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drugs&#46; Antipyretic treatments are effective in lowering temperature&#44; but can have important side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Such drugs should not be used on a routine basis in the Intensive Care Unit &#40;ICU&#41;&#46; The risks and benefits should be evaluated individually in each fever episode&#46; Paracetamol is simple to administer and is safe&#44; with a high therapeutic index and a low risk of side effects in the form of renal&#44; gastrointestinal or hematological disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Metamizol in turn is usually used to treat postoperative pain and fever&#46; Dexketoprofen is a water-soluble salt of ketoprofen&#44; a dextrorotary enantiomer belonging to the group of nonsteroidal antiinflammatory drugs &#40;NSAIDs&#41;&#46; It is used as an analgesic and antiinflammatory agent&#44; and <span class="elsevierStyleItalic">in vitro</span> constitutes one of the most potent inhibitors of prostaglandin synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> To date&#44; the antipyretic effect of dexketoprofen has only been described in animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This drug substance has been compared with other NSAIDs in the management of postoperative pain&#46; It appears to be better tolerated than other NSAIDs&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but its antipyretic effect and hemodynamic profile in critical patients have not been described&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The present study compares the antipyretic and hemodynamic effects of paracetamol&#44; metamizol and dexketoprofen&#8211;the main drugs used to treat fever in critical patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A prospective observational study was carried out in the 16-bed ICU of a University hospital between 2005 and April 2007&#44; involving 150 patients with an episode of fever &#40;over 38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; which the supervising physician decided to treat using one of the three drugs employed in the Unit for this purpose&#46; Each patient was included in the study only once&#46; The decision to treat was established in each patient based on the clinical repercussions of fever&#58; tachypnea&#44; tachycardia&#44; changes in blood pressure and increased production of carbon dioxide or oxygen consumption&#46; The antipyretic treatments commonly used in our Unit for fever are paracetamol 1000<span class="elsevierStyleHsp" style=""></span>mg&#44; metamizol 2000<span class="elsevierStyleHsp" style=""></span>mg and dexketoprofen 50<span class="elsevierStyleHsp" style=""></span>mg &#8211; all administered as an intravenous infusion during 30<span class="elsevierStyleHsp" style=""></span>minutes&#46; An ethics committee of our hospital approved the study without the need for informed consent&#46; The following variables were monitored at baseline &#40;immediately prior to the start of treatment&#41; and 30&#44; 60 and 120<span class="elsevierStyleHsp" style=""></span>minutes after infusion of the drug&#58; axillary temperature&#44; systolic blood pressure&#44; diastolic blood pressure&#44; mean blood pressure &#40;MBP&#41;&#44; heart rate &#40;HR&#41; and oxygen saturation &#40;SatO<span class="elsevierStyleInf">2</span>&#41; measured by pulsioximetry&#46; Temperature was monitored 180<span class="elsevierStyleHsp" style=""></span>minutes after infusion of the drug to determine a decrease of at least 1<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Blood pressure was recorded using an invasive system in those patients in which such a system was already in place&#44; based on a femoral or radial arterial catheter&#44; and noninvasively using a digital arm sphygmomanometer in the rest of the cases&#46; The pressure measurement system of a given patient was not modified in the course of the different measurements&#46; Diuresis was recorded from baseline and up to 120<span class="elsevierStyleHsp" style=""></span>minutes&#46; We also documented the requirements referred to vasopressor drugs&#44; vasodilators and fluid therapy before treatment and during 120<span class="elsevierStyleHsp" style=""></span>minutes after infusion&#46; Likewise&#44; the SAPS &#40;Simplified Acute Physiology Score&#41; II<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> was recorded upon admission&#44; along with the reason for admission and the need for mechanical ventilation &#40;MV&#41; at the time of the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The sample size calculated to detect a decrease of 1<span class="elsevierStyleHsp" style=""></span>&#176;C in temperature was 50 patients per group&#44; with a type I error of 5&#37; &#40;<span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and a statistical power of 80&#37; &#40;<span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;20&#41;&#46; The patients were included in the study until completion of the assigned 50 subjects per group&#46; The quantitative variables were subjected to analysis of variance &#40;ANOVA&#41;&#44; while the chi-squared test was used to analyze the qualitative variables&#46; A two-factors ANOVA was used with the general linear model &#40;GLM&#41;&#46; The factors were&#58; time &#40;start of the study&#44; 30&#44; 60 and 120<span class="elsevierStyleHsp" style=""></span>minutes&#41;&#44; treatment &#40;paracetamol&#44; metamizol and dexketoprofen&#41; and their interaction&#44; which would serve to answer the question of whether the evolution of the treatments differed in the course of follow-up&#46; A <span class="elsevierStyleItalic">post hoc</span> analysis was performed where necessary&#46; In addition&#44; ANOVA was used to compare the decrease in MBP with each treatment from baseline and up to 120<span class="elsevierStyleHsp" style=""></span>minutes&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The SPSS version 14&#46;0&#46;1 statistical package &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41; was used throughout&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 150 patients studied&#44; 102 were males &#40;68&#37;&#41; and 48 females &#40;32&#37;&#41;&#46; The mean age was 58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16 years &#40;range 19&#8211;86&#41;&#46; The SAPS II score was 42&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;4&#46; Each group &#40;paracetamol&#44; metamizol and dexketoprofen&#41; comprised 50 patients&#46; The demographic characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There were no statistically significant differences between the groups for any of these variables&#46; All enrolled patients completed the study&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Temperature</span><p id="par0035" class="elsevierStylePara elsevierViewall">We recorded a significant decrease in temperature of at least 1<span class="elsevierStyleHsp" style=""></span>&#176;C after 180<span class="elsevierStyleHsp" style=""></span>minutes in 38 patients treated with dexketoprofen &#40;76&#37;&#41;&#44; in 36 treated with metamizol &#40;72&#37;&#41; and in 20 treated with paracetamol &#40;40&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; In 37&#37; of the patients no decrease of at least 1<span class="elsevierStyleHsp" style=""></span>&#176;C was observed after 180<span class="elsevierStyleHsp" style=""></span>minutes&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the mean decrease in temperature in each group at the four timepoints&#44; while <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> documents the mean and standard deviation of the temperature drop for each drug and at each of the studied timepoints&#46; A significant decrease in temperature was recorded over time&#44; but there were no interactions among the three different therapies over time &#8211; <span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; none of the treatments lowered body temperature more than the rest at any of the timepoints&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hemodynamics</span><p id="par0040" class="elsevierStylePara elsevierViewall">The systemic hemodynamic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; expressed as the mean and standard deviation&#46; There were no statistically significant differences between the groups in terms of mean blood pressure&#44; oxygen saturation determined by pulsioxymetry or heart rate at the different timepoints studied and for each antipyretic drug&#46; Likewise&#44; there were no differences in diuresis recorded during the study period among the different treatments&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the evolution of MBP<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation at the four timepoints &#40;baseline&#44; and after 30&#44; 60 and 120<span class="elsevierStyleHsp" style=""></span>minutes&#41; in each of the three groups&#46; There were no statistically significant differences between the treatments at any timepoint&#46; A significant decrease in MBP was recorded over time&#44; with interaction of the three different treatments in time&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the mean decrease in MBP in each group&#46; After 120<span class="elsevierStyleHsp" style=""></span>minutes&#44; the mean decrease in MBP was 8&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;6<span class="elsevierStyleHsp" style=""></span>mmHg with paracetamol&#44; 14&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;8<span class="elsevierStyleHsp" style=""></span>mmHg with metamizol&#44; and 16&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;7<span class="elsevierStyleHsp" style=""></span>mmHg with dexketoprofen &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46; The <span class="elsevierStyleItalic">post hoc</span> analysis showed the drop in MBP in the paracetamol group to be smaller than in the metamizol and dexketoprofen groups&#44; while no statistically significant differences were recorded between the metamizol and dexketoprofen groups&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Thirty-nine of the 150 patients &#40;26&#37;&#41; were receiving vasoconstrictors during the fever episode&#58; 15 in the paracetamol group &#40;38&#46;5&#37;&#41;&#44; 9 in the metamizol group &#40;23&#37;&#41; and 15 in the dexketoprofen group &#40;38&#46;5&#37;&#41;&#46; Of these 39 patients&#44; one in the paracetamol group was receiving adrenalin&#44; one in the metamizol group was receiving dopamine&#44; and the rest were all receiving noradrenalin at the doses required to keep the mean blood pressure above 65<span class="elsevierStyleHsp" style=""></span>mmHg&#46; After starting antipyretic treatment&#44; 10 of 15 patients treated with paracetamol &#40;66&#37;&#41;&#44; including the patient receiving adrenalin&#44; required an increase in vasoconstrictor dose&#46; Seven of the 9 patients in the metamizol group &#40;77&#37;&#41; and 12 of the 15 patients in the dexketoprofen group &#40;80&#37;&#41; required an increase in noradrenalin dose&#46; Vasopressor treatment was started to maintain adequate systemic blood pressure in 7 patients&#58; one in the paracetamol group&#44; two in the metamizol group and four in the dexketoprofen group&#46; Twenty-eight of the 150 patients &#40;18&#46;7&#37;&#41; were receiving vasodilators in continuous infusion with nitroprussiate or labetalol&#58; 10 in the paracetamol group &#40;35&#46;7&#37;&#41;&#44; 11 in the metamizol group &#40;39&#46;3&#37;&#41; and 7 in the dexketoprofen group &#40;25&#37;&#41;&#46; The vasodilator dosage had to be lowered in 6 of the 10 patients treated with paracetamol &#40;60&#37;&#41;&#44; in 9 of the 11 patients treated with metamizol &#40;81&#46;8&#37;&#41;&#44; and in 5 of the 7 patients treated with dexketoprofen &#40;71&#46;4&#37;&#41;&#46; In 7 of the patients receiving vasodilators&#44; the treatment had to be suspended&#58; three in the paracetamol group&#44; three in the metamizol group and one in the dexketoprofen group&#46; None of these patients required the start of vasoconstrictor treatment&#46; There were no statistically significant differences in the need for vasoconstrictor increments or for a lowering of vasodilator dose between the groups&#44; and in all patients the aim was to maintain the mean blood pressure above 65<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fifteen of the 150 patients &#40;10&#37;&#41; required fluid therapy while receiving antipyretic treatment&#44; in order to avoid an excessive drop in blood pressure&#46; Four patients in the paracetamol group&#44; 5 in the metamizol group and 6 in the dexketoprofen group required the administration of 250&#8211;500<span class="elsevierStyleHsp" style=""></span>ml of crystalloids&#44; administered during 30<span class="elsevierStyleHsp" style=""></span>minutes after detecting the decrease in blood pressure&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Twenty patients suffered acute renal failure and required hemodialysis before antipyretic treatment&#58; 8 in the paracetamol group&#44; 5 in the metamizol group and 7 in the dexketoprofen group&#46; After antipyretic treatment&#44; a total of 5 additional patients required hemodialysis&#58; four in the paracetamol group and one in the dexketoprofen group&#46; None of the patients were connected to the dialysis system during the study&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The main findings of this observational study were that paracetamol appeared to be the best of the three studied drugs in terms of a lesser reduction in MBP&#46; However&#44; paracetamol only proved capable of lowering temperature by at least 1<span class="elsevierStyleHsp" style=""></span>&#176;C after 180<span class="elsevierStyleHsp" style=""></span>minutes in less than one-half of the patients&#46; These findings suggest that it may be the drug of choice in the treatment of a fever episode when the patient is hemodynamically unstable&#44; although a significant decrease in temperature is unlikely&#46; In patients under hemodynamically stable conditions&#44; metamizol or dexketoprofen could be the first choice for lowering temperature&#44; due to the greater percentage success with these drugs compared with paracetamol&#46; In those patients in which temperature did not decrease &#40;37&#37;&#41;&#44; we do not know what the course would have been without the administration of antipyretic treatment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although physical cooling measures are effective in reducing skin temperature when the physiological thermoregulation mechanisms are altered&#44; such measures do not lower the thermoregulatory center temperature setting&#44; and moreover can increase discomfort and metabolic stress in non-sedated febrile patients&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Our study was carried out with three commonly used drug substances&#58; paracetamol&#44; metamizol and dexketoprofen&#46; A number of studies in the literature have compared changes in temperature and the hemodynamic effects of drugs used for the treatment of fever&#46; The antipyretic effects of metamizol and paracetamol have been described elsewhere&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;15</span></a> Poblete et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> found that paracetamol and metamizol do not induce clinically significant temperature reductions in critical patients with fever&#44; compared with the adoption of physical cooling measures&#46; However&#44; Gozzoli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> compared these same drugs&#44; <span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; metamizol and paracetamol&#44; with physical measures in the treatment of fever&#44; and found all three treatments to lower temperature equally&#46; As in our study&#44; these authors concluded that metamizol should not be regarded as the first choice antipyretic drug in hemodynamically unstable patients&#44; and that paracetamol should be preferred in such cases&#46; The discrepancies between the studies of Poblete and Gozzoli are probably due to the small number of patients studied in each group&#58; 20 in the first and 30 in the second&#46; Oborilov&#225; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> in turn studied 254 fever episodes&#44; fundamentally in hemato-oncological patients treated with metamizol&#44; diclofenac and paracetamol&#46; They found all these drugs to offer a significant antipyretic effect&#44; though metamizol proved better than paracetamol in improving patient discomfort associated to fever&#46; However&#44; this study did not include critical patients and&#44; on the other hand&#44; since these were hemato-oncological patients&#44; the immune alterations produced by the tumor disease or by the associated treatment could have influenced the temperature values&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our study all three drug substances lowered MBP&#46; Of 39 patients receiving vasoconstrictor treatment&#44; a large percentage in each group required a drug dose increment&#44; and vasoconstrictor treatment had to be started in 7 patients&#46; Of the total of 28 patients receiving vasodilators&#44; the drug dose had to be lowered in a large proportion of patients and suspended in 7 of the 28 subjects&#46; In this group of patients&#44; the hypotensive effect of the antipyretic drugs may have been magnified by the concomitant infusion of a vasodilator drug&#46; However&#44; since a low percentage of patients was involved&#44; with a homogeneous distribution among all treatment groups&#44; we suspect that this effect is scantly relevant in terms of the end result&#46; Despite these hemodynamic changes&#44; diuresis was not modified during the 120<span class="elsevierStyleHsp" style=""></span>minutes of follow-up&#46; These results are comparable to those of others in which metamizol induced a significant decrease in MBP compared with paracetamol&#46; Using metamizol&#44; ketorolac and paracetamol as treatment for postoperative pain in critical patients&#44; Avellaneda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> reported a decrease in radial blood pressure in all three treatment groups&#44; while Hoign&#233; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> registered a significant drop in systolic pressure in patients treated with metamizol&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Cruz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> also described a decrease in MBP and in other hemodynamic variables after the administration of metamizol or paracetamol in 60 patients with fever&#46; In the case of hypotension induced by metamizol&#44; this was explained by the relaxing effect of the drug upon the smooth muscle cells&#44; resulting in peripheral vasodilatation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Our study has a number of limitations&#46; A first consideration is the study design involved&#46; Since this is an observational and not a randomized or masked study&#44; the results obtained are not conclusive&#46; The choice of antipyretic treatment based on the decision of the supervising physician may have introduced drug&#8211;patient selection bias&#46; On the other hand&#44; since the effects of the three drug substances were not compared with the adoption of physical cooling measures as in other studies&#44; the comparison possibilities are limited&#46; In turn&#44; we recorded axillary temperature but not core temperature&#8211;the latter only being routinely registered in our ICU once or twice a day&#46; On the other hand&#44; the American College of Critical Care Medicine and the Infectious Diseases Society of America define fever as a temperature of over 38&#46;3<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In our ICU&#44; however&#44; we treat patients with temperatures of 38<span class="elsevierStyleHsp" style=""></span>&#176;C or higher and with clinical repercussions&#46; Our study only reflects our daily clinical practice&#46; In turn&#44; the administered drug dose was not calculated according to body weight&#44; and the prescribed standard dose may have influenced the results&#46; Likewise&#44; no registries were made of pain&#46; In our ICU&#44; patients subjected to mechanical ventilation receive sedation and analgesia in order to maintain a Ramsay Sedation Scale<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> score of between 2 and 3&#46; In our series&#44; 123 patients were on mechanical ventilation at the time of the fever episode&#44; but we do not have specific data referred to the situation of pain among the included patients&#59; a hemodynamic effect of pain therefore cannot be discarded&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">It is not clear whether fever in itself is beneficial or harmful&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21</span></a> Studies in animals with infection describe fever as being beneficial&#44; and there is no evidence that the administration of antipyretic drugs modifies mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Fever complements the host immune defenses against infection<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and activates some immune function parameters&#44; with the activation of T cells&#44; cytokine production and antibodies&#44; and neutrophil and macrophage function&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> On the other hand&#44; an elevated body temperature may be associated to a range of deleterious effects such as increased cardiac output&#44; oxygen consumption and carbon dioxide production&#46; These changes may be poorly tolerated by critical patients with a limited cardiorespiratory reserve&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The negative hemodynamic and metabolic effects of fever are particularly undesirable in the presence of heart problems or in situations of clinical sepsis&#44; in which myocardial function is depressed&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Moreover&#44; during or after a period of brain ischemia or trauma&#44; hyperthermia markedly increases the resulting neuronal damage&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> All these data suggest that the treatment of a fever episode should be evaluated individually taking into account the benefits and possible side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In sum&#44; dexketoprofen and metamizol exhibited a better antipyretic effect at the studied doses&#44; but with a poorer hemodynamic profile&#46; In contrast&#44; paracetamol was associated with increased hemodynamic stability but with a lesser antipyretic effect&#46; The characteristics of each individual patient should be taken into account when prescribing an antipyretic drug&#44; in order to avoid hemodynamic instability&#46; Nevertheless&#44; further studies are needed&#44; involving a randomized design&#44; in order to be able to draw firm conclusions&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective was to study the antipyretic and hemodynamic effects of three different drugs used to treat fever in critically ill patients&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Design and setting&#58; Prospective&#44; observational study in a 16-bed&#44; general ICU of a university hospital&#46; Patient population&#58; We studied 150 patients who had a febrile episode &#40;temperature &#62;38&#176;<span class="elsevierStyleHsp" style=""></span>C&#41;&#58; 50 received paracetamol&#44; 50 metamizol and 50 dexketoprofen&#46; Interventions&#58; None&#46; Body temperature&#44; systolic&#44; diastolic and mean arterial pressure&#44; heart rate&#44; central venous pressure and oxygen saturation were determined at baseline and at 30&#44; 60 and 120<span class="elsevierStyleHsp" style=""></span>minutes after infusion of the drug&#46; Additionally&#44; we recorded temperature 180<span class="elsevierStyleHsp" style=""></span>minutes after starting drug infusion&#46; Diuresis and the need for or change of dose of vasodilator or vasoconstrictor drugs were also recorded&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics&#44; baseline temperature and hemodynamics were similar in all groups&#46; We observed a significant decrease of at least 1<span class="elsevierStyleHsp" style=""></span>&#176;C in temperature after 180<span class="elsevierStyleHsp" style=""></span>minutes in 38 patients treated with dexketoprofen &#40;76&#37;&#41;&#44; in 36 with metamizol &#40;72&#37;&#41;&#44; and in 20 with paracetamol &#40;40&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; After 120<span class="elsevierStyleHsp" style=""></span>minutes&#44; the mean decrease in mean arterial pressure was 8&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;6<span class="elsevierStyleHsp" style=""></span>mmHg with paracetamol&#44; 14&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;8<span class="elsevierStyleHsp" style=""></span>mmHg with metamizol&#44; and 16&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;7<span class="elsevierStyleHsp" style=""></span>mmHg with dexketoprofen &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dexketoprofen was the most effective antipyretic agent at the doses tested&#46; Although all three drugs reduced mean arterial pressure&#44; the reduction with paracetamol was less pronounced&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo fue estudiar los efectos antipir&#233;ticos y hemodin&#225;micos de 3 f&#225;rmacos diferentes utilizados para tratar la fiebre en pacientes cr&#237;ticos&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Dise&#241;o&#58; estudio prospectivo&#44; observacional&#44; en una UCI de 16 camas de un Hospital Universitario&#46; Pacientes&#58; 150 pacientes que tuvieron un episodio febril &#40;temperatura<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>38&#176;<span class="elsevierStyleHsp" style=""></span>C&#41;&#46; Intervenci&#243;n&#58; 50 recibieron paracetamol&#44; 50 metamizol y 50 dexketoprofeno&#46; Se determinaron la temperatura axilar&#44; presi&#243;n arterial sist&#243;lica&#44; diast&#243;lica y media&#44; frecuencia card&#237;aca&#44; presi&#243;n venosa central y saturaci&#243;n de ox&#237;geno&#44; en situaci&#243;n basal y a los 30&#44; 60 y 120 minutos tras la administraci&#243;n del f&#225;rmaco&#46; Tambi&#233;n se registr&#243; la temperatura a los 180 minutos despu&#233;s de haber iniciado el f&#225;rmaco&#46; La diuresis y las necesidades de tratamiento vasodilatador y vasoconstrictor durante el tratamiento tambi&#233;n se registraron&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las caracter&#237;sticas de los pacientes&#44; la temperatura y la hemodin&#225;mica basal fueron similares en todos los grupos&#46; Observamos un descenso significativo de al menos un grado en la temperatura despu&#233;s de 180 minutos en 38 pacientes tratados con dexketoprofeno &#40;76&#37;&#41;&#44; en 36 con metamizol &#40;72&#37;&#41;&#44; y en 20 con paracetamol &#40;40&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Despu&#233;s de 120 minutos&#44; la media del descenso de la presi&#243;n arterial media fue de 8&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg con paracetamol&#44; 14&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;8<span class="elsevierStyleHsp" style=""></span>mmHg con metamizol y 16&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;7<span class="elsevierStyleHsp" style=""></span>mmHg con dexketoprofeno &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Dexketoprofeno fue el f&#225;rmaco antipir&#233;tico m&#225;s efectivo&#44; a las dosis estudiadas&#46; Aunque los 3 f&#225;rmacos redujeron la tensi&#243;n arterial media&#44; la reducci&#243;n con paracetamol fue menos pronunciada&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Vera P&#44; et al&#46; Efectos hemodin&#225;micos y antipir&#233;ticos del paracetamol&#44; metamizol y dexketoprofeno en pacientes cr&#237;ticos&#46; Med Intensiva&#46; 2012&#59;36&#58;619&#8211;25&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean and standard deviation of temperature at baseline and after 30&#44; 60 and 120<span class="elsevierStyleHsp" style=""></span>minutes with each treatment&#46;</p>"
        ]
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mean and standard deviation of mean blood pressure &#40;MBP&#41; at baseline and after 30&#44; 60 and 120<span class="elsevierStyleHsp" style=""></span>minutes with each treatment&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Mean and standard deviation of the change in mean blood pressure &#40;MBP&#41; between baseline and after 120<span class="elsevierStyleHsp" style=""></span>minutes&#46; Differences between paracetamol and metamizol &#40;&#42;&#41; and paracetamol and dexketoprofen &#40;&#42;&#42;&#41; were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; COPD&#58; chronic obstructive pulmonary disease&#59; M&#58; male&#59; F&#58; female&#59; ns&#58; nonsignificant&#59; SAPS&#58; Simplified Acute Physiology Score&#46;</p>"
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>150&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Metamizol &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age &#40;mean years<span class="elsevierStyleHsp" style=""></span></span>&#177;<span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&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
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                  \t\t\t\t"><span class="elsevierStyleItalic">SAPS II</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \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">43&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;3&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
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                  \t\t\t\t">41&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gender&#58; M&#47;F</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">102&#47;48&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">34&#47;16&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  " align="left" valign="\n
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                  \t\t\t\t">40&#47;10&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  " align="left" valign="\n
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                  \t\t\t\t">28&#47;22&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mechanical ventilation</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">123 &#40;82&#37;&#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
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                  \t\t\t\t">41 &#40;82&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38 &#40;76&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44 &#40;88&#37;&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pneumonia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35 &#40;23&#37;&#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">12 &#40;24&#37;&#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">12 &#40;24&#37;&#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">11 &#40;22&#37;&#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
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">14 &#40;28&#37;&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;28&#37;&#41;&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"><span class="elsevierStyleHsp" style=""></span>Cardiovascular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \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">7 &#40;14&#37;&#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">4 &#40;8&#37;&#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">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Abdominal surgery&nbsp;\t\t\t\t\t\t\n
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                  \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">10 &#40;20&#37;&#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">10 &#40;20&#37;&#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">17 &#40;34&#37;&#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">ns&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleHsp" style=""></span>Exacerbated COPD-asthma&nbsp;\t\t\t\t\t\t\n
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                  \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">3 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#37;&#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">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#37;&#41;&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;10&#37;&#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">7 &#40;14&#37;&#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">5 &#40;10&#37;&#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">3 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab12359.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics at baseline and per treatment group&#46; There were no statistically significant differences between the groups&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
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          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Baseline&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">38&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&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">37&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">MBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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