Home-based intravenous analgesia with elastomeric pump as an outpatient procedure for pain control after anterior cruciate ligament repair | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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Villalba, J. Peñalver, P. Torner, M. Serra, J. Planell" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Villalba" "email" => array:1 [ 0 => "jvillalba@tauli.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Peñalver" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Torner" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Serra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Planell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Corporación Sanitaria Parc Taulí, Servicio de Cirugía Ortopédica y Traumatología, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Corporación Sanitària Parc Taulí, Servicio de Anestesiología, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Analgesia intravenosa domiciliaria mediante bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamento cruzado anterior" ] ] "textoCompleto" => "IntroductionAnterior cruciate ligament (ACL) surgery is a common procedure, particularly in arthroscopic treatment. Good postoperative pain control is very important for good rehabilitation and satisfactory final functional outcomes. Even so, more than 60% of patients who undergo this surgery experience moderate to severe pain with conventional oral analgesic regimens,<a class="elsevierStyleCrossRef" href="#bib0105">1</a> such as alternating paracetamol with nonsteroidal anti-inflammatory drugs, plus a rescue drug like tramadol.<a class="elsevierStyleCrossRefs" href="#bib0110">2,3</a>This operation is currently increasingly being undertaken in the form of day-case surgery.<a class="elsevierStyleCrossRefs" href="#bib0110">2,4</a> There are many studies that have demonstrated that outpatient ACL surgery is safe and effective, and with good pain control there is no increase in the need for rehospitalisation and/or complications.<a class="elsevierStyleCrossRefs" href="#bib0110">2,5</a>Most of the published articles present the circuits that these patients undergo when they receive nerve block analgesia by infusion on discharge.<a class="elsevierStyleCrossRefs" href="#bib0130">6,7</a>The Spanish Association of Major Ambulatory Surgery (Asociación Española de Cirugía Mayor Ambulatoria) (ASECMA) underwrite a decologue, which is the first consensus document endorsed by other medical and surgical societies, and indicate that a multidisciplinary, multimodal and individualised approach should be taken to pain.<a class="elsevierStyleCrossRef" href="#bib0120">4</a> The advent of elastomeric infusers, and drug infusion pumps have proved a major advance in the administration of all sorts of drugs for the treatment of postoperative pain. Maintenance of stable plasma levels have resulted in better pain control, improved efficacy and reduced side effects compared with the administration of bolus medication.<a class="elsevierStyleCrossRef" href="#bib0110">2</a>The objective of this study was to present the results of the pain control and complications protocol that we use in our centre, for patients who undergo arthroscopic ACL reconstruction as day cases in our department and receive postoperative pain control through a continuous intravenous infusion pump (elastomeric pumps).Material and methodsA retrospective study was undertaken of a consecutive series from 2009 to 2015, which included 309 patients who had undergone ACL ligamentoplasty with bone-tendon-bone (BTB) autologous plasty. The BTB allograft technique was employed for reconstruction of the ACL. The anaesthetic technique was chiefly by laryngeal mask (in 243 patients), only the initial 66 patients received spinal anaesthesia, and no locoregional block was used in any of the cases. All the patients received preoperative prophylaxis of 2g cefazolin perfused 20min before performing the tourniquet, which was routinely used. The femoral tunnel was prepared through the transtibial portal and the plasty was fixed to the tunnels by metal interference screws. Before closing the wound, haemostasis was performed plus infiltration of 20cc of 0.25% levobupivacaine through the wound and the portals. Staples were used for wound closure and no drains were placed in any case. A splinted pressure bandage was placed, which was removed after one week. Partial weight bearing with crutches was allowed on discharge.Since 2009, the great majority of arthroscopic ACL reconstructions have been performed as day cases.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the inclusion and exclusion criteria for major ambulatory surgery (MAS) for ACL repair in our centre.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>On arrival at the surgical outpatients department, an intravenous line was placed in the patient's non-dominant forearm, where the elastomeric pump was later attached. Approximately 20min before surgery, a nonsteroidal anti-inflammatory drug (dexketoprofen 50mg) and a corticosteroid (dexamethasone 4/8mg according to body weight) were administered intravenously, as preventive analgesia and as prophylaxis for nausea and vomiting, either induced by subsequent tramadol administration or the general anaesthetic itself.<a class="elsevierStyleCrossRefs" href="#bib0115">3,8</a>In all cases, the elastomeric pump was started in the postoperative care unit (POCU). After immediate anaesthetic recovery, the patients were transferred to the recovery room (RR), until they were in a condition to leave the hospital. The visual analogue scale (VAS) was used to assess pain levels, in the hospital (POCU and RR), and after the first 24–48–72h at home. The need for rescue medication, adverse effects and visits to the emergency department were also monitored.Elastomeric regimen 1 was used in 229 patients (74.1%) (400mg tramadol+250mg dexketoprofen+2.5mg haloperidol in 100cc physiological saline, for 48h) and elastomeric regimen 2 was used in 74 patients (23.9%) (400mg tramadol+12g metamizole+2.5mg haloperidol in 100cc physiological saline, for 48h. Short regimens of 24h were only used in 6 patients (1.9%), and at the beginning of the study. These were replaced by the current 48h regimens.Currently regimen 1 is routinely used, unless the patient suffers from an ulcerative condition, high blood pressure with 2 or more drugs, or an allergy to dexketoprofen, when regimen 2 is used, which contains metamizole. In addition to the pump, patients were advised, when they left the surgical outpatients department, to take paracetamol 1g every 6h orally, a gastric protector such as 20mg omeprazole every 24h orally and 10mg metoclopramide every 12h orally if they were to experience nausea and/or vomiting. Twenty-four hours following the procedure, the home care unit contacted the patient by telephone to enquire about their general condition and pain using the VAS, onset of side effects, need for rescue analgesia or possible visit to the emergency department. If the patient presented no associated problems, the unit visited the patient at home, where they were reassessed, and the elastomeric pump was removed. At that time, the patient followed an oral regimen of 1g paracetamol alternated with 600mg ibuprofen orally every 4h, plus 20mg omeprazole every 24h and 50mg tramadol, if required for pain. After 72h the patients were again contacted by telephone to assess their pain.A week after the operation, the patients were seen by their surgeon in the outpatient clinic, immobilisation was discontinued and rehabilitation started. During this first postoperative week, the patients were allowed to fully weight bear with the help of 2 crutches.ResultsOf the 309 patients operated, 264 were male and 45 female, with a mean age of 33 years (range from 18 to 55 years).<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the progression of the operated patients’ pain. In general, it can be observed that the majority of the patients had no, or mild pain during their hospital stay or at their home follow-up visits at 24, 48 and 72h after surgery. A reduction of the mean pain scores from 1.4 (SD=1.8) POCU, to 0.6 (SD=0.9) RR. At home, the levels dropped to 0.6 (SD=0.9) after 24h to 0.4 (SD=0.9) after 72h.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Of the 309 operated patients, 27 (8.7%) had to use analgesic medication at some point, with 50mg tramadol every 8h.The adverse effects recorded were the onset of postoperative nausea and vomiting, often intravenous analgesia-related, and drowsiness. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the frequency of adverse effect per sex. Few side effects were observed, with no differences between the sexes. Only 10 patients (3.2%) presented nausea after 24h and 2 (0.6%) after 48h. Four patients (1.3%) presented vomiting after 48h and none of the patients reported vomiting after 24h. Four patients (1.3%) reported drowsiness after 24h, which disappeared entirely after 48h.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In addition, 3 patients (1.0%) presented pruritis during the administration of intravenous analgesia at home.In terms of issues with the elastomeric device, it is worth highlighting that there was extravasation of the peripheral line in 4 (1.3%) patients, which was resolved by the home care unit. Finally, one patient burned the extension lead of their elastomeric pump with a cigarette, which had to be removed.The visits that the patients made to our hospital's emergency department during the first week were recorded, just before the visit to their surgeon in the outpatient clinic. Of the 309 patients, 22 had to attend the emergency departments with problems associated with the bandage. Of these patients, 12 had joint effusion, and of these 8 had effusion under tension. All the cases improved when the bandage was checked and the symptoms of all the cases of effusion under tension improved after evacuation by arthrocentesis. Only one case attended the emergency department with acute surgical wound infection, which was resolved with debridement and oral antibiotic therapy.DiscussionGood postoperative pain control is one of the keys to the success of MAS, as well as the patient's level of satisfaction. In MAS, postoperative pain, nausea and vomiting are still causes for delayed hospital discharge and readmission.<a class="elsevierStyleCrossRef" href="#bib0145">9</a>Therefore, in order to introduce more complex procedures into ambulatory surgery, it is essential to improve these factors, since oral analgesia has sometimes proved insufficient.Arthroscopic reconstructive ACL surgery is an optimal procedure to be undertaken in MAS programmes, if we can ensure good postoperative analgesia. The practice of multimodal analgesia is currently very widespread, using different analgesic techniques and thus minimising side effects.<a class="elsevierStyleCrossRefs" href="#bib0130">6,10–12</a>In our hospital, the ambulatory surgery department is an easily accessed separate building, for low- and medium-complexity procedures. We opted for continuous intravenous analgesia at home because we believe that it is better suited to our social environment and health structure.<a class="elsevierStyleCrossRef" href="#bib0110">2</a> There is currently a great tendency to place perineural and peri-incisional catheters. Reviewing the literature, we found that the rate of complications, especially nerve complications, is very low, but when they do occur there is no rapid resolution.<a class="elsevierStyleCrossRefs" href="#bib0135">7,13</a> Nerve blocks can also be helpful in managing postoperative pain in cruciate ligament reconstruction surgery,<a class="elsevierStyleCrossRef" href="#bib0170">14</a> although a motor block can be uncomfortable in terms of the patient's autonomy.This analgesic procedure enabled us to provide our patients good analgesia and wellbeing. Moreover, the patients felt safe with home visits from nursing staff to support them.<a class="elsevierStyleCrossRefs" href="#bib0105">1,2,4,5</a>There are studies that compare the results between surgery with admission and ambulatory surgery in surgical cruciate ligament repair, and note that there are no differences in terms of safety between the 2 techniques.<a class="elsevierStyleCrossRefs" href="#bib0170">14,15</a> These studies, however, are smaller series than ours and used multimodal anaesthesia systems with blocks and oral medication.<a class="elsevierStyleCrossRefs" href="#bib0180">16,17</a>Krywulak et al.<a class="elsevierStyleCrossRef" href="#bib0190">18</a> performed a randomised study on the degree of satisfaction among patients who were treated as outpatients and as inpatients, and noted that the patients who were not admitted to hospital had a higher degree of satisfaction. Although this was a study with very few cases, this also indicates that treatment without hospital admission is more satisfactory for patients. We confirm this in our study with far more case studies.Other studies describe good results with elastomeric pumps. Hoenecke et al.<a class="elsevierStyleCrossRef" href="#bib0195">19</a> reported less pain and less need for narcotics in patients operated for ACL who followed an ambulatory continuous infusion regimen of bupivacaine through the surgical wound via an elastomeric pump for the first 48h. López Alvarez et al.<a class="elsevierStyleCrossRef" href="#bib0200">20</a> performed continuous femoral nerve blocks using bupivacaine via an elastomeric pump for the first 24h, with good pain control. However, they described the incidence of surgical infection and motor block as complications.ConclusionsWe consider that the use of ambulatory elastomeric pumps after ACL reconstruction achieved good results on discharge, with few complications, compared to other procedures that use elastomeric pumps for direct infusion of the wound or for locoregional block. This procedure, however, requires the support of a home care unit, which some hospitals lack.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the research was carried out according to the ethical standards set by the responsible human experimentation committee, the World Medical Association and the Helsinki Declaration.Confidentiality of dataThe authors declare that they have followed the protocols of their centre of work regarding the publication of patient data.Right to privacy and informed consentThe authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document is held by the corresponding author.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres972049" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec942622" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres972048" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Discusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec942621" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-14" "fechaAceptado" => "2017-07-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec942622" "palabras" => array:3 [ 0 => "Anterior cruciate ligament" 1 => "Outpatient treatment" 2 => "Elastomeric pump" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec942621" "palabras" => array:3 [ 0 => "Ligamento cruzado anterior" 1 => "Tratamiento ambulatorio" 2 => "Bomba elastomérica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo follow up pain in the immediate postoperative period, using an elastomeric pump in anterior cruciate ligament surgery. Material and methods309 patients who had undergone anterior cruciate ligament repair with bone-tendon-bone allograft. Pain control was assessed with a visual analogue scale (VAS) during the immediate postoperative period, in the postoperative care unit, in the recovery room, and after the first 24–48–72h following home discharge. The need for rescue medication, adverse effects observed and emergency visits were also registered. Results309 patients were assessed (264 males, 45 females), mean age 33 (range: 18–55). Postoperative pain was mild in 44.7% of patients, and 38.5% were pain-free. At discharge, 41.1% of patients reported mild pain and 57% were pain-free. At home, mild to moderate levels of pain were maintained and over 97% of patients presented VAS values ≤3. Fewer than 3% had adverse effects, 8.7% had to use analgesic medication at some point. Pruritus occurred in less than 1% of patients receiving intravenous analgesia at home, and fewer than 2% had device-related complications. DiscussionThere is no consensus regarding the postoperative management of anterior cruciate ligament lesions, although most surgeons use multimode anaesthesia and different combinations of analgesics to reduce postoperative pain. ConclusionsThe use of an intravenous elastomeric pump as postoperative analgesia for anterior cruciate ligamentoplasty has yielded good results." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoHacer un seguimiento del dolor en el posoperatorio inmediato, mediante el uso de bomba elastomérica en la cirugía del ligamento cruzado anterior (LCA). Material y métodosTrescientos nueve pacientes intervenidos de ligamentoplastia del LCA mediante plastia autóloga de hueso-tendón-hueso. Durante el posoperatorio inmediato se realizó un seguimiento del dolor mediante escala visual analógica (EVA); tanto en la unidad de reanimación posoperatoria, como en la sala de adaptación al medio, y durante las primeras 24–48–72h en el domicilio. Registramos también la necesidad de medicación de rescate, efectos adversos observados y visitas al servicio de urgencias. ResultadosSe estudió a 309 pacientes (264 varones, 45 mujeres) con una edad media de 33 años (rango: 18–55). El 44,7% de los pacientes reportaron dolor posoperatorio inmediato leve y el 38,5% no tenía dolor. Al alta, el 41,1% de los pacientes reportaron dolor leve y el 57% no tenía dolor. En domicilio, se mantuvieron los valores de dolor leve/moderado, con más del 97% de los pacientes con valores EVA ≤3. Se registraron efectos adversos en menos del 3% de los casos. El 8,7% de los casos tuvo que hacer uso en algún momento de medicación analgésica. Menos del 1% presentó prurito mientras llevaban la analgesia intravenosa en el domicilio y menos del 2% presentó problemas relacionados con el dispositivo. DiscusiónActualmente, no hay consenso en cuanto al manejo posoperatorio de las lesiones del LCA, aunque la tendencia es el uso de anestesia multimodal y de sistemas para reducir el dolor posoperatorio. ConclusionesEl uso de bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamiento cruzado anterior ha reportado buenos resultados." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Discusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Villalba J, Peñalver J, Torner P, Serra M, Planell J. Analgesia intravenosa domiciliaria mediante bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamento cruzado anterior. Rev Esp Cir Ortop Traumatol. 2018;62:65–70." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inclusion criteria \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">Patients with ACL tear \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">Acceptance by the patient to be operated as an outpatient \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">Availability of an accessible telephone and a responsible adult for the first 24–48 postoperative hours \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">Patients classified as ASA I–II and, for some less aggressive procedures, as ASA III–IV, stables and with no episodes of decompensation in the past 3 months \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 informed consent \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"> \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">Exclusion criteria \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">Previous ACL plasty rupture \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">Patients with cognitive dysfunction \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">Drug-dependent or psychiatric patients \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">Patients with no family support at home \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">Patients living outside our hospital's catchment area \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">Patients with complications who required hospitalisation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644842.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Inclusion and exclusion criteria for ACL repair as MAS." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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 " colspan="14" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pain in POCU and in RR</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VAS \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">0 \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">1 \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">2 \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">3 \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">4 \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">5 \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">6 \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">7 \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">8 \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">9 \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">10 \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="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \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">POCU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">119 (38.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (32.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (8.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (3.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (5.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (6.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (3.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">176 (57.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 (31.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (7.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644837.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="14" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pain at home</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VAS \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">0 \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">1 \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">2 \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">3 \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">4 \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">5 \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">6 \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">7 \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">8 \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">9 \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">10 \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="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \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">24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">156 (50.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">138 (44.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">48h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162 (52.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">135 (43.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">72h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">210 (68.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 (28.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644836.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Postoperative pain." ] ] 2 => 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:4 [ 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 " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nausea and vomiting after 24–48h</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">24h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \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">% \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">No. \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">% \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">No. \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">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nausea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644840.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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">48h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \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">% \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">No. \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">% \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">No. \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">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nausea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top" style="border-bottom: 2px solid black">Vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">1.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644839.png" ] ] 2 => 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="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Drowsiness 24–48h</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">24h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \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">% \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">No. \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">% \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">No. \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">% \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="left" valign="top" style="border-bottom: 2px solid black">Drowsiness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top" style="border-bottom: 2px solid black">1.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644841.png" ] ] 3 => 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">48h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \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">% \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">No. \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">% \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">No. \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">% \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">Drowsiness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1644838.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Adverse effects." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis coste-efectividad de la PCA postoperatoria frente a la infusión continua elastomérica de tramadol y metamizol" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.H. 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Original Article

Home-based intravenous analgesia with elastomeric pump as an outpatient procedure for pain control after anterior cruciate ligament repair

Analgesia intravenosa domiciliaria mediante bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamento cruzado anterior

J. Villalbaa,

Corresponding author

jvillalba@tauli.cat

Corresponding author.

, J. Peñalvera, P. Tornera, M. Serrab, J. Planellb

a Corporación Sanitaria Parc Taulí, Servicio de Cirugía Ortopédica y Traumatología, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain

b Corporación Sanitària Parc Taulí, Servicio de Anestesiología, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain

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            "entidad" => "Corporaci&#243;n Sanitaria Parc Taul&#237;&#44; Servicio de Cirug&#237;a Ortop&#233;dica y Traumatolog&#237;a&#44; Hospital de Sabadell&#44; Institut Universitari Parc Taul&#237;&#44; Universitat Aut&#242;noma de Barcelona&#44; Sabadell&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
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            "entidad" => "Corporaci&#243;n Sanit&#224;ria Parc Taul&#237;&#44; Servicio de Anestesiolog&#237;a&#44; Hospital de Sabadell&#44; Institut Universitari Parc Taul&#237;&#44; Universitat Aut&#242;noma de Barcelona&#44; Sabadell&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
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            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Analgesia intravenosa domiciliaria mediante bomba elastom&#233;rica como procedimiento ambulatorio de control del dolor en la reparaci&#243;n del ligamento cruzado anterior"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Anterior cruciate ligament &#40;ACL&#41; surgery is a common procedure&#44; particularly in arthroscopic treatment&#46; Good postoperative pain control is very important for good rehabilitation and satisfactory final functional outcomes&#46; Even so&#44; more than 60&#37; of patients who undergo this surgery experience moderate to severe pain with conventional oral analgesic regimens&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> such as alternating paracetamol with nonsteroidal anti-inflammatory drugs&#44; plus a rescue drug like tramadol&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This operation is currently increasingly being undertaken in the form of day-case surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;4</span></a> There are many studies that have demonstrated that outpatient ACL surgery is safe and effective&#44; and with good pain control there is no increase in the need for rehospitalisation and&#47;or complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Most of the published articles present the circuits that these patients undergo when they receive nerve block analgesia by infusion on discharge&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The Spanish Association of Major Ambulatory Surgery &#40;<span class="elsevierStyleItalic">Asociaci&#243;n Espa&#241;ola de Cirug&#237;a Mayor Ambulatoria</span>&#41; &#40;ASECMA&#41; underwrite a decologue&#44; which is the first consensus document endorsed by other medical and surgical societies&#44; and indicate that a multidisciplinary&#44; multimodal and individualised approach should be taken to pain&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> The advent of elastomeric infusers&#44; and drug infusion pumps have proved a major advance in the administration of all sorts of drugs for the treatment of postoperative pain&#46; Maintenance of stable plasma levels have resulted in better pain control&#44; improved efficacy and reduced side effects compared with the administration of bolus medication&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study was to present the results of the pain control and complications protocol that we use in our centre&#44; for patients who undergo arthroscopic ACL reconstruction as day cases in our department and receive postoperative pain control through a continuous intravenous infusion pump &#40;elastomeric pumps&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective study was undertaken of a consecutive series from 2009 to 2015&#44; which included 309 patients who had undergone ACL ligamentoplasty with bone-tendon-bone &#40;BTB&#41; autologous plasty&#46; The BTB allograft technique was employed for reconstruction of the ACL&#46; The anaesthetic technique was chiefly by laryngeal mask &#40;in 243 patients&#41;&#44; only the initial 66 patients received spinal anaesthesia&#44; and no locoregional block was used in any of the cases&#46; All the patients received preoperative prophylaxis of 2<span class="elsevierStyleHsp" style=""></span>g cefazolin perfused 20<span class="elsevierStyleHsp" style=""></span>min before performing the tourniquet&#44; which was routinely used&#46; The femoral tunnel was prepared through the transtibial portal and the plasty was fixed to the tunnels by metal interference screws&#46; Before closing the wound&#44; haemostasis was performed plus infiltration of 20<span class="elsevierStyleHsp" style=""></span>cc of 0&#46;25&#37; levobupivacaine through the wound and the portals&#46; Staples were used for wound closure and no drains were placed in any case&#46; A splinted pressure bandage was placed&#44; which was removed after one week&#46; Partial weight bearing with crutches was allowed on discharge&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Since 2009&#44; the great majority of arthroscopic ACL reconstructions have been performed as day cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the inclusion and exclusion criteria for major ambulatory surgery &#40;MAS&#41; for ACL repair in our centre&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">On arrival at the surgical outpatients department&#44; an intravenous line was placed in the patient&#39;s non-dominant forearm&#44; where the elastomeric pump was later attached&#46; Approximately 20<span class="elsevierStyleHsp" style=""></span>min before surgery&#44; a nonsteroidal anti-inflammatory drug &#40;dexketoprofen 50<span class="elsevierStyleHsp" style=""></span>mg&#41; and a corticosteroid &#40;dexamethasone 4&#47;8<span class="elsevierStyleHsp" style=""></span>mg according to body weight&#41; were administered intravenously&#44; as preventive analgesia and as prophylaxis for nausea and vomiting&#44; either induced by subsequent tramadol administration or the general anaesthetic itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In all cases&#44; the elastomeric pump was started in the postoperative care unit &#40;POCU&#41;&#46; After immediate anaesthetic recovery&#44; the patients were transferred to the recovery room &#40;RR&#41;&#44; until they were in a condition to leave the hospital&#46; The visual analogue scale &#40;VAS&#41; was used to assess pain levels&#44; in the hospital &#40;POCU and RR&#41;&#44; and after the first 24&#8211;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h at home&#46; The need for rescue medication&#44; adverse effects and visits to the emergency department were also monitored&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Elastomeric regimen 1 was used in 229 patients &#40;74&#46;1&#37;&#41; &#40;400<span class="elsevierStyleHsp" style=""></span>mg tramadol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>250<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>mg haloperidol in 100<span class="elsevierStyleHsp" style=""></span>cc physiological saline&#44; for 48<span class="elsevierStyleHsp" style=""></span>h&#41; and elastomeric regimen 2 was used in 74 patients &#40;23&#46;9&#37;&#41; &#40;400<span class="elsevierStyleHsp" style=""></span>mg tramadol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>g metamizole<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>mg haloperidol in 100<span class="elsevierStyleHsp" style=""></span>cc physiological saline&#44; for 48<span class="elsevierStyleHsp" style=""></span>h&#46; Short regimens of 24<span class="elsevierStyleHsp" style=""></span>h were only used in 6 patients &#40;1&#46;9&#37;&#41;&#44; and at the beginning of the study&#46; These were replaced by the current 48<span class="elsevierStyleHsp" style=""></span>h regimens&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Currently regimen 1 is routinely used&#44; unless the patient suffers from an ulcerative condition&#44; high blood pressure with 2 or more drugs&#44; or an allergy to dexketoprofen&#44; when regimen 2 is used&#44; which contains metamizole&#46; In addition to the pump&#44; patients were advised&#44; when they left the surgical outpatients department&#44; to take paracetamol 1<span class="elsevierStyleHsp" style=""></span>g every 6<span class="elsevierStyleHsp" style=""></span>h orally&#44; a gastric protector such as 20<span class="elsevierStyleHsp" style=""></span>mg omeprazole every 24<span class="elsevierStyleHsp" style=""></span>h orally and 10<span class="elsevierStyleHsp" style=""></span>mg metoclopramide every 12<span class="elsevierStyleHsp" style=""></span>h orally if they were to experience nausea and&#47;or vomiting&#46; Twenty-four hours following the procedure&#44; the home care unit contacted the patient by telephone to enquire about their general condition and pain using the VAS&#44; onset of side effects&#44; need for rescue analgesia or possible visit to the emergency department&#46; If the patient presented no associated problems&#44; the unit visited the patient at home&#44; where they were reassessed&#44; and the elastomeric pump was removed&#46; At that time&#44; the patient followed an oral regimen of 1<span class="elsevierStyleHsp" style=""></span>g paracetamol alternated with 600<span class="elsevierStyleHsp" style=""></span>mg ibuprofen orally every 4<span class="elsevierStyleHsp" style=""></span>h&#44; plus 20<span class="elsevierStyleHsp" style=""></span>mg omeprazole every 24<span class="elsevierStyleHsp" style=""></span>h and 50<span class="elsevierStyleHsp" style=""></span>mg tramadol&#44; if required for pain&#46; After 72<span class="elsevierStyleHsp" style=""></span>h the patients were again contacted by telephone to assess their pain&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A week after the operation&#44; the patients were seen by their surgeon in the outpatient clinic&#44; immobilisation was discontinued and rehabilitation started&#46; During this first postoperative week&#44; the patients were allowed to fully weight bear with the help of 2 crutches&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 309 patients operated&#44; 264 were male and 45 female&#44; with a mean age of 33 years &#40;range from 18 to 55 years&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the progression of the operated patients&#8217; pain&#46; In general&#44; it can be observed that the majority of the patients had no&#44; or mild pain during their hospital stay or at their home follow-up visits at 24&#44; 48 and 72<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; A reduction of the mean pain scores from 1&#46;4 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;8&#41; POCU&#44; to 0&#46;6 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#41; RR&#46; At home&#44; the levels dropped to 0&#46;6 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#41; after 24<span class="elsevierStyleHsp" style=""></span>h to 0&#46;4 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#41; after 72<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Of the 309 operated patients&#44; 27 &#40;8&#46;7&#37;&#41; had to use analgesic medication at some point&#44; with 50<span class="elsevierStyleHsp" style=""></span>mg tramadol every 8<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The adverse effects recorded were the onset of postoperative nausea and vomiting&#44; often intravenous analgesia-related&#44; and drowsiness&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the frequency of adverse effect per sex&#46; Few side effects were observed&#44; with no differences between the sexes&#46; Only 10 patients &#40;3&#46;2&#37;&#41; presented nausea after 24<span class="elsevierStyleHsp" style=""></span>h and 2 &#40;0&#46;6&#37;&#41; after 48<span class="elsevierStyleHsp" style=""></span>h&#46; Four patients &#40;1&#46;3&#37;&#41; presented vomiting after 48<span class="elsevierStyleHsp" style=""></span>h and none of the patients reported vomiting after 24<span class="elsevierStyleHsp" style=""></span>h&#46; Four patients &#40;1&#46;3&#37;&#41; reported drowsiness after 24<span class="elsevierStyleHsp" style=""></span>h&#44; which disappeared entirely after 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In addition&#44; 3 patients &#40;1&#46;0&#37;&#41; presented pruritis during the administration of intravenous analgesia at home&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In terms of issues with the elastomeric device&#44; it is worth highlighting that there was extravasation of the peripheral line in 4 &#40;1&#46;3&#37;&#41; patients&#44; which was resolved by the home care unit&#46; Finally&#44; one patient burned the extension lead of their elastomeric pump with a cigarette&#44; which had to be removed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The visits that the patients made to our hospital&#39;s emergency department during the first week were recorded&#44; just before the visit to their surgeon in the outpatient clinic&#46; Of the 309 patients&#44; 22 had to attend the emergency departments with problems associated with the bandage&#46; Of these patients&#44; 12 had joint effusion&#44; and of these 8 had effusion under tension&#46; All the cases improved when the bandage was checked and the symptoms of all the cases of effusion under tension improved after evacuation by arthrocentesis&#46; Only one case attended the emergency department with acute surgical wound infection&#44; which was resolved with debridement and oral antibiotic therapy&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Good postoperative pain control is one of the keys to the success of MAS&#44; as well as the patient&#39;s level of satisfaction&#46; In MAS&#44; postoperative pain&#44; nausea and vomiting are still causes for delayed hospital discharge and readmission&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Therefore&#44; in order to introduce more complex procedures into ambulatory surgery&#44; it is essential to improve these factors&#44; since oral analgesia has sometimes proved insufficient&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Arthroscopic reconstructive ACL surgery is an optimal procedure to be undertaken in MAS programmes&#44; if we can ensure good postoperative analgesia&#46; The practice of multimodal analgesia is currently very widespread&#44; using different analgesic techniques and thus minimising side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;10&#8211;12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our hospital&#44; the ambulatory surgery department is an easily accessed separate building&#44; for low- and medium-complexity procedures&#46; We opted for continuous intravenous analgesia at home because we believe that it is better suited to our social environment and health structure&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> There is currently a great tendency to place perineural and peri-incisional catheters&#46; Reviewing the literature&#44; we found that the rate of complications&#44; especially nerve complications&#44; is very low&#44; but when they do occur there is no rapid resolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7&#44;13</span></a> Nerve blocks can also be helpful in managing postoperative pain in cruciate ligament reconstruction surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> although a motor block can be uncomfortable in terms of the patient&#39;s autonomy&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">This analgesic procedure enabled us to provide our patients good analgesia and wellbeing&#46; Moreover&#44; the patients felt safe with home visits from nursing staff to support them&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">There are studies that compare the results between surgery with admission and ambulatory surgery in surgical cruciate ligament repair&#44; and note that there are no differences in terms of safety between the 2 techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#44;15</span></a> These studies&#44; however&#44; are smaller series than ours and used multimodal anaesthesia systems with blocks and oral medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Krywulak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> performed a randomised study on the degree of satisfaction among patients who were treated as outpatients and as inpatients&#44; and noted that the patients who were not admitted to hospital had a higher degree of satisfaction&#46; Although this was a study with very few cases&#44; this also indicates that treatment without hospital admission is more satisfactory for patients&#46; We confirm this in our study with far more case studies&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Other studies describe good results with elastomeric pumps&#46; Hoenecke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> reported less pain and less need for narcotics in patients operated for ACL who followed an ambulatory continuous infusion regimen of bupivacaine through the surgical wound via an elastomeric pump for the first 48<span class="elsevierStyleHsp" style=""></span>h&#46; L&#243;pez Alvarez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> performed continuous femoral nerve blocks using bupivacaine via an elastomeric pump for the first 24<span class="elsevierStyleHsp" style=""></span>h&#44; with good pain control&#46; However&#44; they described the incidence of surgical infection and motor block as complications&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">We consider that the use of ambulatory elastomeric pumps after ACL reconstruction achieved good results on discharge&#44; with few complications&#44; compared to other procedures that use elastomeric pumps for direct infusion of the wound or for locoregional block&#46; This procedure&#44; however&#44; requires the support of a home care unit&#44; which some hospitals lack&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that the research was carried out according to the ethical standards set by the responsible human experimentation committee&#44; the World Medical Association and the Helsinki Declaration&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their centre of work regarding the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in the article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To follow up pain in the immediate postoperative period&#44; using an elastomeric pump in anterior cruciate ligament surgery&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">309 patients who had undergone anterior cruciate ligament repair with bone-tendon-bone allograft&#46; Pain control was assessed with a visual analogue scale &#40;VAS&#41; during the immediate postoperative period&#44; in the postoperative care unit&#44; in the recovery room&#44; and after the first 24&#8211;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h following home discharge&#46; The need for rescue medication&#44; adverse effects observed and emergency visits were also registered&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">309 patients were assessed &#40;264 males&#44; 45 females&#41;&#44; mean age 33 &#40;range&#58; 18&#8211;55&#41;&#46; Postoperative pain was mild in 44&#46;7&#37; of patients&#44; and 38&#46;5&#37; were pain-free&#46; At discharge&#44; 41&#46;1&#37; of patients reported mild pain and 57&#37; were pain-free&#46; At home&#44; mild to moderate levels of pain were maintained and over 97&#37; of patients presented VAS values &#8804;3&#46; Fewer than 3&#37; had adverse effects&#44; 8&#46;7&#37; had to use analgesic medication at some point&#46; Pruritus occurred in less than 1&#37; of patients receiving intravenous analgesia at home&#44; and fewer than 2&#37; had device-related complications&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There is no consensus regarding the postoperative management of anterior cruciate ligament lesions&#44; although most surgeons use multimode anaesthesia and different combinations of analgesics to reduce postoperative pain&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The use of an intravenous elastomeric pump as postoperative analgesia for anterior cruciate ligamentoplasty has yielded good results&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Discussion"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hacer un seguimiento del dolor en el posoperatorio inmediato&#44; mediante el uso de bomba elastom&#233;rica en la cirug&#237;a del ligamento cruzado anterior &#40;LCA&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Trescientos nueve pacientes intervenidos de ligamentoplastia del LCA mediante plastia aut&#243;loga de hueso-tend&#243;n-hueso&#46; Durante el posoperatorio inmediato se realiz&#243; un seguimiento del dolor mediante escala visual anal&#243;gica &#40;EVA&#41;&#59; tanto en la unidad de reanimaci&#243;n posoperatoria&#44; como en la sala de adaptaci&#243;n al medio&#44; y durante las primeras 24&#8211;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h en el domicilio&#46; Registramos tambi&#233;n la necesidad de medicaci&#243;n de rescate&#44; efectos adversos observados y visitas al servicio de urgencias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a 309 pacientes &#40;264 varones&#44; 45 mujeres&#41; con una edad media de 33 a&#241;os &#40;rango&#58; 18&#8211;55&#41;&#46; El 44&#44;7&#37; de los pacientes reportaron dolor posoperatorio inmediato leve y el 38&#44;5&#37; no ten&#237;a dolor&#46; Al alta&#44; el 41&#44;1&#37; de los pacientes reportaron dolor leve y el 57&#37; no ten&#237;a dolor&#46; En domicilio&#44; se mantuvieron los valores de dolor leve&#47;moderado&#44; con m&#225;s del 97&#37; de los pacientes con valores EVA &#8804;3&#46; Se registraron efectos adversos en menos del 3&#37; de los casos&#46; El 8&#44;7&#37; de los casos tuvo que hacer uso en alg&#250;n momento de medicaci&#243;n analg&#233;sica&#46; Menos del 1&#37; present&#243; prurito mientras llevaban la analgesia intravenosa en el domicilio y menos del 2&#37; present&#243; problemas relacionados con el dispositivo&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusi&#243;n</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Actualmente&#44; no hay consenso en cuanto al manejo posoperatorio de las lesiones del LCA&#44; aunque la tendencia es el uso de anestesia multimodal y de sistemas para reducir el dolor posoperatorio&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El uso de bomba elastom&#233;rica como procedimiento ambulatorio de control del dolor en la reparaci&#243;n del ligamiento cruzado anterior ha reportado buenos resultados&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Discusi&#243;n"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Villalba J&#44; Pe&#241;alver J&#44; Torner P&#44; Serra M&#44; Planell J&#46; Analgesia intravenosa domiciliaria mediante bomba elastom&#233;rica como procedimiento ambulatorio de control del dolor en la reparaci&#243;n del ligamento cruzado anterior&#46; Rev Esp Cir Ortop Traumatol&#46; 2018&#59;62&#58;65&#8211;70&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Inclusion criteria</span>&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"><span class="elsevierStyleHsp" style=""></span>Patients with ACL tear&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"><span class="elsevierStyleHsp" style=""></span>Acceptance by the patient to be operated as an outpatient&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"><span class="elsevierStyleHsp" style=""></span>Availability of an accessible telephone and a responsible adult for the first 24&#8211;48 postoperative hours&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"><span class="elsevierStyleHsp" style=""></span>Patients classified as ASA I&#8211;II and&#44; for some less aggressive procedures&#44; as ASA III&#8211;IV&#44; stables and with no episodes of decompensation in the past 3 months&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"><span class="elsevierStyleHsp" style=""></span>Surgical and anaesthetic informed consent&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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&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"><span class="elsevierStyleItalic">Exclusion criteria</span>&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"><span class="elsevierStyleHsp" style=""></span>Previous ACL plasty rupture&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"><span class="elsevierStyleHsp" style=""></span>Patients with cognitive dysfunction&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"><span class="elsevierStyleHsp" style=""></span>Drug-dependent or psychiatric patients&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"><span class="elsevierStyleHsp" style=""></span>Patients with no family support at home&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"><span class="elsevierStyleHsp" style=""></span>Patients living outside our hospital&#39;s catchment area&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"><span class="elsevierStyleHsp" style=""></span>Patients with complications who required hospitalisation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1644842.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Inclusion and exclusion criteria for ACL repair as MAS&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "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  " colspan="14" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pain in POCU and in RR</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VAS&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">0&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">1&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">2&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">3&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">4&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">5&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">6&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">7&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">8&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">9&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">10&nbsp;\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">&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">SD&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">POCU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">119 &#40;38&#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">100 &#40;32&#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">26 &#40;8&#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">12 &#40;3&#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">18 &#40;5&#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">20 &#40;6&#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">12 &#40;3&#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;0&#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">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><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&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;8&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">RR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">176 &#40;57&#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">97 &#40;31&#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">23 &#40;7&#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">7 &#40;2&#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">2 &#40;0&#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">3 &#40;1&#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;0&#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">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><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><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1644837.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="14" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pain at home</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VAS&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">0&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">1&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">2&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">3&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">4&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">5&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">6&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">7&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">8&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">9&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">10&nbsp;\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">&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">SD&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">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156 &#40;50&#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">138 &#40;44&#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">4 &#40;1&#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">4 &#40;1&#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">2 &#40;0&#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">2 &#40;0&#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">3 &#40;1&#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><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><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&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&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">48<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">162 &#40;52&#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">135 &#40;43&#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;0&#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">1 &#40;0&#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">5 &#40;1&#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">4 &#40;1&#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">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><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><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&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&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">72<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">210 &#40;68&#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">87<br>&#40;28&#46;2&#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;0&#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">1 &#40;0&#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">4 &#40;1&#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">5 &#40;1&#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">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><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><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&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "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="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nausea and vomiting after 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</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">No&#46;&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">&#37;&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">No&#46;&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">&#37;&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">No&#46;&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">&#37;&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
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0&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&#46;0&nbsp;\t\t\t\t\t\t\n
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            1 => array:2 [
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</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">No&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&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">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&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" style="border-bottom: 2px solid black">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            2 => array:2 [
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                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="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Drowsiness 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h</th></tr><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total</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">No&#46;&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">&#37;&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">No&#46;&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">&#37;&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">No&#46;&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">&#37;&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" style="border-bottom: 2px solid black">1&#46;3&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" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            3 => array:2 [
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                0 => """
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2017.07.001

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Year/Month	Html	Pdf	Total

2024 November	4	0	4
2024 October	40	5	45
2024 September	63	4	67
2024 August	39	11	50
2024 July	31	9	40
2024 June	17	1	18
2024 May	24	7	31
2024 April	77	12	89
2024 March	34	3	37
2024 February	44	8	52
2024 January	56	7	63
2023 December	42	7	49
2023 November	53	6	59
2023 October	48	12	60
2023 September	37	4	41
2023 August	36	15	51
2023 July	41	13	54
2023 June	58	5	63
2023 May	105	10	115
2023 April	99	6	105
2023 March	77	6	83
2023 February	34	7	41
2023 January	27	3	30
2022 December	39	6	45
2022 November	25	4	29
2022 October	16	8	24
2022 September	23	9	32
2022 August	20	12	32
2022 July	16	8	24
2022 June	23	5	28
2022 May	32	10	42
2022 April	27	13	40
2022 March	63	10	73
2022 February	30	7	37
2022 January	36	5	41
2021 December	29	15	44
2021 November	15	11	26
2021 October	25	16	41
2021 September	14	14	28
2021 August	36	10	46
2021 July	27	3	30
2021 June	28	12	40
2021 May	22	5	27
2021 April	49	8	57
2021 March	148	11	159
2021 February	24	17	41
2021 January	12	9	21
2020 June	1	0	1

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