => "Miocardiopatía dilatada" 1 => "Hipotensión" 2 => "Índice de Predicción de la Hipotensión" 3 => "dP/dt<span class="elsevierStyleInf">max</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The Hypotension Prediction Index (HPi) is a new parameter, recently developed to predict the risk of a patient developing a hypotensive event, defined as a fall in mean arterial pressure below 65 mmHg. The calculated HPi value is displayed on a monitor as a number ranging from 1 to 100; where the first warning for the appearance of such event occurs when HPi values exceed 85. A secondary screen shows the stroke volume variation value; the dP/dt max; and the dynamic arterial elastance. We described a patient with a mild to moderately dilated cardiomyopathy that presented several episodes of hypotension after induction of anaesthesia and how by using HPi technology, these were successfully solved. We recommend the use of a HPi value >85 as a warning of intervention, and to use the secondary screen to determine the cause and the treatment. We consider that HPi technology may be a valid alternative for the anaesthetic management of patients with a dilated cardiomyopathy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El Índice de Predicción de la Hipotensión (iPH) es un nuevo parámetro diseñado para predecir el riesgo de aparición de un evento hipotensor, definido como una caída de la presión arterial media por debajo de 65 mmHg. El valor numérico del iPH se muestra en un monitor como un digito que va de 1 a 100, donde la primera alarma de aparición de la hipotensión ocurre cuando dicho valor excede de 85. Una pantalla secundaria muestra el volumen de variación sistólica; el dP/dt<span class="elsevierStyleInf">max</span> ; y la elastancia dinámica arterial. Describimos un caso de un paciente con una miocardiopatía dilatada moderada que presento varios episodios de hipotensión tras la inducción anestésica, y cómo usando la tecnología iPH éstos fueron resueltos. Recomendamos usar el valor de iPH > 85 como alarma de intervención, y utilizar la pantalla secundaria para determinar su causa y adecuar su tratamiento. Creemos que la tecnología iHP puede ser una alternativa válida en el manejo anestésico de los pacientes con una miocardiopatía dilatada.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Solares G, Barredo F, Monge García MI. Valor del índice de predicción de la hipotensión y el dP/dt<span class="elsevierStyleInf">max</span> para predecir y tratar la hipotensión en un paciente con miocardiopatía dilatada. Rev Esp Anestesiol Reanim. 2020;67:563–567.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1116 "Ancho" => 1508 "Tamanyo" => 150218 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Secondary screen after propofol administration.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">dP/dt: dP/dt<span class="elsevierStyleInf">max</span>; Ea<span class="elsevierStyleInf">dyn</span>: arterial elastance; FP: pulse rate; GC: cardiac output; PAM: mean arterial pressure; P (↓ BP): hypotension prediction index; RVSI: systemic vascular resistance index; RVS: systemic vascular resistance; VS: stroke volume; VVS: systolic variation volume.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1196 "Ancho" => 2341 "Tamanyo" => 224849 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Changes in hypotension predictor index values, mean arterial pressure (MAP), systolic blood pressure (SBP) and cardiac index (CI) before anaesthesia induction and after administration of the second dose of dopamine.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">D<span class="elsevierStyleInf">1</span>: dobutamine 4 µg/kg/min; D<span class="elsevierStyleInf">2</span>: dobutamine 2 µg/kg/min; E<span class="elsevierStyleInf">1</span>: first 15 mg bolus of ephedrine; E<span class="elsevierStyleInf">2,3,4</span>: consecutive 15 mg ephedrine boluses; P: propofol.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amiodarone, phaechromocitoma and cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Solares" 1 => "F. Ramos" 2 => "R. Martin-Duran" 3 => "J.M. San Jose" 4 => "M. Buitrago" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.1986.tb13178.x" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia." "fecha" => "1986" "volumen" => "41" "paginaInicial" => "186" "paginaFinal" => "190" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3953991" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Machine-learning algorithm to predict hypotension based on high-fidelity arterial pressure waveform analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Hatib" 1 => "Z. Jian" 2 => "S. Buddi" 3 => "C Lee" 4 => "J Settels" 5 => "K Sibert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0000000000002300" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology." "fecha" => "2018" "volumen" => "129" "paginaInicial" => "663" "paginaFinal" => "674" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29894315" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severity of illness and risk of death associated with pulmonary artery catheter use" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.R. Chittock" 1 => "V.K. Dhingra" 2 => "J.J. Ronco" 3 => "JA Russell" 4 => "DM Forrest" 5 => "M Tweeddale" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.ccm.0000119423.38610.65" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med." "fecha" => "2004" "volumen" => "32" "paginaInicial" => "911" "paginaFinal" => "915" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15071376" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ability of an arterial waveform analysis-derived hypotension prediction index future hypotensive events in surgical patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Davies" 1 => "S.T. Vistisen" 2 => "Z. Jian" 3 => "F. Hatib" 4 => "T.W.L. Sheeren" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000004121" "Revista" => array:5 [ "tituloSerie" => "Anesth Anal." "fecha" => "2019" "volumen" => "130" "paginaInicial" => "352" "paginaFinal" => "359" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dynamic arterial elastance to predict arterial pressure response to volume loading in preload-dependent patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Monge Garcia" 1 => "A. Gil Cano" 2 => "M. Gracia Romero" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Crit Care." "fecha" => "2011" "volumen" => "15" "paginaInicial" => "15" "paginaFinal" => "24" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Performance comparison of ventricular and arterial dp/dt<span class="elsevierStyleInf">max</span> for asses left ventricular systolic function during different experimental loading and contractile conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Monge Garcia" 1 => "Z. Jian" 2 => "J. Settles" 3 => "C Hunley" 4 => "M Cecconi" 5 => "F Hatib" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13054-018-2260-1" "Revista" => array:6 [ "tituloSerie" => "Crit Care." "fecha" => "2018" "volumen" => "22" "paginaInicial" => "325" "paginaFinal" => "337" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30486866" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of a new parameter the hypotension probability indicator to predict and treat hypotension during spinal anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Solares" 1 => "C. Garicano" 2 => "J. Rabanal" 3 => "L. Solano" 4 => "S. Paredes" 5 => "A. Solar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur J Anesthesiol." "fecha" => "2018" "volumen" => "35" "numero" => "S56" "paginaInicial" => "AP03" "paginaFinal" => "09" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Maheshwari" 1 => "A. Turan" 2 => "G. Mao" 3 => "D Yang" 4 => "AK Niazi" 5 => "D Agarwal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/anae.14416" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia." "fecha" => "2018" "volumen" => "73" "paginaInicial" => "1223" "paginaFinal" => "1228" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30144029" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmacology & physiology in anesthetic practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Stoelting" 1 => "S. Hillier" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "4<span class="elsevierStyleSup">th</span> ed" "fecha" => "2006" "editorial" => "Lippincott Williams & Wilkins" "editorialLocalizacion" => "Philadelphia" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiodynamic effects of propofol in comparison with thiopental: assesment with a transesophageal echocardiographic approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.P. Mulier" 1 => "P.F. Wouters" 2 => "H. Van Aken" 3 => "G. Vermaut" 4 => "E. Vandermeersch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/00000539-199101000-00006" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg." "fecha" => "1991" "volumen" => "72" "paginaInicial" => "28" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1984373" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006700000010/v1_202012131408/S2341192920301554/v1_202012131408/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006700000010/v1_202012131408/S2341192920301554/v1_202012131408/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301554?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 February | 1 | 0 | 1 |
| 2022 June | 1 | 0 | 1 |
| 2021 May | 1 | 0 | 1 |
