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array:22 [ "pii" => "S0034935616000578" "issn" => "00349356" "doi" => "10.1016/j.redar.2016.02.007" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "695" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:251-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 304 "formatos" => array:3 [ "EPUB" => 2 "HTML" => 193 "PDF" => 109 ] ] "itemSiguiente" => array:19 [ "pii" => "S0034935615001784" "issn" => "00349356" "doi" => "10.1016/j.redar.2015.07.006" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "639" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:253-60" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 260 "formatos" => array:3 [ "EPUB" => 20 "HTML" => 129 "PDF" => 111 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL</span>" "titulo" => "Utilización de la monitorización analgésica intraoperatoria mediante pupilometría en el consumo de analgésicos durante las primeras 12 horas del postoperatorio" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "253" "paginaFinal" => "260" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The use of pupillometry as monitoring of intraoperative analgesia in the consumption of analgesics during the first 12 hours after surgery" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1127 "Ancho" => 1676 "Tamanyo" => 94973 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Consumo de analgésicos en las primeras 12<span class="elsevierStyleHsp" style=""></span>h en planta.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Abad Torrent, V. Rodríguez Bustamante, N. Carrasco Fons, F.J. Roca Tutusaus, D. Blanco Vargas, C. González García" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Abad Torrent" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Rodríguez Bustamante" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Carrasco Fons" ] 3 => array:2 [ "nombre" => "F.J." "apellidos" => "Roca Tutusaus" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Blanco Vargas" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "González García" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192915001067" "doi" => "10.1016/j.redare.2015.12.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192915001067?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935615001784?idApp=UINPBA00004N" "url" => "/00349356/0000006300000005/v1_201604150052/S0034935615001784/v1_201604150052/es/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Should we maintain deep–moderate neuromuscular block until the end of laparoscopic surgery? The evidence and a clash of strong opinions" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "251" "paginaFinal" => "252" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "T. Ledowski" "autores" => array:1 [ 0 => array:4 [ "nombre" => "T." "apellidos" => "Ledowski" "email" => array:1 [ 0 => "thomas.ledowski@health.wa.gov.au" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "School of Medicine and Pharmacology, University of Western Australia, Perth, Australia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Correspondence to: School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Hwy, Crawley, Perth, WA 6009, Australia. Tel.: +61 8 9224 0201; fax: +61 8 92240279." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Se debería mantener un bloqueo neuromuscular profundo-moderado hasta completar las intervenciones laparoscópicas? Los hallazgos y el choque de posturas definidas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Since the introduction of neuromuscular blocking agents (NMBA) into anaesthesia practice in 1942, the benefits vs. dangers of neuromuscular block (NMB) have always been intensely discussed.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1,2</span></a> Though it is clear that NMBA facilitate many operations which were previously thought to be impossible,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> the ideal depth of NMB is much less certain. Based on a review by Ali et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> in 1976, a single twitch depression of 90–95% was seen as providing surgeons with satisfactory operating conditions. Since it was theoretically possible to antagonize such block with neostigmine, Ali's recommendation must also be viewed as a necessary compromise between depth of NMB and the need for reversal at the end of surgery. Surgeons had to accept that a deeper NMB was not usually provided, and anaesthetists developed a “plan of action” (i.e. changing ventilation patterns or deepening anaesthesia<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a>) to respond to surgeon complaints without further muscle relaxation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">However, with the introduction of sugammadex this game has changed. Economic considerations left aside, it is now certainly possible to maintain a moderate (1–3 twitches in the train of four [TOF]) to even deep (twitches in the post tetanic count but not in the TOF) NMB until the very end of surgery. The latter has re-opened the discussion about the most desirable depth of NMB – an ongoing debate unfortunately not just based on science, but also strong opinions. Adding to the confusion, some recent trials<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6–8</span></a> have compared various outcomes under “no block” vs. “deep block” conditions. Though these have uniformly concluded that deep NMB was beneficial, the question may be allowed whether a “no block” group actually reflects standard practice. It is at least the author's opinion that for laparoscopic procedures currently more often than not NMBA are administered at the time of tracheal intubation, and thereafter only if surgeons complain about unsatisfactory operating conditions. Comparators better suited to match “real life” may hence be a continuously maintained deep–moderate NMB vs. a deep block at the start of a case and spontaneous recovery/shallow NMB thereafter. Such studies do in fact exist, and though limited in numbers, all have concluded that a continuously maintained moderate–deep block resulted in better operating conditions,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> increased intraabdominal space<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> and lower postoperative pain scores.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In a clinical context, findings of benefits for continuously maintained deep–moderate block could make sense: the closure of abdominal fascia or retrieval of resected organs (i.e. gallbladder) are time points at the end of the procedure during which surgeons are likely to appreciate a deeper level of muscle relaxation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The question remains whether moderate block is sufficient or whether deep NMB must be maintained. To date only two<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12,13</span></a> studies appear to be sufficiently well designed to provide an answer. Martini et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> found significantly better operating conditions in 12 deeply paralyzed vs. 12 moderately paralyzed patients undergoing laparoscopic surgery. Though the study was well designed, its major pitfall is the small number of patients in each group. An investigation by Yoo et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> randomized 67 patients for robotic assisted laparoscopic prostatectomies to receive either moderate or deep NMB. They found that surgery could be accomplished at a relatively low intraabdominal pressure of 8<span class="elsevierStyleHsp" style=""></span>mmHg in 88% of the deeply paralyzed patients, but only 25% of patients with moderate NMB. Though the latter studies may provide a hint towards a benefit for deeper NMB, the evidence may not yet be sufficient to justify the <span class="elsevierStyleItalic">routine</span> administration of deep NMB.</p><p id="par0025" class="elsevierStylePara elsevierViewall">However, the concept of a continuously maintained deep–moderate NMB also has its opponents.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,14</span></a> In fact, both reviews finding no plausible benefit for deep–moderate continuously maintained NMB stem from the same senior authors, namely Drs. Kopman and Naguib. But what exactly do they criticize? On the scientific side one of their stronger arguments is that to date no study has investigated postoperative patient outcome.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Though this is correct, one may want to keep in mind that differences in “hard” outcome parameters such as postoperative mortality are notoriously difficult to prove. With a mortality rate after laparoscopic cholecystectomies of about 0.02% (USA),<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> very large studies would be required. These can and should be done – but usually such projects follow rather than precede smaller “pilot” trials. Unfortunately, the reviews also mix science with opinion: the authors argue that before sugammadex became available (and hence theoretically allowed continuously maintained deep NMB) in the USA (2016) surgeons in the US quiet successfully performed thousands of laparoscopies without continuously maintained neuromuscular block.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> This is surely correct, but the lack of experience of US surgeons with continuously maintained deep–moderate NMB is per se certainly no valid argument against it. Not surprisingly, the first of these reviews<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> was heavily criticized by the proponents of deep NMB (the author of this editorial included)<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">16,17</span></a> and the second,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> once print published, is likely to face similar criticism. But are Kopman and Naguib really completely wrong? Certainly not. Their conclusion that there is yet not sufficient evidence for the <span class="elsevierStyleItalic">routine</span> administration of continuously maintained deep block is a valid point. It is the dismissal of any benefit for a continuously maintained deep to moderate block which makes these reviews, at least in the authors view, problematic.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Now, since we know that large randomized outcome studies comparing deep to moderate NMB with standard practice (one-off dose of NMBA with no continuously maintained NMB) are not yet available – what conclusions are permitted based on current publications?</p><p id="par0035" class="elsevierStylePara elsevierViewall">Firstly, that during laparoscopic surgery deep–moderate NMB is superior to no block. Secondly, that when compared to spontaneous recovery/shallow block continuously maintained deep–moderate NMB appears to result in better operating conditions and, under certain circumstances, possibly less postoperative pain. Thirdly, whether or not a continuously maintained NMB needs to be “deep” or can be “moderate” will need further investigation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Lastly, potential benefits (i.e. faster surgery, better patient outcome) as well as costs (i.e. costs for NMB reversal) of continuously maintained NMB are significant. Well-designed studies, larger or small, investigating this topic further should be strongly encouraged.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of curare in general anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.R. Griffith" 1 => "G.E. Johnson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Anesthesiology" "fecha" => "1942" "volumen" => "3" "paginaInicial" => "418" "paginaFinal" => "420" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0095" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A study of the deaths associated with anaesthesia and surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.K.T.D. Beecher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "1954" "volumen" => "140" "paginaInicial" => "2" "paginaFinal" => "34" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13159140" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0100" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthesia before and after curare" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.F. Foldes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anaesthesiol Reanim" "fecha" => "1993" "volumen" => "18" "paginaInicial" => "128" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8280340" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0105" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Monitoring of neuromuscular function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.H. Ali" 1 => "J.J. Savarese" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "1976" "volumen" => "45" "paginaInicial" => "216" "paginaFinal" => "249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/180849" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0110" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is deep neuromuscular block beneficial in laparoscopic surgery? No, probably not" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.F. Kopman" 1 => "M. Naguib" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2016" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7572002" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0115" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep neuromuscular blockade leads to a larger intraabdominal volume during laparoscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.L. Lindekaer" 1 => "H. Halvor Springborg" 2 => "O. Istre" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3791/51911" "Revista" => array:3 [ "tituloSerie" => "J Vis Exp" "fecha" => "2013" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25285454" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0120" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuromuscular blockade improves surgical conditions (NISCO)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Blobner" 1 => "C.G. Frick" 2 => "R.B. Stauble" 3 => "H. Feussner" 4 => "S.J. Schaller" 5 => "C. Unterbuchner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00464-014-3711-7" "Revista" => array:6 [ "tituloSerie" => "Surg Endosc" "fecha" => "2015" "volumen" => "29" "paginaInicial" => "627" "paginaFinal" => "636" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25125097" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0125" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Van Wijk" 1 => "R.W. Watts" 2 => "T. Ledowski" 3 => "M. Trochsler" 4 => "J.L. Moran" 5 => "G.W. Arenas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/aas.12491" "Revista" => array:6 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2015" "volumen" => "59" "paginaInicial" => "434" "paginaFinal" => "440" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25684372" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0130" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.E. Dubois" 1 => "L. Putz" 2 => "J. Jamart" 3 => "M.L. Marotta" 4 => "M. Gourdin" 5 => "O. Donnez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/EJA.0000000000000094" "Revista" => array:6 [ "tituloSerie" => "Eur J Anaesthesiol" "fecha" => "2014" "volumen" => "31" "paginaInicial" => "430" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24809482" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0135" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: a randomized clinical study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.K. Staehr-Rye" 1 => "L.S. Rasmussen" 2 => "J. Rosenberg" 3 => "P. Juul" 4 => "A.L. Lindekaer" 5 => "C. Riber" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Anesth Analg" "fecha" => "2014" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12456431" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0140" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: a randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.V. Madsen" 1 => "O. Istre" 2 => "A.K. Staehr-Rye" 3 => "H.H. Springborg" 4 => "J. Rosenberg" 5 => "J. Lund" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Eur J Anaesthesiol" "fecha" => "2015" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0145" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.H. Martini" 1 => "M. Boon" 2 => "R.F. Bevers" 3 => "L.P. Aarts" 4 => "A. Dahan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aet377" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2014" "volumen" => "112" "paginaInicial" => "498" "paginaFinal" => "505" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24240315" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0150" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The intraocular pressure under deep versus moderate neuromuscular blockade during low-pressure robot assisted laparoscopic radical prostatectomy in a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.C. Yoo" 1 => "N.Y. Kim" 2 => "S. Shin" 3 => "Y.D. Choi" 4 => "J.H. Hong" 5 => "C.Y. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0135412" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2015" "volumen" => "10" "paginaInicial" => "e0135412" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26317357" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0155" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic surgery and muscle relaxants: is deep block helpful?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.F. Kopman" 1 => "M. Naguib" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000000471" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2015" "volumen" => "120" "paginaInicial" => "51" "paginaFinal" => "58" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25625254" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0160" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and an analysis of 77,604 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.J. Deziel" 1 => "K.W. Millikan" 2 => "S.G. Economou" 3 => "A. Doolas" 4 => "S.T. Ko" 5 => "M.C. Airan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "1993" "volumen" => "165" "paginaInicial" => "9" "paginaFinal" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8418705" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0165" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimal surgical conditions in laparoscopic surgery: just relax and lower the pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.D. de Boer" 1 => "J.P. Mulier" 2 => "A. Dahan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000000907" "Revista" => array:5 [ "tituloSerie" => "Anesth Analg" "fecha" => "2016" "volumen" => "122" "paginaInicial" => "288" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26678475" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0170" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic surgery and muscle relaxants: is deep block really not helpful?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T. Ledowski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000001007" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2016" "volumen" => "122" "paginaInicial" => "290" "paginaFinal" => "293" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26678478" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00349356/0000006300000005/v1_201604150052/S0034935616000578/v1_201604150052/en/main.assets" "Apartado" => array:4 [ "identificador" => "50880" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editorial article" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00349356/0000006300000005/v1_201604150052/S0034935616000578/v1_201604150052/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935616000578?idApp=UINPBA00004N" ]
