Scientific Letter
Shock following subcutaneous injections of polymethylmethacrylate
Shock después de inyecciones subcutáneas de polimetilmetacrilato
M. Boattini
, A.R. Francisco, R. Cavaco, J. Rodrigues, L. Bento
Corresponding author
Unidade de Urgência Médica, Hospital São José, Centro Hospitalar Lisboa Central, Portugal
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Boattini, A.R. Francisco, R. Cavaco, J. Rodrigues, L. Bento" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Boattini" "email" => array:1 [ 0 => "matteoboattini@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A.R." "apellidos" => "Francisco" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Cavaco" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Rodrigues" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Bento" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidade de Urgência Médica, Hospital São José, Centro Hospitalar Lisboa Central, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Shock después de inyecciones subcutáneas de polimetilmetacrilato" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2597 "Ancho" => 1677 "Tamanyo" => 358555 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">1A. Chest X-ray showing bilateral lung infiltrates. 1B-E. Chest CT angiographyshowing bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 35-year-old transsexual (male to female) went to emergency with 24<span class="elsevierStyleHsp" style=""></span>h of mild fever, cough and dyspnoea. Four days before he had been submitted to multiple gluteus subcutaneous injections of polymethylmethacrylate (PMMA) microspheres. Patient had a past medical history of uncontrolled hypertension.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On admission patient had Glasgow Coma Scale Score of 15, tachypnea and tachycardia, with central cyanosis and was sweating. No fever. Blood pressure was 100/70<span class="elsevierStyleHsp" style=""></span>mmHg and respiratory rate 40/min. Arterial blood gas analysis under 15<span class="elsevierStyleHsp" style=""></span>l/min oxygen therapy by a non-rebreathing mask with reservoir showed global respiratory insufficiency and sever acidemia (pH 7.22, pO<span class="elsevierStyleInf">2</span> 31<span class="elsevierStyleHsp" style=""></span>mmHg, pCO<span class="elsevierStyleInf">2</span> 49<span class="elsevierStyleHsp" style=""></span>mmHg, HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">−</span> 17.6<span class="elsevierStyleHsp" style=""></span>mEq/L, SatO<span class="elsevierStyleInf">2</span> 55%, lactate 6.17<span class="elsevierStyleHsp" style=""></span>mmol/L). Heart auscultation revealed audible S1 and S2 and chest auscultation revealed bilateral rales. The remaining physical examination just was unremarkable with exception of mild redness, warmth and swelling of the gluteus. No fluctuation was detected and no indication for surgical approach was considered. Chest X-ray showed bilateral lung infiltrates (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). At this time was intubated and mechanically ventilated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On intensive care unit (ICU) admission presented with hypotension, tachycardia, oligoanuric renal failure, mixed acidemia and pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio of 40. Biochemistry showed: normocytic normochromic anaemia, high white blood cells count, coagulation times prolonged, acute renal lesion with hyperkalemia, hyperbilirubinemia 1.49<span class="elsevierStyleHsp" style=""></span>mg/dL [0.3–1.2], conjugated bilirubin 0.79 [0–0.2], hepatic cytolysis high lactate dehydrogenase and C-reactive protein. Patient was started on empirical antibiotic therapy with meropenem due to the inflammatory signs in gluteus.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Electrocardiogram showed sinus tachycardia with S1Q3T3 pattern. Computed tomography angiography ruled out pulmonary embolism and disclosed bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B–E). Transthoracic echocardiogram revealed normal left ventricular systolic function with no contractility alterations, valve dysfunctions or pericardial effusion.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pulse contour cardiac output (PiCCO) catheter was placed and haemodynamic monitoring showed low cardiac index (CI), low intrathoracic blood volume index (ITBVI), low central venous oxygen saturation (cvSatO<span class="elsevierStyleInf">2</span>), high venous-to-arterial CO<span class="elsevierStyleInf">2</span> gap (pCO<span class="elsevierStyleInf">2</span> gap), high extravascular lung water index (EVLWI) and normal systemic vascular resistance (SVR) on norepinephrine 0.55<span class="elsevierStyleHsp" style=""></span>μg/kg/min. Distributive shock (DS) with vasoplegia, functional hypovolemia and pulmonary oedema complicated with multiple organ dysfunction syndrome (MODS) was diagnosed (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Patient was started on vasopressors and continuous renal replacement technique. He developed severe (pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>100)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> acute respiratory distress syndrome (ARDS) with need of prone position and curarization.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Serologies for HIV, HBV, HCV, EBV, CMV, <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> and respiratory virus were negative. Tracheobronchial aspirate, uroculture and pneumococcal and <span class="elsevierStyleItalic">Legionella</span> urinary antigen tests were negative. Three sets of blood culture specimens exhibited no growth. Meropenem stopped on the 5th day of therapy.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patient remained apyretic, inflammatory markers decreased and gluteus inflammatory signs improved rapidly. Patient remained under continuous renal replacement technique for 5 days with gradual recovery of renal function and vasopressor support was stopped on 2nd day. He was mechanically ventilated for 15 days and was extubated on 16th day.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest CT with significant reduction of pulmonary infiltrates. Laboratory tests evidenced recovery of hepatic function with correction of the coagulation disorder.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patient was transferred to intermediate care on 17th day and then to the general ward, requiring only physical rehabilitation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Shock is a high mortality acute syndrome characterized by cellular dysoxia, and can lead if not quickly and appropriately managed to organ failure and death. It is classically rated has hypovolemic, cardiogenic, obstructive or distributive. The first three are associated with low CI while distributive shock is associated with normal or supranormal levels of CI,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> impaired distribution of microvascular blood flow and metabolic distress. DS occurs mainly during systemic inflammatory response syndrome (SIRS) which can be due to infectious or non-infectious causes. The most common aetiology of DS is septic shock. Non-infectious causes include burns, pancreatitis, toxic shock syndrome, anaphylaxis and drugs or toxins. PMMA is a no biodegradable injectable filling used for a variety of conditions such as percutaneous vertebroplasty and cosmetic soft tissue filling. PMMA subcutaneous injections local complications are nodules, filler migration and granulomas. Mostly described following percutaneous vertebroplasty systemic complications include pulmonary embolism,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> pulmonary embolism with ARDS,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> ventricular perforation,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> intracardiac embolism,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> aortic embolism,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> renal embolism<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and deep vein thrombosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Our patient never had fever. Inflammatory markers decreased rapidly and did not relapse after meropenem has been stopped. No pathogenic organisms were isolated. We assisted to a favourable evolution even in absence of antibiotherapy. These facts make infectious aetiology less probable. Most probable hypothesis due to patient's history of PMMA gluteus subcutaneous injections four days before, absence of positive culture results and favourable evolution just with organ support therapy is SIRS triggered by chemical insult induced by PMMA. To the best of our knowledge, this is the first case reported in literature of shock and MODS secondary to subcutaneous injection of PMMA.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">All the authors have reported no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2597 "Ancho" => 1677 "Tamanyo" => 358555 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">1A. Chest X-ray showing bilateral lung infiltrates. 1B-E. Chest CT angiographyshowing bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BP, blood pressure; HR, heart rate; CVP, central venous pressure; CI, cardiac index; SVR, systemic vascular resistance; EVLWI, extravascular lung water index; ITBVI, intrathoracic blood volume index; paO<span class="elsevierStyleInf">2</span>, arterial oxygen partial pressure; aSatO<span class="elsevierStyleInf">2</span>, arterial oxygen saturation; pvO<span class="elsevierStyleInf">2</span>, venous oxygen partial pressure; cvSatO<span class="elsevierStyleInf">2</span>, central venous oxygen saturation; pCO<span class="elsevierStyleInf">2</span> gap, venous-to-arterial CO<span class="elsevierStyleInf">2</span> gap; FiO<span class="elsevierStyleInf">2</span>, fraction of inspired oxygen; PEEP, positive end-expiratory pressure; Hb, haemoglobin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">On admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 36<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 72<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 96<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Norepinephrine, μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">151/66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">139/66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">145/80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">148/89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90/54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">179/103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">121/70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">HR, bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">CVP, cm H<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">CI (2.8–3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SVR (770–1500) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1169 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">731 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1034 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1115 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">630 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1720 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">725 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">EVLWI (3–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ITBVI (850–1000) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">486 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">594 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">619 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">676 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">714 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">766 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1043 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">paO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">122 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">116 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">162.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">111 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">aSatO<span class="elsevierStyleInf">2</span>% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">99.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pvO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">cvSatO<span class="elsevierStyleInf">2</span>% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pCO<span class="elsevierStyleInf">2</span> gap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FiO<span class="elsevierStyleInf">2</span> (21–100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PEEP, cm H<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lactate, mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hb, g/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab902827.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PiCCO haemodynamic monitoring.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ 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Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jvs.2012.02.039" "Revista" => array:6 [ "tituloSerie" => "J Vasc Surg" "fecha" => "2012" "volumen" => "56" "paginaInicial" => "1119" "paginaFinal" => "1123" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22572011" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003900000004/v3_201509260116/S2173572715000260/v3_201509260116/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003900000004/v3_201509260116/S2173572715000260/v3_201509260116/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000260?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 9 | 14 |
| 2024 October | 60 | 61 | 121 |
| 2024 September | 52 | 41 | 93 |
| 2024 August | 76 | 51 | 127 |
| 2024 July | 49 | 31 | 80 |
| 2024 June | 64 | 44 | 108 |
| 2024 May | 58 | 33 | 91 |
| 2024 April | 43 | 33 | 76 |
| 2024 March | 59 | 23 | 82 |
| 2024 February | 58 | 40 | 98 |
| 2024 January | 47 | 31 | 78 |
| 2023 December | 42 | 39 | 81 |
| 2023 November | 47 | 44 | 91 |
| 2023 October | 39 | 32 | 71 |
| 2023 September | 36 | 29 | 65 |
| 2023 August | 36 | 14 | 50 |
| 2023 July | 36 | 17 | 53 |
| 2023 June | 44 | 13 | 57 |
| 2023 May | 57 | 29 | 86 |
| 2023 April | 62 | 19 | 81 |
| 2023 March | 63 | 32 | 95 |
| 2023 February | 61 | 34 | 95 |
| 2023 January | 61 | 24 | 85 |
| 2022 December | 75 | 23 | 98 |
| 2022 November | 58 | 42 | 100 |
| 2022 October | 40 | 20 | 60 |
| 2022 September | 26 | 32 | 58 |
| 2022 August | 47 | 36 | 83 |
| 2022 July | 28 | 22 | 50 |
| 2022 June | 31 | 16 | 47 |
| 2022 May | 39 | 43 | 82 |
| 2022 April | 30 | 34 | 64 |
| 2022 March | 46 | 42 | 88 |
| 2022 February | 47 | 22 | 69 |
| 2022 January | 55 | 25 | 80 |
| 2021 December | 45 | 42 | 87 |
| 2021 November | 38 | 39 | 77 |
| 2021 October | 72 | 64 | 136 |
| 2021 September | 51 | 33 | 84 |
| 2021 August | 51 | 38 | 89 |
| 2021 July | 36 | 29 | 65 |
| 2021 June | 39 | 26 | 65 |
| 2021 May | 35 | 37 | 72 |
| 2021 April | 111 | 76 | 187 |
| 2021 March | 55 | 11 | 66 |
| 2021 February | 46 | 26 | 72 |
| 2021 January | 42 | 21 | 63 |
| 2020 December | 35 | 17 | 52 |
| 2020 November | 45 | 20 | 65 |
| 2020 October | 29 | 28 | 57 |
| 2020 September | 35 | 12 | 47 |
| 2020 August | 29 | 14 | 43 |
| 2020 July | 34 | 19 | 53 |
| 2020 June | 22 | 17 | 39 |
| 2020 May | 27 | 8 | 35 |
| 2020 April | 29 | 8 | 37 |
| 2020 March | 10 | 11 | 21 |
| 2020 February | 33 | 43 | 76 |
| 2020 January | 37 | 17 | 54 |
| 2019 December | 22 | 30 | 52 |
| 2019 November | 30 | 16 | 46 |
| 2019 October | 25 | 11 | 36 |
| 2019 September | 28 | 18 | 46 |
| 2019 August | 23 | 13 | 36 |
| 2019 July | 20 | 20 | 40 |
| 2019 June | 24 | 14 | 38 |
| 2019 May | 32 | 26 | 58 |
| 2019 April | 30 | 15 | 45 |
| 2019 March | 24 | 15 | 39 |
| 2019 February | 22 | 27 | 49 |
| 2019 January | 28 | 26 | 54 |
| 2018 December | 35 | 22 | 57 |
| 2018 November | 46 | 33 | 79 |
| 2018 October | 33 | 23 | 56 |
| 2018 September | 15 | 5 | 20 |
| 2018 August | 11 | 4 | 15 |
| 2018 July | 14 | 10 | 24 |
| 2018 June | 19 | 7 | 26 |
| 2018 May | 10 | 3 | 13 |
| 2018 April | 15 | 4 | 19 |
| 2018 March | 12 | 4 | 16 |
| 2018 February | 9 | 8 | 17 |
| 2018 January | 22 | 6 | 28 |
| 2017 December | 17 | 4 | 21 |
| 2017 November | 22 | 6 | 28 |
| 2017 October | 17 | 5 | 22 |
| 2017 September | 17 | 8 | 25 |
| 2017 August | 19 | 6 | 25 |
| 2017 July | 17 | 10 | 27 |
| 2017 June | 22 | 4 | 26 |
| 2017 May | 9 | 7 | 16 |
| 2017 April | 18 | 7 | 25 |
| 2017 March | 10 | 1 | 11 |
| 2017 February | 7 | 2 | 9 |
| 2017 January | 6 | 3 | 9 |
| 2016 December | 23 | 2 | 25 |
| 2016 November | 32 | 3 | 35 |
| 2016 October | 23 | 7 | 30 |
| 2016 September | 16 | 5 | 21 |
| 2016 August | 13 | 5 | 18 |
| 2016 July | 9 | 6 | 15 |
Show all
