Should we maintain deep–moderate neuromuscular block until the end of laparoscopic surgery? The evidence and a clash of strong opinions

Ledowski, T.

doi:10.1016/j.redar.2016.02.007

array:22 ["pii" => "S0034935616000578" "issn" => "00349356" "doi" => "10.1016/j.redar.2016.02.007" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "695" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:251-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 304 "formatos" => array:3 [ "EPUB" => 2 "HTML" => 193 "PDF" => 109 ] ] "itemSiguiente" => array:19 [ "pii" => "S0034935615001784" "issn" => "00349356" "doi" => "10.1016/j.redar.2015.07.006" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "639" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:253-60" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 260 "formatos" => array:3 [ "EPUB" => 20 "HTML" => 129 "PDF" => 111 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "ORIGINAL" "titulo" => "Utilización de la monitorización analgésica intraoperatoria mediante pupilometría en el consumo de analgésicos durante las primeras 12 horas del postoperatorio" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "253" "paginaFinal" => "260" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The use of pupillometry as monitoring of intraoperative analgesia in the consumption of analgesics during the first 12 hours after surgery" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1127 "Ancho" => 1676 "Tamanyo" => 94973 ] ] "descripcion" => array:1 [ "es" => "Consumo de analgésicos en las primeras 12h en planta." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Abad Torrent, V. Rodríguez Bustamante, N. Carrasco Fons, F.J. Roca Tutusaus, D. Blanco Vargas, C. González García" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Abad Torrent" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Rodríguez Bustamante" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Carrasco Fons" ] 3 => array:2 [ "nombre" => "F.J." "apellidos" => "Roca Tutusaus" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Blanco Vargas" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "González García" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192915001067" "doi" => "10.1016/j.redare.2015.12.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192915001067?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935615001784?idApp=UINPBA00004N" "url" => "/00349356/0000006300000005/v1_201604150052/S0034935615001784/v1_201604150052/es/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Editorial article" "titulo" => "Should we maintain deep–moderate neuromuscular block until the end of laparoscopic surgery? The evidence and a clash of strong opinions" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "251" "paginaFinal" => "252" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "T. Ledowski" "autores" => array:1 [ 0 => array:4 [ "nombre" => "T." "apellidos" => "Ledowski" "email" => array:1 [ 0 => "thomas.ledowski@health.wa.gov.au" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "School of Medicine and Pharmacology, University of Western Australia, Perth, Australia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Correspondence to: School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Hwy, Crawley, Perth, WA 6009, Australia. Tel.: +61 8 9224 0201; fax: +61 8 92240279." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Se debería mantener un bloqueo neuromuscular profundo-moderado hasta completar las intervenciones laparoscópicas? Los hallazgos y el choque de posturas definidas" ] ] "textoCompleto" => "Since the introduction of neuromuscular blocking agents (NMBA) into anaesthesia practice in 1942, the benefits vs. dangers of neuromuscular block (NMB) have always been intensely discussed.<a class="elsevierStyleCrossRefs" href="#bib0090">1,2</a> Though it is clear that NMBA facilitate many operations which were previously thought to be impossible,<a class="elsevierStyleCrossRef" href="#bib0100">3</a> the ideal depth of NMB is much less certain. Based on a review by Ali et al.<a class="elsevierStyleCrossRef" href="#bib0105">4</a> in 1976, a single twitch depression of 90–95% was seen as providing surgeons with satisfactory operating conditions. Since it was theoretically possible to antagonize such block with neostigmine, Ali's recommendation must also be viewed as a necessary compromise between depth of NMB and the need for reversal at the end of surgery. Surgeons had to accept that a deeper NMB was not usually provided, and anaesthetists developed a “plan of action” (i.e. changing ventilation patterns or deepening anaesthesia<a class="elsevierStyleCrossRef" href="#bib0110">5</a>) to respond to surgeon complaints without further muscle relaxation.However, with the introduction of sugammadex this game has changed. Economic considerations left aside, it is now certainly possible to maintain a moderate (1–3 twitches in the train of four [TOF]) to even deep (twitches in the post tetanic count but not in the TOF) NMB until the very end of surgery. The latter has re-opened the discussion about the most desirable depth of NMB – an ongoing debate unfortunately not just based on science, but also strong opinions. Adding to the confusion, some recent trials<a class="elsevierStyleCrossRefs" href="#bib0115">6–8</a> have compared various outcomes under “no block” vs. “deep block” conditions. Though these have uniformly concluded that deep NMB was beneficial, the question may be allowed whether a “no block” group actually reflects standard practice. It is at least the author's opinion that for laparoscopic procedures currently more often than not NMBA are administered at the time of tracheal intubation, and thereafter only if surgeons complain about unsatisfactory operating conditions. Comparators better suited to match “real life” may hence be a continuously maintained deep–moderate NMB vs. a deep block at the start of a case and spontaneous recovery/shallow NMB thereafter. Such studies do in fact exist, and though limited in numbers, all have concluded that a continuously maintained moderate–deep block resulted in better operating conditions,<a class="elsevierStyleCrossRef" href="#bib0130">9</a> increased intraabdominal space<a class="elsevierStyleCrossRef" href="#bib0135">10</a> and lower postoperative pain scores.<a class="elsevierStyleCrossRef" href="#bib0140">11</a>In a clinical context, findings of benefits for continuously maintained deep–moderate block could make sense: the closure of abdominal fascia or retrieval of resected organs (i.e. gallbladder) are time points at the end of the procedure during which surgeons are likely to appreciate a deeper level of muscle relaxation.The question remains whether moderate block is sufficient or whether deep NMB must be maintained. To date only two<a class="elsevierStyleCrossRefs" href="#bib0145">12,13</a> studies appear to be sufficiently well designed to provide an answer. Martini et al.<a class="elsevierStyleCrossRef" href="#bib0145">12</a> found significantly better operating conditions in 12 deeply paralyzed vs. 12 moderately paralyzed patients undergoing laparoscopic surgery. Though the study was well designed, its major pitfall is the small number of patients in each group. An investigation by Yoo et al.<a class="elsevierStyleCrossRef" href="#bib0150">13</a> randomized 67 patients for robotic assisted laparoscopic prostatectomies to receive either moderate or deep NMB. They found that surgery could be accomplished at a relatively low intraabdominal pressure of 8mmHg in 88% of the deeply paralyzed patients, but only 25% of patients with moderate NMB. Though the latter studies may provide a hint towards a benefit for deeper NMB, the evidence may not yet be sufficient to justify the routine administration of deep NMB.However, the concept of a continuously maintained deep–moderate NMB also has its opponents.<a class="elsevierStyleCrossRefs" href="#bib0110">5,14</a> In fact, both reviews finding no plausible benefit for deep–moderate continuously maintained NMB stem from the same senior authors, namely Drs. Kopman and Naguib. But what exactly do they criticize? On the scientific side one of their stronger arguments is that to date no study has investigated postoperative patient outcome.<a class="elsevierStyleCrossRef" href="#bib0110">5</a> Though this is correct, one may want to keep in mind that differences in “hard” outcome parameters such as postoperative mortality are notoriously difficult to prove. With a mortality rate after laparoscopic cholecystectomies of about 0.02% (USA),<a class="elsevierStyleCrossRef" href="#bib0160">15</a> very large studies would be required. These can and should be done – but usually such projects follow rather than precede smaller “pilot” trials. Unfortunately, the reviews also mix science with opinion: the authors argue that before sugammadex became available (and hence theoretically allowed continuously maintained deep NMB) in the USA (2016) surgeons in the US quiet successfully performed thousands of laparoscopies without continuously maintained neuromuscular block.<a class="elsevierStyleCrossRef" href="#bib0110">5</a> This is surely correct, but the lack of experience of US surgeons with continuously maintained deep–moderate NMB is per se certainly no valid argument against it. Not surprisingly, the first of these reviews<a class="elsevierStyleCrossRef" href="#bib0155">14</a> was heavily criticized by the proponents of deep NMB (the author of this editorial included)<a class="elsevierStyleCrossRefs" href="#bib0165">16,17</a> and the second,<a class="elsevierStyleCrossRef" href="#bib0110">5</a> once print published, is likely to face similar criticism. But are Kopman and Naguib really completely wrong? Certainly not. Their conclusion that there is yet not sufficient evidence for the routine administration of continuously maintained deep block is a valid point. It is the dismissal of any benefit for a continuously maintained deep to moderate block which makes these reviews, at least in the authors view, problematic.Now, since we know that large randomized outcome studies comparing deep to moderate NMB with standard practice (one-off dose of NMBA with no continuously maintained NMB) are not yet available – what conclusions are permitted based on current publications?Firstly, that during laparoscopic surgery deep–moderate NMB is superior to no block. Secondly, that when compared to spontaneous recovery/shallow block continuously maintained deep–moderate NMB appears to result in better operating conditions and, under certain circumstances, possibly less postoperative pain. Thirdly, whether or not a continuously maintained NMB needs to be “deep” or can be “moderate” will need further investigation.Lastly, potential benefits (i.e. faster surgery, better patient outcome) as well as costs (i.e. costs for NMB reversal) of continuously maintained NMB are significant. Well-designed studies, larger or small, investigating this topic further should be strongly encouraged." "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of curare in general anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.R. Griffith" 1 => "G.E. Johnson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Anesthesiology" "fecha" => "1942" "volumen" => "3" "paginaInicial" => "418" "paginaFinal" => "420" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0095" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A study of the deaths associated with anaesthesia and surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.K.T.D. Beecher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "1954" "volumen" => "140" "paginaInicial" => "2" "paginaFinal" => "34" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13159140" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0100" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthesia before and after curare" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.F. Foldes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anaesthesiol Reanim" "fecha" => "1993" "volumen" => "18" "paginaInicial" => "128" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8280340" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0105" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Monitoring of neuromuscular function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.H. Ali" 1 => "J.J. Savarese" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "1976" "volumen" => "45" "paginaInicial" => "216" "paginaFinal" => "249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/180849" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0110" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is deep neuromuscular block beneficial in laparoscopic surgery? No, probably not" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.F. Kopman" 1 => "M. Naguib" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2016" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7572002" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0115" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep neuromuscular blockade leads to a larger intraabdominal volume during laparoscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.L. Lindekaer" 1 => "H. Halvor Springborg" 2 => "O. Istre" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3791/51911" "Revista" => array:3 [ "tituloSerie" => "J Vis Exp" "fecha" => "2013" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25285454" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0120" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuromuscular blockade improves surgical conditions (NISCO)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Blobner" 1 => "C.G. Frick" 2 => "R.B. Stauble" 3 => "H. Feussner" 4 => "S.J. Schaller" 5 => "C. Unterbuchner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00464-014-3711-7" "Revista" => array:6 [ "tituloSerie" => "Surg Endosc" "fecha" => "2015" "volumen" => "29" "paginaInicial" => "627" "paginaFinal" => "636" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25125097" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0125" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Van Wijk" 1 => "R.W. Watts" 2 => "T. Ledowski" 3 => "M. Trochsler" 4 => "J.L. Moran" 5 => "G.W. Arenas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/aas.12491" "Revista" => array:6 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2015" "volumen" => "59" "paginaInicial" => "434" "paginaFinal" => "440" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25684372" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0130" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.E. Dubois" 1 => "L. Putz" 2 => "J. Jamart" 3 => "M.L. Marotta" 4 => "M. Gourdin" 5 => "O. Donnez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/EJA.0000000000000094" "Revista" => array:6 [ "tituloSerie" => "Eur J Anaesthesiol" "fecha" => "2014" "volumen" => "31" "paginaInicial" => "430" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24809482" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0135" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: a randomized clinical study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.K. Staehr-Rye" 1 => "L.S. Rasmussen" 2 => "J. Rosenberg" 3 => "P. Juul" 4 => "A.L. Lindekaer" 5 => "C. Riber" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Anesth Analg" "fecha" => "2014" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12456431" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0140" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: a randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.V. Madsen" 1 => "O. Istre" 2 => "A.K. Staehr-Rye" 3 => "H.H. Springborg" 4 => "J. Rosenberg" 5 => "J. Lund" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Eur J Anaesthesiol" "fecha" => "2015" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0145" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.H. Martini" 1 => "M. Boon" 2 => "R.F. Bevers" 3 => "L.P. Aarts" 4 => "A. Dahan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aet377" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2014" "volumen" => "112" "paginaInicial" => "498" "paginaFinal" => "505" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24240315" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0150" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The intraocular pressure under deep versus moderate neuromuscular blockade during low-pressure robot assisted laparoscopic radical prostatectomy in a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.C. Yoo" 1 => "N.Y. Kim" 2 => "S. Shin" 3 => "Y.D. Choi" 4 => "J.H. Hong" 5 => "C.Y. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0135412" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2015" "volumen" => "10" "paginaInicial" => "e0135412" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26317357" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0155" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic surgery and muscle relaxants: is deep block helpful?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.F. Kopman" 1 => "M. Naguib" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000000471" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2015" "volumen" => "120" "paginaInicial" => "51" "paginaFinal" => "58" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25625254" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0160" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and an analysis of 77,604 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.J. Deziel" 1 => "K.W. Millikan" 2 => "S.G. Economou" 3 => "A. Doolas" 4 => "S.T. Ko" 5 => "M.C. Airan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "1993" "volumen" => "165" "paginaInicial" => "9" "paginaFinal" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8418705" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0165" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimal surgical conditions in laparoscopic surgery: just relax and lower the pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.D. de Boer" 1 => "J.P. Mulier" 2 => "A. Dahan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000000907" "Revista" => array:5 [ "tituloSerie" => "Anesth Analg" "fecha" => "2016" "volumen" => "122" "paginaInicial" => "288" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26678475" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0170" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic surgery and muscle relaxants: is deep block really not helpful?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T. Ledowski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000001007" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2016" "volumen" => "122" "paginaInicial" => "290" "paginaFinal" => "293" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26678478" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00349356/0000006300000005/v1_201604150052/S0034935616000578/v1_201604150052/en/main.assets" "Apartado" => array:4 [ "identificador" => "50880" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editorial article" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00349356/0000006300000005/v1_201604150052/S0034935616000578/v1_201604150052/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935616000578?idApp=UINPBA00004N"]

ISSN: 0034-9356

La Revista Española de Anestesiología y Reanimación (REDAR) es el órgano científico de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Esta es una revista mensual (10 números) que publica artículos científicos de todas las áreas que abarca la especialidad: anestesia clínica, reanimación-medicina intensiva y cuidados críticos, diagnóstico y tratamiento del dolor agudo y crónico, urgencias y emergencias, así como trabajos de ciencias básicas y relacionadas. La REDAR acepta trabajos tanto en español como en inglés.

Ver más Opción Open Access

Revista Española de Anestesiología y Reanimación ha recibido Factor de Impacto (JCR) por primera vez en 2023. Guía para autores - Envío de manuscritos

Indexada en:

Web of Science, Emerging Sources Citation Index (WoS, Clarivate), PubMed/Medline, Scopus, EMBASE, IBECS

Artículo

Opciones para acceder a los textos completos de la publicación Revista Española de Anestesiología y Reanimación

Suscriptor

Suscriptor de la revista

Si ya tiene sus datos de acceso, clique aquí.

Si olvidó su clave de acceso puede recuperarla clicando aquí y seleccionando la opción "He olvidado mi contraseña".

Suscribirse a:

Revista Española de Anestesiología y Reanimación

Más información

Comprar

Comprar acceso al artículo

Comprando el artículo el PDF del mismo podrá ser descargado

Precio 19,34 €

Comprar ahora

Contactar

Teléfono para suscripciones e incidencias

De lunes a viernes de 9h a 18h (GMT+1) excepto los meses de julio y agosto que será de 9 a 15h

Llamadas desde España

932 415 960

Llamadas desde fuera de España

+34 932 415 960

E-mail

atencionalcliente@elsevier.com

Publique en

Revista Española de Anestesiología y Reanimación

Herramientas

Artículos
recomendados

Conexiones NRFit en anestesia regional: evitando errores de...

Rev Esp Anestesiol Reanim. 2024;71:538-44

Dexmedetomidina y analgesia perioperatoria en...

Rev Esp Anestesiol Reanim. 2022;69:487-92

Sitio de acción del bloqueo del plano del músculo erector...

Rev Esp Anestesiol Reanim. 2021;68:424-5

Revista Española de Anestesiología y Reanimación se adhiere a los principios y procedimientos dictados por el Committee on Publication Ethics (COPE)
www.publicationethics.org.

Artículos de acceso gratuito

Manejo de la anemia periquirúrgica en cirugía...

Rev Esp Anestesiol Reanim. 2024;71:454-65

Recomendaciones del grupo de trabajo para la...

Rev Esp Anestesiol Reanim. 2024;71:403-11

Ecoanatomía de la vía aérea...

10.1016/j.redar.2024.06.001

Indexada en:

Síguenos:

Suscribirse:

Artículo

Indexada en:

Síguenos:

Suscribirse:

Artículo

Suscríbase a la newsletter