Papel de los coadyuvantes en la anestesia regional: revisión sistemática | Revista Española de Anestesiología y Reanimación

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da&#241;o neurol&#243;gico&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">5</span></a>&#46; Realizar una analgesia continua mediante cat&#233;ter percut&#225;neo en nervio&#44; plexo o espacio fascial presenta un fallo del 20-50&#37; debido a la migraci&#243;n&#44; obstrucci&#243;n o rotura del cat&#233;ter<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; Lograr el &#233;xito de las t&#233;cnicas de analgesia continua requiere de una formaci&#243;n adecuada de los profesionales para disminuir la tasa de error&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Algunas opciones atractivas para lograr la finalidad de analgesia prolongada son la bupivaca&#237;na liposomal o la posibilidad de a&#241;adir un coadyuvante al anest&#233;sico local&#46; Ambas soluciones buscan prolongar la duraci&#243;n de acci&#243;n del anest&#233;sico local sin aumentar los eventos adversos&#46; Con la encapsulaci&#243;n del anest&#233;sico local en una vaina lip&#237;dica se intenta prolongar su liberaci&#243;n&#46; La principal ventaja es no requerir el recurso del cat&#233;ter&#44; aunque su uso est&#225; limitado por problemas de registro &#40;no est&#225; operativa en Europa&#41;&#44; disponibilidad y los metaan&#225;lisis no aportan un adecuado beneficio con respecto a la infiltraci&#243;n con anest&#233;sico normal<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Asociar un f&#225;rmaco coadyuvante a los anest&#233;sicos locales podr&#237;a acelerar el bloqueo sensorial y prolongar el efecto analg&#233;sico&#46; Existen m&#250;ltiples f&#225;rmacos que prolongan la duraci&#243;n de un bloqueo perif&#233;rico&#44; pero hay controversias acerca de cu&#225;les son los m&#225;s indicados&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Esta revisi&#243;n analiza los estudios que exploran la administraci&#243;n perineural o fascial de los f&#225;rmacos coadyuvantes m&#225;s utilizados durante los &#250;ltimos cinco a&#241;os asociados con un anest&#233;sico local&#46; El objetivo principal ha sido evaluar si la adicci&#243;n de un coadyuvante al anest&#233;sico local es eficaz para prolongar la analgesia postoperatoria y reducir la utilizaci&#243;n de opioides y como objetivo secundario si esa pr&#225;ctica es segura identificando la presencia de eventos adversos asociados al uso del coadyuvante&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material y m&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">En la revisi&#243;n se incluyeron estudios que utilizan coadyuvantes asociados a los anest&#233;sicos locales administrados v&#237;a perineural &#40;nervios o plexos&#41; o en espacios fasciales en procedimientos quir&#250;rgicos electivos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los tipos de estudio elegibles incluyeron&#58; estudios controlados randomizados&#44; estudios prospectivos comparativos no randomizados&#44; estudios prospectivos observacionales&#44; series de casos o casos cl&#237;nicos&#46; El nivel de evidencia se calific&#243; de acuerdo con el documento de niveles de evidencia del <span class="elsevierStyleItalic">Oxford Center for Evidence-based Medicine</span> de 2011&#58; nivel 1&#44; evidencia de los ensayos aleatorios o revisiones sistem&#225;ticas de ensayos aleatorios&#59; nivel 2&#44; evidencia de ensayos aleatorizados o estudios observacionales&#59; nivel 3&#44; evidencia de cohortes controladas no aleatorias o estudios de seguimiento&#59; nivel 4&#44; evidencia de series de casos&#44; estudios de casos y controles</p><p id="par0040" class="elsevierStylePara elsevierViewall">Realizamos la revision sistem&#225;tica usando la metodolog&#237;a sistem&#225;tica de Cochrane para revisiones<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">9</span></a>&#46; Los resultados de la b&#250;squeda se informaron de acuerdo con los elementos de notificaci&#243;n preferidos para las gu&#237;as de revisiones sistem&#225;ticas y metaan&#225;lisis &#40;PRISMA&#41;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">10</span></a>&#46; Se sigui&#243; la gu&#237;a de revisi&#243;n por pares para evitar posibles errores de b&#250;squeda&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Las bases de datos en las que se realizaron las b&#250;squedas fueron&#58; MEDLINE&#44; Medline en proceso&#47;ePubs&#44; Embase&#44; Registro Cochrane Central de Ensayos Controlados y la base de datos Cochrane de revisiones sistem&#225;ticas&#46; Tambi&#233;n se realizaron b&#250;squedas en la base de datos PubMed &#40;Biblioteca Nacional de Medicina&#41; en busca de citas no incluidas en Medline&#44; Scopus&#44; Web of Science y Clinicaltrials&#46;gov &#40;National Institutes of Health&#41; y World Health&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">El periodo evaluado estuvo comprendido desde el 1 de enero 2015 hasta el 31 de enero de 2021&#46; De una b&#250;squeda preliminar se extrajo literatura de texto completo para posibles palabras clave y t&#233;rminos de vocabulario apropiados&#46; Tras analizar la literatura de texto completo las palabras clave utilizadas &#40;MeSH&#41; fueron&#58; &#171;<span class="elsevierStyleItalic">adjuvants regional anesthesia</span>&#187; y &#171;<span class="elsevierStyleItalic">adjuvants peripheral nerve block</span>&#187;&#46; No se aplicaron restricciones de tipo&#44; estado o idioma de publicaci&#243;n&#46; Los estudios potencialmente elegibles se identificaron mediante la selecci&#243;n del t&#237;tulo y el resumen de todas las publicaciones identificadas mediante la b&#250;squeda bibliogr&#225;fica en una poblaci&#243;n mayor de 18 a&#241;os&#46; A continuaci&#243;n&#44; se obtuvo el texto completo de estos estudios para su posterior evaluaci&#243;n&#46; Se evalu&#243; el tiempo de prolongaci&#243;n del bloqueo sensitivo-motor&#44; el comienzo de acci&#243;n del bloqueo&#44; posibles efectos adversos&#44; ventajas y desventajas de los coadyuvantes a examen&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La evaluaci&#243;n y selecci&#243;n de estudios para la inclusi&#243;n en la revisi&#243;n se realizaron de manera independiente por dos autores &#40;MF y SL&#41;&#46; Los desacuerdos sobre la elegibilidad de un art&#237;culo fueron resueltos por un tercer revisor &#40;CA&#41;&#44; quien analiz&#243; el riesgo de sesgos de todos los art&#237;culos incluidos en la revisi&#243;n&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Los resultados de la estrategia de b&#250;squeda se presentan en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">La investigaci&#243;n electr&#243;nica identific&#243; con nuestros criterios de b&#250;squeda &#171;<span class="elsevierStyleItalic">adjuvant regional anesthesia</span>&#187; cuatro revisiones Cochrane&#44; pero una s&#243;lo una cumple el objetivo de esta revision<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">11</span></a> y una&#44; la misma&#44; con &#171;adjuvant regional anesthesia&#187;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">11</span></a>&#46; De los 92 estudios elegibles&#44; 13 correspond&#237;an a revisiones bibliogr&#225;ficas&#44; por lo que fueron excluidos para el an&#225;lisis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Son incluidos en la revisi&#243;n 79 art&#237;culos&#44; con una clara prevalencia de los relacionados con la utilizaci&#243;n de dexametasona &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41; y dexmedetomidina &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41;&#46; Otros coadyuvantes evaluados han sido sulfato de magnesio &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#44; clonidina &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; opioides &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; y vitamina B1 &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; De los estudios comparativos entre coadyuvantes en este tiempo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#44; ha captado la atenci&#243;n de la sociedad cient&#237;fica el evaluar la eficacia de la dexametasona vs&#46; la dexmedetomidina en cuatro estudios publicados&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A tenor de estos datos&#44; podemos afirmar que en la actualidad hay dos coadyuvantes que claramente destacan sobre los dem&#225;s&#58; dexametasona y dexmedetomidina&#44; desplazando a los que hasta ahora parec&#237;an los m&#225;s utilizados &#40;opioides&#44; bicarbonato&#41;&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Dexmedetomidina</span><p id="par0080" class="elsevierStylePara elsevierViewall">La dexmedetomidina es un agonista alfa-2 con efecto simpaticol&#237;tico a trav&#233;s de la disminuci&#243;n de la liberaci&#243;n de noradrenalina en las terminaciones nerviosas simp&#225;ticas&#46; Su gran afinidad por los receptores lo convierte casi en un agonista puro&#46; Puede causar sedaci&#243;n&#44; ansiolisis&#44; reducci&#243;n de analg&#233;sicos&#44; de la secreci&#243;n salival y depresi&#243;n respiratoria m&#237;nima y como efectos secundarios bradicardia e hipotensi&#243;n&#46; Presenta un mecanismo de acci&#243;n perineural similar a la clonidina&#44; pero mejores resultados cl&#237;nicos<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Su efecto cl&#237;nico tras su administraci&#243;n intravenosa se debe al efecto sobre los receptores perif&#233;ricos y centrales&#46; El efecto sedante se asocia con la estimulaci&#243;n de los receptores localizados en el locus coeruleus&#46; Sin embargo&#44; el efecto analg&#233;sico est&#225; asociado con la estimulaci&#243;n de los receptores localizados en la asta posterior medular&#44; inhibiendo la secreci&#243;n de la sustancia P y glutamina<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En condiciones fisiol&#243;gicas&#44; la expresi&#243;n de los receptores alfa-2 en nervios perif&#233;ricos est&#225; ausente<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">14</span></a>&#44; pero al asociar clonidina o dexmedetomidina al anest&#233;sico local prolongan el efecto analg&#233;sico por una acci&#243;n perif&#233;rica y central&#46; El efecto directo sobre las fibras perif&#233;ricas se basa en la inhibici&#243;n de la creaci&#243;n del potencial de acci&#243;n en las fibras <span class="elsevierStyleSmallCaps">C</span> amiel&#237;nicas y a la hiperpolarizaci&#243;n celular por activaci&#243;n de los canales de voltaje dependientes<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La evidencia cient&#237;fica m&#225;s reciente a trav&#233;s de los estudios publicados&#44; indica que la dexmedetomidina prolonga la duraci&#243;n de la anestesia regional intravenosa&#44; bloqueos nerviosos perif&#233;ricos y anestesia intradural&#46; El aspecto controvertido viene por la posible neurotoxicidad perif&#233;rica en pacientes con neuropat&#237;a diab&#233;tica<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">15&#44;16</span></a> o por la necesidad de ser monitorizados los pacientes en el intraoperatorio por el potencial da&#241;o&#44; aunque reversible sobre la frecuencia cardiaca &#40;bradicardia&#41;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de los estudios seleccionados &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; constatamos c&#243;mo la dexmedetomidina perineural &#40;50-60<span class="elsevierStyleHsp" style=""></span>&#956;g&#41; en el bloqueo del plexo braquial incrementa la duraci&#243;n media de la analgesia&#46; Destacamos el metan&#225;lisis de Vorobeichik et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">18</span></a> que demuestra que su administraci&#243;n prolonga el bloqueo sensitivo y motor &#40;264<span class="elsevierStyleHsp" style=""></span>min&#46; Vs&#46; 228<span class="elsevierStyleHsp" style=""></span>min&#46; y 192<span class="elsevierStyleHsp" style=""></span>min&#46;&#44; respectivamente&#41;&#46; Este beneficio analg&#233;sico y de calidad se debe de poner en balanza con el riesgo de un bloqueo motor prolongado o de los efectos cardiovasculares ya mencionados&#46; Helal et al&#46; refieren una eficacia similar y de efectos secundarios con su administraci&#243;n en bloqueo ci&#225;tico y femoral<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">19</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">La mayor&#237;a de los estudios utilizan dosis de 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#44; tanto a nivel de nervio perif&#233;rico<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">20</span></a> como a nivel de espacio fascial<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">21</span></a> y siempre asociado a anest&#233;sico local&#46; En este &#250;ltimo contexto&#44; Sun et al&#46; en un metaan&#225;lisis que incluye 20 estudios con 1&#46;212 pacientes&#44; concluyen que la adici&#243;n de la dexmedetomidina disminuye el dolor postoperatorio a las 8 horas postquir&#250;rgicas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; el consumo de opioides &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; comparado con el grupo control&#46; As&#237; mismo&#44; prolonga el efecto del bloqueo del plano tranverso del abdomen&#44; sin afectar a la incidencia de n&#225;useas y v&#243;mitos postoperatorios&#44; hipotensi&#243;n o bradicardia&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Su perfil de posibles efectos adversos nos hace ser prudentes a la hora de recomendarlo como coadyuvante en todos los contextos cl&#237;nicos&#59; sin embargo&#44; la evidencia cient&#237;fica al respecto es inconsistente&#46; Estudios <span class="elsevierStyleItalic">in vivo</span> que eval&#250;an la dexmedetomidina junto a ropivaca&#237;na revelan su acci&#243;n neuroprotectora al disminuir la inflamaci&#243;n perineural en ratas<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">22</span></a>&#46; El efecto podr&#237;a ser secundario a la inhibici&#243;n de la actividad del factor NF k&#946; y por lo tanto disminuir la transcripci&#243;n de citoquinas inflamatorias y la modulaci&#243;n de la desgranulaci&#243;n de los mastocitos&#46; Asociada a la lidoca&#237;na disminuye la concentraci&#243;n efectiva del f&#225;rmaco<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">23</span></a>&#46; Por tanto&#44; aunque es un f&#225;rmaco relativamente seguro&#44; no debemos olvidar sus efectos neurot&#243;xicos<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">16</span></a>&#44; ser prudentes y seguir investigando<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">24</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Corticosteroides&#58; dexametasona</span><p id="par0115" class="elsevierStylePara elsevierViewall">El mecanismo responsable de prolongar la duraci&#243;n de acci&#243;n de un bloqueo tras la administraci&#243;n perineural de dexametasona junto al anest&#233;sico local es muy complejo<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">25</span></a>&#46; Disminuye la actividad de las fibras amiel&#237;nicas C&#44; inhibe los canales de potasio&#44; tiene efecto vasoconstrictor local&#44; favorece la hiperpolarizaci&#243;n de las fibras nerviosas perif&#233;ricas&#44; bloquea la transmisi&#243;n sin&#225;ptica y reduce la inflamaci&#243;n perineural&#46; A nivel sist&#233;mico tiene efecto antiinflamatorio y un efecto central sobre los receptores alfa-2&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se resumen los principales estudios&#46; Diferentes metaan&#225;lisis han evaluado la dexametasona perineural y su empleo se ha vuelto com&#250;n en la pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">11&#44;26&#8211;28</span></a>&#46; Adem&#225;s de prolongar el efecto analg&#233;sico de los anest&#233;sicos locales&#44; su administraci&#243;n perineural prolonga la duraci&#243;n media del bloqueo motor&#44; disminuyendo el dolor evaluado postoperatoriamente tanto en reposo como en movimiento a las 8-24 horas y con ello el consumo acumulado de morfina&#46; En el bloqueo axilar&#44; 4<span class="elsevierStyleHsp" style=""></span>mg de dexametasona parecen ser el techo con anest&#233;sicos locales de corta y media duraci&#243;n<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">29</span></a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Existe controversia sobre si ese mismo efecto se observa administrando dexametasona intravenosa&#46; Diferentes estudios muestran que tanto la administraci&#243;n de dexametasona intravenosa como perineural prolonga la duraci&#243;n de acci&#243;n de los anest&#233;sicos locales&#44; sin ofrecer consenso sobre si alguna de las dos administraciones ofrece alguna ventaja sobre la otra<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">30</span></a>&#46; Hay estudios que avalan que la administraci&#243;n intravenosa no muestra una mayor duraci&#243;n de bloqueo que el placebo &#40;suero fisiol&#243;gico&#41;&#44; si bien este hallazgo podr&#237;a deberse a que los participantes eran voluntarios y no hab&#237;a incisi&#243;n quir&#250;rgica&#46; Es posible que la ausencia de injuria quir&#250;rgica no dejara a la dexametasona la oportunidad de presentar su efecto antiinflamatorio&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Sin embargo&#44; la revision de Heesen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">27</span></a> con 10 estudios evaluados y 783 pacientes&#44; encontr&#243; una diferencia estad&#237;sticamente significativa en la prolongaci&#243;n de la analgesia con la administraci&#243;n perineural&#44; aunque con un grado de evidencia bajo&#46; El metaan&#225;lisis de Zorrilla-Vaca<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">31</span></a> afirma&#44; tras evaluar 13 estudios con 937 pacientes&#44; que la administraci&#243;n perineural de dexametasona produce mejores resultados analg&#233;sicos que la inyecci&#243;n intravenosa&#44; y adem&#225;s apoya la hip&#243;tesis de la interacci&#243;n local entre el corticoide y el nervio como uno de los mecanismos de la modulaci&#243;n del dolor&#44; porque la absorci&#243;n sist&#233;mica sola no podr&#237;a explicar la calidad superior del bloqueo<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">32</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La dexametasona puede inducir un aumento en la concentraci&#243;n de glucosa en sangre&#46; Tras la administraci&#243;n perineural el aumento es menor que en la inyecci&#243;n intravenosa&#44; encontrando el m&#225;ximo incremento a las cuatro horas<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">33</span></a>&#46; La preocupaci&#243;n por la teor&#237;a del retraso en la curaci&#243;n de la herida o la infecci&#243;n sist&#233;mica no se demostr&#243; en una revisi&#243;n sistem&#225;tica<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">34</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Con respecto a la neurotoxicidad&#44; estudios <span class="elsevierStyleItalic">in vivo</span> demuestran que la dexametasona aten&#250;a la citotoxicidad de la bupivacaina en c&#233;lulas de neuroblastoma del rat&#243;n<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">33</span></a> o de la ropivaca&#237;na en el asta posterior medular&#44; pero podr&#237;a cristalizar con este mismo anest&#233;sico a nivel del nervio<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">34</span></a>&#46; En humanos&#44; los estudios no muestran asociaci&#243;n entre la administraci&#243;n de dexametasona y complicaciones neurol&#243;gicas<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">11&#44;27</span></a>&#44; pero s&#237; podr&#237;a cristalizar con ropivaca&#237;na<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">35</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A pesar de ello&#44; la falta de evidencias de da&#241;o no es evidencia de su ausencia&#46; Dada la baja incidencia de da&#241;o nerviosos subsecuente a las t&#233;cnicas de anestesia regional&#44; se ha estimado un tama&#241;o muestral de 16&#46;000 pacientes para mostrar una ratio de 0&#44;4&#37; de complicaciones<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">36</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Sulfato de magnesio</span><p id="par0150" class="elsevierStylePara elsevierViewall">El magnesio es un antagonista del receptor N-methyl-D-aspartato &#40;NMDA&#41;&#44; que ha demostrado aumentar el umbral de excitaci&#243;n&#44; mayor en fibras A&#946; que en fibras C<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">37</span></a>&#46; Su mecanismo de acci&#243;n tras la administraci&#243;n perineural es probablemente debido a los efectos de su carga positiva sobre el potencial de acci&#243;n de las c&#233;lulas neuronales y su acci&#243;n fisiol&#243;gica como calcioantagonista<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">38&#44;39</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En el estudio de Beiranvand et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">40</span></a> se concluye que la adici&#243;n de sulfato de magnesio a la lidoca&#237;na aumenta la duraci&#243;n del bloqueo sensitivo y motor del bloqueo axilar&#46; Resultados parecidos encuentran Jebali et al&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">41</span></a> en el bloqueo femoral&#46; Sin embargo&#44; no afirman lo mismo Imani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">42</span></a> cuando asocian sulfato de magnesio a ropivaca&#237;na en el bloqueo del plano transverso del abdomen&#44; cuyos resultados muestran que no hay diferencia en las valoraciones de dolor y rescate analg&#233;sico entre los grupos comparados&#46; Los seis estudios encontrados se muestran en la <a class="elsevierStyleCrossRef" href="#sec0055">tabla 1 del material complementario</a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">El sulfato de magnesio podr&#237;a ser un prometedor adyuvante en los bloqueos perif&#233;ricos pero&#44; a la vista de los dispares resultados&#44; son necesarios m&#225;s estudios al respecto&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Opioides&#58; buprenorfina</span><p id="par0165" class="elsevierStylePara elsevierViewall">A lo largo de los a&#241;os muchos han sido los estudios que se han realizado para determinar los beneficios de la administraci&#243;n perineural de los opioides como coadyuvantes de los anest&#233;sicos locales&#46; Aun ahora&#44; es dif&#237;cil determinar si este efecto analg&#233;sico es el resultado s&#243;lo de su efecto sobre los receptores perif&#233;ricos o es un efecto central tras la redistribuci&#243;n del f&#225;rmaco al compartimento central<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">43</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Dentro de la familia de los opioides&#44; la buprenorfina&#44; un agonista parcial &#956; y agonista del receptor k&#44; ha mostrado una prolongaci&#243;n de la duraci&#243;n de la analgesia tras administrarse de forma perineural junto al anest&#233;sico local&#46; Su mecanismo de acci&#243;n se debe probablemente al bloqueo&#44; concentraci&#243;n dependiente&#44; de los canales voltaje dependientes de sodio&#44; inhibiendo la generaci&#243;n de potenciales de acci&#243;n e interactuando con los receptores &#956; en los axones de las fibras amiel&#237;nicas C<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">44</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Analizando diferentes estudios sobre su efectividad&#44; los ambiguos resultados no permiten recomendar su uso&#46; Por un lado&#44; Schnabel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">45</span></a> eval&#250;an en su metaan&#225;lisis la administraci&#243;n de buprenorfina al anest&#233;sico local en bloqueo axilar&#44; femoral y ci&#225;tico&#46; Demuestra que la administraci&#243;n perineural de 0&#44;1-0&#44;3 mg junto al anest&#233;sico local prolongar&#237;a la analgesia postoperatoria&#44; sin diferencias en la instauraci&#243;n del bloqueo sensitivo- motor&#46; Este efecto no se observ&#243; al utilizar la buprenorfina intravenosa&#44; lo que claramente indica un mecanismo de acci&#243;n local&#46; Por otro lado&#44; van Beek et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">46</span></a> afirman que la adici&#243;n de buprenorfina en el bloqueo femoral no se traduce en una mejor&#237;a postoperatoria en pacientes operados de rodilla&#46; En ambos estudios hay un aumento del riesgo de n&#225;useas y v&#243;mitos postoperatorios&#44; adem&#225;s de prurito<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">46</span></a>&#46; Se ha estudiado <span class="elsevierStyleItalic">in vitro</span> e <span class="elsevierStyleItalic">in vitro</span> la neurotoxicidad en ratas<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">47</span></a>&#44; sin hallarse da&#241;os sobre los nervios&#46; Los tres estudios encontrados se muestran en la <a class="elsevierStyleCrossRef" href="#sec0055">tabla 2 del material complementario</a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">La buprenorfina como coadyuvante de los anest&#233;sicos locales es una opci&#243;n m&#225;s a utilizar por sus efectos sobre la prolongaci&#243;n del efecto&#44; valorando la posibilidad de la manifestaci&#243;n de sus efectos adversos&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Son importantes las caracter&#237;sticas de cada coadyuvante&#44; siempre buscando el complemento ideal&#46; En la <a class="elsevierStyleCrossRef" href="#sec0055">figura 1 del material complementario</a> se muestran las m&#225;s destacables de desmedetomidina y dexametasona&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="par0190" class="elsevierStylePara elsevierViewall">Los programas de cirug&#237;a ambulatoria y m&#225;s recientemente la implementaci&#243;n de los protocolos ERAS &#40;<span class="elsevierStyleItalic">Enhanced Recovery After Surgery</span>&#41; han potenciado las t&#233;cnicas de anestesia y analgesia basadas en bloqueos perif&#233;ricos y fasciales&#46; En ambos&#44; un control efectivo del dolor minimizando la utilizaci&#243;n de opioides son claves para el &#233;xito de estos programas&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">En este contexto&#44; el uso de f&#225;rmacos coadyuvantes con los anest&#233;sicos locales est&#225; en continua evoluci&#243;n&#44; a&#241;adiendo nuevos agentes para mejorar la analgesia&#46; Al momento de elegir el coadyuvante para la anestesia regional perif&#233;rica se deben tener en cuenta la duraci&#243;n de la analgesia y el bloqueo sensitivo vs&#46; las desventajas de la duraci&#243;n del bloqueo motor y sus efectos adversos &#40;<a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">M&#250;ltiples metaan&#225;lisis eval&#250;an la duraci&#243;n de los coadyuvantes a&#241;adidos a los anest&#233;sicos locales y sugieren un bloqueo de caracter&#237;sticas superiores con dexmedetomidina que clonidina y de la dexametasona vs&#46; la dexmedetomina al administrarse perineuralmente<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">12&#44;48</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">De los coadyuvantes empleados&#44; la dexametasona perineural parece mostrar el menor riesgo de efectos secundarios &#40;sedaci&#243;n&#44; hipotensi&#243;n&#41; si se compara con la dexmedetomidina&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">En ausencia de administraci&#243;n perineural&#44; la v&#237;a intravenosa a dosis 0&#44;1-0&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg disminuye el dolor postoperatorio y el consumo de opioides&#44; si bien la efectividad es superior en la administraci&#243;n local&#46; Ambas v&#237;as permiten otorgar al paciente un mayor confort en el postoperatorio inmediato&#44; incluyendo la noche<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">49</span></a>&#46; Utilizada de manera intravenosa&#44; la dexametasona tiene un efecto antiem&#233;tico a tener en cuenta&#46; Pero no podemos perder un dato de vista&#58; salvo la adrenalina&#44; ninguno de los f&#225;rmacos que ocupan esta revision han sido aprobados para uso como coadyuvante&#44; por lo tanto&#44; todos ellos se usan &#171;of label&#187;&#44; fuera de ficha t&#233;cnica&#46; Es importante recordar que la administraci&#243;n perineural est&#225; restringida a f&#225;rmacos sin conservantes&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Como conclusiones&#44; podemos afirmar que hay una evidencia de calidad moderada que sugiere que la dexametasona usada como coadyuvante en bloqueos nervios perif&#233;ricos prolonga la duraci&#243;n del bloqueo sensorial y es efectiva reduciendo el dolor posoperatorio y el consumo de opi&#225;ceos&#46; Tal como sugieren los &#250;ltimos estudios&#44; la prolongaci&#243;n de analgesia es mayor cuando se administra a nivel perineural que por v&#237;a endovenosa&#44; aunque seguimos desconociendo si dicho efecto se debe a su acci&#243;n sobre la vaina nerviosa o por un efecto de absorci&#243;n sist&#233;mica&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Referente a la dexdemedetomidina&#44; hay una evidencia de calidad baja-moderada que indica que prolonga la duraci&#243;n de bloqueos nerviosos perif&#233;ricos&#44; pero sus efectos adversos podr&#237;an limitar su uso en la pr&#225;ctica cl&#237;nica &#40;posible neurotoxicidad perif&#233;rica o bradicardia&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">En base a estas conclusiones&#44; hasta la publicaci&#243;n de nuevos estudios&#44; los autores apoyamos empleo de dexametasona como coadyuvante de la anestesia regional perif&#233;rica en aquellos procedimientos que el dolor postoperatorio esperados sea de moderado-intenso y siempre teniendo en cuenta la relaci&#243;n riesgo-beneficio para cada paciente de modo individual&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Financiaci&#243;n</span><p id="par0250" class="elsevierStylePara elsevierViewall">Esta revisi&#243;n no recibi&#243; financiaci&#243;n econ&#243;mica o beca para su realizaci&#243;n&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicto de intereses</span><p id="par0235" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Dexmedetomidina"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Corticosteroides&#58; dexametasona"
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            2 => array:2 [
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              "titulo" => "Sulfato de magnesio"
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    "fechaRecibido" => "2021-04-11"
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          "palabras" => array:6 [
            0 => "Coadyuvantes"
            1 => "Anestesia regional"
            2 => "Bloqueo nervioso perif&#233;rico"
            3 => "Anest&#233;sicos locales"
            4 => "Dolor postoperatorio"
            5 => "Opioides"
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            1 => "Regional anaesthesia"
            2 => "Peripheral nerve block"
            3 => "Local anaesthetic"
            4 => "Postoperative pain"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La combinaci&#243;n de f&#225;rmacos y v&#237;as de administraci&#243;n consigue un efecto sin&#233;rgico&#44; por eso las estrategias analg&#233;sicas multimodales incorporan bloqueos perif&#233;ricos como componente imprescindible para un buen control del dolor&#46; La asociaci&#243;n de un coadyuvante al anest&#233;sico local prolongar&#237;a su efecto&#46; Esta revisi&#243;n sistem&#225;tica ha incluido estudios sobre coadyuvantes asociados a anest&#233;sicos locales en bloqueos perif&#233;ricos publicados en los &#250;ltimos cinco a&#241;os&#46; El objetivo principal ha sido evaluar su eficacia&#46; Los resultados de la b&#250;squeda se informaron de acuerdo con los elementos PRISMA&#46; Los 79 art&#237;culos seleccionados seg&#250;n criterios&#44; mostraron una clara prevalencia de dexametasona &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41; y dexmedetomidina &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41; sobre los dem&#225;s coadyuvantes&#46; Diferentes metaan&#225;lisis que comparan a los coadyuvantes sugieren un bloqueo de caracter&#237;sticas superiores y menores efectos adversos con dexametasona vs&#46; dexmedetomidina perineuralmente&#46; Con base en los estudios&#44; encontramos una evidencia moderada en el empleo de dexametasona como coadyuvante de la anestesia regional perif&#233;rica en cirug&#237;as que generen dolor moderado- severo&#44; lo que har&#237;a recomendable su empleo&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The combination of drugs and routes of administration produces a synergistic effect&#44; and one of the most important components of multimodal analgesic strategies are&#44; therefore&#44; nerve blocks for pain management&#46; The effect of a local anaesthetic can be prolonged by administering an adjuvant&#46; In this systematic review&#44; we included studies on adjuvants associated with local anaesthetics in peripheral nerve blocks published in the last 5 years in order to evaluate their effectiveness&#46; The results were reported according to the PRISMA guidelines&#46; The 79 studies selected using our criteria showed a clear prevalence of dexamethasone &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41; and dexmedetomidine &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41; over other adjuvants&#46; Different meta-analyses comparing adjuvants suggest that dexamethasone administered perineurally achieves superior blockade with fewer side effects than dexmedetomidine&#46; Based on the studies reviewed&#44; we found moderate evidence to recommend the use of dexamethasone as an adjuvant to peripheral regional anaesthesia in surgeries that can cause moderate to severe pain&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de estudio&#47;pacientes&#47;dosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">a&#241;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Principales hallazgos cl&#237;nicos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hussain et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Metan&#225;lisis&#58; 18 RCT&#44; 1&#46;092 pacientes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Acorta el inicio de acci&#243;n y prolonga la duraci&#243;n del bloqueo&#46;Necesaria monitorizaci&#243;n por riesgo de bradicardia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vorobeichik et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metan&#225;lisis&#58; 32 RTC&#44; 2&#46;007 pacientes50-60<span class="elsevierStyleHsp" style=""></span>&#956;g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prolonga bloqueo sensorial&#44; motor y duraci&#243;n analgesiaReduce consumo morfina&#46; Beneficios superan a los riesgos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Helal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RTC&#58; 60 pacientes&#44; 100<span class="elsevierStyleHsp" style=""></span>&#956;g a bupivaca&#237;naBloqueo femoral y ci&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La duraci&#243;n del bloqueo sensorial y motor fue m&#225;s prolongada Analgesia m&#225;s prolongada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Zhao et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 9 RTC&#44; 580 pacientes1-2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina en bloqueo femoral prolonga analgesia&#44; disminuye consumo de opioides&#59; aumenta hipotensi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 20 RCT&#44; 1&#46;212 pacientes35-100<span class="elsevierStyleHsp" style=""></span>&#956;g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Facilita la analgesia postoperatoria&#46; Prolonga el bloqueo TAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes&#46; Dexmedeto 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asociada a lidoca&#237;na disminuye la concentraci&#243;n media efectiva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kaye et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metan&#225;lisis&#58; <span class="elsevierStyleItalic">ASA Guidelines</span> 2017&#40;2&#46;000 pacientes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">El empleo en protocolos ERAS mejora los resultados postoperatorios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Somsunder et al&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RTC&#58; 60 pacientesDexmedetomidina&#44; 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#46;kg-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina administrado IV es igual de efectiva que perineural&#44; pero produce mayor inestabilidad hemodin&#225;mica&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bansal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 9 RTC&#44; 598 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&#241;adida al anest&#233;sico local en bloqueo TAP disminuyen consumo de opioides y prolonga el tiempo de rescate analg&#233;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neethirajan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">52</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RTC&#58; 60 pacientes0&#44;125&#37; bupivacaine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg-1 dexmedeto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La dexmedetomidinaa en bloqueo TAP prolonga la analgesia postoperatoria y reduce los rescates analg&#233;sicos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avula et al&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">53</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes&#46; 0&#44;5&#37; bupivacaine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>dexmedetomidina &#40;75<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina en bloqueo supraclavicular acorta el comienzo de acci&#243;n y prolonga la duraci&#243;n del bloqueo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Akhondzadeh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">54</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 72 pacientes3 mg&#47;kg&#44; lidoca&#237;na 2&#37;&#44; Dexdemetomidina &#40;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina asociada con lidoca&#237;na mejora el bloqueo supraclavicular y disminuye el dolor postoperatorio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rashmi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">55</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes0&#44;75&#37; ropivacaina<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>&#956;g dexmedetomidina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina en bloqueo interescal&#233;nico disminuye el tiempo de inicio y la duraci&#243;n del bloqueo sensitivo y motor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 90 pacientes&#46; Continua 2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg dexmedetomidina<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#37; ropivaca&#237;na&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina preserva la fuerza de m&#250;sculo cu&#225;driceps con buena analgesia en un bloqueo femoral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sharma et al&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">57</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes&#46; Continua 1&#44;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg dexmedetomidina<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#44;2&#37; ropivaca&#237;na&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina acorta el comienzo y prolonga la duraci&#243;n del bloqueo sensitivo-motor&#44; sin destacables efectos adversos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ahuja et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">58</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 90 pacientes&#46; 0&#44;5&#37; ropivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg dexdemetomidina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">El uso de dexmedetomidina en el bloqueo ci&#225;tico disminuye el consumo de tramadol en cirug&#237;a de rodilla&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">59</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n&#58; 22 RCT&#44; 1&#46;412 pacientes&#58; 0&#44;5&#37; ropivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL dexmedetomidina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina es adecuado coadyuvante&#44; pero con efectos adversos &#40;hipotensi&#243;n&#44; bradicardia&#41; a tener en consideraci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Packiasabapathy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">60</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes&#46;0&#44;25&#37; bupivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg o 2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg dexmedetomidina&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dosis superiores producen un efecto superior&#44; pero la deambulaci&#243;n necesita de m&#225;s estudios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Samar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">61</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 40 pacientes&#46; Dexmedetomidina iv 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>infusi&#243;n 0&#44;4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;h vs&#46; perineural 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina IV mejor resultado que perineural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thapa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">62</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 105 pacientes&#46; Dexmedetomidina iv 0&#44;5&#63;&#956;g&#47;&#63;kg<span class="elsevierStyleSup">&#8722;1</span> vs&#46; perineural 0&#44;5&#63;&#956;g&#47;&#63;kg<span class="elsevierStyleSup">&#8722;1</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#44;5&#37; ropivaca&#237;na&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina perineural produce un menor consumo de morfina a las 4<span class="elsevierStyleHsp" style=""></span>h que iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bisui et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">63</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 70 pacientes&#46; Levobupivaca&#237;na &#40;0&#44;5&#37;&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#44;75<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg dexmedetomidina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina en bloqueo supraclavicular acorta el inicio y prolonga el efecto sensitivo- motor del bloqueo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Andersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">64</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 22 pacientes&#46; Ropivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>dexmedetomidina 100<span class="elsevierStyleHsp" style=""></span>&#956;g iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina perineural prolonga m&#225;s la duraci&#243;n del bloqueo que v&#237;a sist&#233;mica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Xue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 40 ratas&#46; Ropivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg o 20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg dexmedetomidina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexmedetomidina prolonga la duraci&#243;n del bloqueo dosis dependiente y previene la neurotoxicidad de la ropivacaina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Taylan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">65</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 24 ratasDosis acumulativas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Altas dosis de dexmedetomidina inhiben conducci&#243;n nerviosa en nervio ci&#225;tico aislado de animal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ping et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">66</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 18 RCT&#44; 515 pacientesDexmedetomidina 50-100<span class="elsevierStyleHsp" style=""></span>&#956;g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DEX es un f&#225;rmaco que puede mejorar la analgesia y el bloqueo&#44; pero tambi&#233;n aumenta el riesgo de bradicardia e hipotensi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bansal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">67</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 9 RCT&#44; 598 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disminuye el consumo de opioides en cirug&#237;a con TAP&#46; En la evaluaci&#243;n del dolor postoperatorio no es definitivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vel&#225;zquez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">68</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; Dexmedetomidina 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mejor control del dolor postoperatorio durante las primeras 24 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Andersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">69</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 21 voluntarios sanosRopivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>dexmedetomidina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prolonga el bloqueo por un efecto perif&#233;rico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Karan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">70</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientesDexmedetomidina 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Produce una importante prolongaci&#243;n del bloqueo ilioinguinal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">71</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 12 RCT&#44; 671 pacientesDexmedetomidina 50-100<span class="elsevierStyleHsp" style=""></span>&#956;g<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ropivaca&#237;na&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acorta el comienzo y prolonga el efecto&#44; sin diferencias en la incidencia de bradicardia o hipotensi&#243;n sobre grupo control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Memary et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">72</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 62 pacientesDexmedetomidina 100<span class="elsevierStyleHsp" style=""></span>&#956;g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Podr&#237;a disminuir el consumo de opioides en el bloqueo femoral&#44; con descenso de efectos adversos de los opioides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liping et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 7 RCT&#44; 546 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disminuye el consumo de opioides en artroplastia de rodilla y es seguro&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">73</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientesDexmedetomidina 50<span class="elsevierStyleHsp" style=""></span>&#956;g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mejora la eficacia de la ropivaca&#237;na en bloqueo popl&#237;teo &#40;acorta el comienzo y prolonga el bloqueo&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Resumen de los art&#237;culos referidos a la utilizaci&#243;n de la dexmedetomidina</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de estudio&#47;pacientes&#47;dosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">A&#241;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Principales hallazgos cl&#237;nicos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pehora et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica Cochrane35 RCT&#44; 2&#46;702 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En miembro superior&#44; tanto perineural como iv&#44; prolonga el bloqueo y ahorra opioidesEn miembro inferior&#58; no concluyente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sehmbi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">26</span></a>&#44;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 100 RCT&#44; 5&#46;728 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexametasona prolonga m&#225;s que dexdemetomidinaSin diferencias significativas entre perineural e iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heesen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 10 RCT&#44; 783 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perineural prolonga m&#225;s el bloqueo que iv&#46; Baja evidencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marhofer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 24 pacientes&#59; 4 mg perineural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sin significativo efecto sobre el bloqueo cubital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kirkham et al&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 33 RCT&#44; 2&#46;138 pacientes&#40;1-4 mg&#41;&#47;&#40;5-10 mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4<span class="elsevierStyleHsp" style=""></span>mg perineural es dosis techo para prolongar efecto&#46; Baja evidencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hussain et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 14 RCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perineural e iv equivalente analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Zorrilla-Vaca et al&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 13 RCT&#44; 937 pacientes4<span class="elsevierStyleHsp" style=""></span>mg perineural&#47;iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La administraci&#243;n perineural produce mejores resultados analg&#233;sicos&#46; Hip&#243;tesis&#58; acci&#243;n local sobre el nervio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">49</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 132 pacientes0&#44;375&#37; ropivaca&#237;na<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mg dexametasona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduce el rebote hiperalg&#233;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chen et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 9 RCT&#44; 575 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Utilizada en el bloqueo TAP prolonga el efecto y mejora la analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Veneziano et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 77 pacientes&#59; 4<span class="elsevierStyleHsp" style=""></span>mg perineural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En adolescentes no modifica el efecto del bloqueo femoral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wegner et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 82 pacientesdexametasona 8 mg<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ropivaca&#237;na 0&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No prolonga el efecto del TAP&#44; pero mejora la valoraci&#243;n del dolor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vetriselvan et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 40 pacientes4<span class="elsevierStyleHsp" style=""></span>mg perineural&#47;8<span class="elsevierStyleHsp" style=""></span>mg iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ambas v&#237;as tienen un efecto similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sakae et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes4<span class="elsevierStyleHsp" style=""></span>mg dexametasona iv&#47;perineural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dosis perineural m&#225;s efectiva que iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bindal et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 120 pacientesDexametasona 8<span class="elsevierStyleHsp" style=""></span>mg perineural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&#241;adida a bupivica&#237;na y ropivaca&#237;na prolonga el bloqueo sensitivo motor y disminuye el rescate analg&#233;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ibrahim et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 60 pacientes8<span class="elsevierStyleHsp" style=""></span>mg dexametasona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&#241;adida a bupivaca&#237;na prolonga el bloqueo del canal abductor y prolonga el requerimiento analg&#233;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Zhao et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metaan&#225;lisis&#58; 10 RCT&#44; 749 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La dosis perineural prolonga el bloqueo si se a&#241;ade a anest&#233;sico local con epinefrina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marty et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 100 pacientes&#59; 4 mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En cirug&#237;a de pie son igual de efectivas las dosis perineural e iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jaeger et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 20 voluntarios&#59; 2 mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cuestionable efecto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bjorn et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 40 pacientes&#59; 4 mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perineural prolonga el bloqueo safeno y disminuye las necesidades de opioides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wiesmann et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Los autores prefieren v&#237;a venosa por entender mejor los efectos secundarios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mai et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RCT&#58; 96 pacientes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perineural mejora analgesia perioperatoria&#44; reduce tiempo recuperaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                          "etal" => true
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