Resultados preliminares del tratamiento con hemoperfusión con polimixina B en el shock séptico de origen abdominal

Duque, P.; Terradillos, E.; Zaballos, M.; Fernández-Quero, L.
doi:10.1016/j.redar.2017.02.004
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siguiendo las normas &#233;ticas del comit&#233; de investigaci&#243;n&#44; as&#237; como la Declaraci&#243;n de Helsinki de 1975&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El manejo del shock s&#233;ptico en nuestra unidad sigue las recomendaciones internacionales<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; El tratamiento con hemoperfusi&#243;n de polimixina B consisti&#243; en la aplicaci&#243;n de 2 sesiones de 2<span class="elsevierStyleHsp" style=""></span>h de duraci&#243;n en las primeras 24<span class="elsevierStyleHsp" style=""></span>h tras el diagn&#243;stico&#46; Recogimos variables demogr&#225;ficas&#44; antecedentes m&#233;dicos&#44; escalas APACHE y SOFA&#44; amplitud de distribuci&#243;n eritrocitaria&#44; niveles de lactato&#44; &#237;ndice de oxigenaci&#243;n&#44; recuento leucocitario y necesidad de f&#225;rmacos vasoactivos al ingreso e inmediatamente antes y despu&#233;s del tratamiento&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En cuanto al an&#225;lisis estad&#237;stico&#44; se realizaron comparaciones pre y postratamiento&#44; y entre los pacientes que sobrevivieron con respecto a los que fallecieron usando como variable la mortalidad a los 28 d&#237;as del ingreso&#46; Las variables continuas las expresamos como media y desviaci&#243;n est&#225;ndar&#44; y las variables categ&#243;ricas&#44; como frecuencias&#46; Se utiliz&#243; el test no param&#233;trico de Mann-Whitney para las variables continuas y el test de McNemar para las variables cualitativas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treinta y tres pacientes cumpl&#237;an nuestros criterios de inclusi&#243;n&#44; de los cuales excluimos 9 &#40;5 por carecer de datos completos en la historia cl&#237;nica y 4 por no haber recibido las 2 dosis de hemoperfusi&#243;n&#41;&#44; por lo que finalmente incluimos 24 pacientes en el estudio&#46; Todos presentaban shock s&#233;ptico abdominal secundario a dehiscencia de suturas de cirug&#237;a previa colorrectal &#40;11&#41;&#44; biliar &#40;3&#41; y gastrointestinal &#40;10&#41;&#46; En todos se realiz&#243; control quir&#250;rgico del foco y antibioterapia precoz&#44; emp&#237;rica de amplio espectro al inicio y dirigida seg&#250;n cultivos posteriormente&#46; El APACHE medio al ingreso fue de 20&#44;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;72&#44; y la mortalidad global observada fue del 37&#44;5&#37;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> describimos la evoluci&#243;n de los par&#225;metros cl&#237;nicos y de las escalas de gravedad en el conjunto de los pacientes&#44; destacando una disminuci&#243;n estad&#237;sticamente significativa en los datos de la escala SOFA&#44; en la necesidad de vasopresores&#44; en las cifras de lactato y creatinina a las 24 y 48<span class="elsevierStyleHsp" style=""></span>h del tratamiento con hemoperfusi&#243;n con polimixina B&#44; as&#237; como en el recuento leucocitario a las 48<span class="elsevierStyleHsp" style=""></span>h del mismo&#46; Es decir&#44; que en nuestros pacientes&#44; la terapia con hemoperfusi&#243;n con polimixina B fue beneficiosa&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">El an&#225;lisis realizado entre los pacientes supervivientes y fallecidos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; mostr&#243; que estos &#250;ltimos ten&#237;an de manera estad&#237;sticamente significativa una mayor puntuaci&#243;n en la escala APACHE &#40;24&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;4&#41;&#44; una mayor elevaci&#243;n del recuento leucocitario con neutrofilia al inicio del tratamiento y a las 24<span class="elsevierStyleHsp" style=""></span>h de comenzar este&#44; as&#237; como una mayor necesidad de f&#225;rmacos vasopresores a las 48<span class="elsevierStyleHsp" style=""></span>h del tratamiento combinado &#40;convencional<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>hemoperfusi&#243;n con polimixina B&#41;&#44; lo que indica la persistencia en el estado de shock a pesar de dicho tratamiento&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Seg&#250;n las &#250;ltimas recomendaciones de los expertos<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#44; hemos utilizado la escala SOFA para evaluar la disfunci&#243;n org&#225;nica y el incremento de lactato junto con la necesidad de vasopresores para valorar el shock s&#233;ptico&#46; En este sentido&#44; es destacable que si bien el SOFA al ingreso fue menor en los pacientes que sobrevivieron &#40;6&#44;47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;4 vs&#46; 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;2&#41;&#44; el SOFA previo al tratamiento fue muy similar &#40;10&#44;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 vs&#46; 10&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;9&#41; y a las 48<span class="elsevierStyleHsp" style=""></span>h del mismo nuevamente fue llamativamente mejor en los sobrevivientes &#40;6&#44;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 vs&#46; 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;3&#41;&#46; Por su parte&#44; el lactato sigui&#243; un patr&#243;n similar&#46; Las otras variables que estudiamos no mostraron correlaci&#243;n con la mortalidad&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Nuestros datos parecen indicar que si bien el efecto de la hemoperfusi&#243;n con polimixina B sobre nuestra muestra globalmente considerada ha sido beneficioso&#44; el tratamiento no ha sido eficaz ante la presencia de un shock s&#233;ptico franco muy evolucionado al ingreso en la unidad&#46; Los pacientes que ingresan con criterios de gravedad y que empeoran en sus primeras horas de ingreso son los que potencialmente obtendr&#237;an un mayor beneficio de la terapia con hemoperfusi&#243;n con polimixina B&#46; Tendremos que esperar a los resultados de los estudios EUPHRATES<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> y EUPHAS-2<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> para establecer claramente sus indicaciones&#44; as&#237; como su posible uso en el shock s&#233;ptico de otro origen diferente al abdominal&#44; ya que la hipoperfusi&#243;n asociada al shock produce traslocaci&#243;n bacteriana y potencialmente endotoxemia<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Entre las limitaciones del presente estudio cabe se&#241;alar el peque&#241;o tama&#241;o muestral y que carece de grupo control &#40;pacientes en shock s&#233;ptico de origen abdominal manejados &#250;nicamente con terapia convencional&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Con nuestros resultados&#44; planteamos la siguiente hip&#243;tesis&#58; el tratamiento precoz con hemoperfusi&#243;n de polimixina B en shock s&#233;ptico de origen abdominal podr&#237;a ser &#250;til en un grupo seleccionado de pacientes&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;86<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;06&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">Lactato prepolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;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&#44;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">Lactato 24<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;32&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">Lactato 48<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;11&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">Leucocitos 0<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="left" valign="top">16&#44;24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#44;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;02&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">Leucocitos 24<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#44;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#44;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;03&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">Leucocitos 48<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#44;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#44;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;55&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">Neutr&#243;filos 0<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="left" valign="top">14&#44;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#44;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;03&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">Neutr&#243;filos 24<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#44;97<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#44;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;23&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">Neutr&#243;filos 48<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#44;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;072&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;11&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">F&#225;rmacos vasoactivos 24<span class="elsevierStyleHsp" style=""></span>h pospolimixina B &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;11&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">F&#225;rmacos vasoactivos 48<span class="elsevierStyleHsp" style=""></span>h pospolimixina B &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;002&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#44;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#44;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#44;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#44;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#205;ndice de O<span class="elsevierStyleInf">2</span> 24<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>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&#44;35&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">&#205;ndice de O<span class="elsevierStyleInf">2</span> 48<span class="elsevierStyleHsp" style=""></span>h pospolimixina B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Escalas de gravedad&#44; datos anal&#237;ticos y evoluci&#243;n en pacientes vivos y fallecidos</p>"
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                    0 => array:2 [
                      "titulo" => "Surviving sepsis campaign&#58; International guidelines for management of severe sepsis and septic shock&#58; 2012"
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                          "etal" => false
                          "autores" => array:6 [
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                            2 => "A&#46; Rhodes"
                            3 => "D&#46; Annane"
                            4 => "H&#46; Gerlach"
                            5 => "S&#46;M&#46; Opal"
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                    0 => array:2 [
                      "doi" => "10.1097/CCM.0b013e31827e83af"
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                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2013"
                        "volumen" => "41"
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                        "paginaFinal" => "6637"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
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              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The third international consensus definitions for sepsis and septic shock &#40;Sepsis-3&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Singer"
                            1 => "C&#46;S&#46; Deutschman"
                            2 => "C&#46;W&#46; Seymour"
                            3 => "M&#46; Shankar-Hari"
                            4 => "D&#46; Annane"
                            5 => "M&#46; Bauer"
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2016.0287"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2016"
                        "volumen" => "315"
                        "paginaInicial" => "801"
                        "paginaFinal" => "810"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26903338"
                            "web" => "Medline"
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              "identificador" => "bib0040"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Polymyxin B hemoperfusion in clinical practice&#58; The picture from an unbound collaborative registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Early Use of Polymyxin B Hemoperfusion in the Abdominal Sepsis 2 Collaborative Group"
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                    0 => array:2 [
                      "doi" => "10.1159/000356835"
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                        "tituloSerie" => "Blood Purif"
                        "fecha" => "2014"
                        "volumen" => "37"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "22"
                        "paginaFinal" => "25"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24457492"
                            "web" => "Medline"
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The EUPHRATES Trial &#40;Evaluation of the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial for Adults Treated of Endotoxemia and Septic shock&#41;&#58; Study protocol for a randomized controlled trial"
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                            1 => "D&#46; Foster"
                            2 => "C&#46;A&#46; Schorr"
                            3 => "K&#46; Kazempour"
                            4 => "P&#46;M&#46; Walker"
                            5 => "R&#46;P&#46; Dellinger"
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                    0 => array:2 [
                      "doi" => "10.1186/1745-6215-15-218"
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                        "tituloSerie" => "Trials"
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