Noninvasive hemoglobin monitoring in critically ill pediatric patients at risk of bleeding

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Tomasa Irriguible, J. Sabater Riera, E. Poch López de Briñas, J. Fort Ros, M.J. Lloret Cora, J. Roca Antònio, A. Navas Pérez, P. Ortiz Ballujera, L. Servià Goixart, F.J. González de Molina Ortiz, C. Rovira Anglès, M. Rodríguez López, A. Roglan Piqueras" "autores" => array:14 [ 0 => array:2 [ "nombre" => "T.M." "apellidos" => "Tomasa Irriguible" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Sabater Riera" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Poch López de Briñas" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Fort Ros" ] 4 => array:2 [ "nombre" => "M.J." "apellidos" => "Lloret Cora" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Roca Antònio" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Navas Pérez" ] 7 => array:2 [ "nombre" => "P." "apellidos" => "Ortiz Ballujera" ] 8 => array:2 [ "nombre" => "L." "apellidos" => "Servià Goixart" ] 9 => array:2 [ "nombre" => "F.J." "apellidos" => "González de Molina Ortiz" ] 10 => array:2 [ "nombre" => "C." 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These figures show increase in complication rates according to ED waiting time. (A) There is a tendency of increase in shock rate with longer ED LOS (but no significant, p=0.10). (B) There is a significant tendency of increase in renal failure rate with longer ED LOS (p=0.001). (C) There is a significant tendency of increase in coagulopathy rate with longer ED LOS (p<0.001). (D) There is a significant tendency of increase in multiple organ failure rate with longer ED LOS (p=0.009)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. García-Gigorro, F. de la Cruz Vigo, E.M. Andrés-Esteban, S. Chacón-Alves, G. Morales Varas, J.A. Sánchez-Izquierdo, J.C. Montejo González" "autores" => array:7 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "García-Gigorro" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "de la Cruz Vigo" ] 2 => array:2 [ "nombre" => "E.M." "apellidos" => "Andrés-Esteban" ] 3 => array:2 [ "nombre" => "S." 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García-Soler, J.M. Camacho Alonso, J.M. González-Gómez, G. Milano-Manso" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "García-Soler" "email" => array:1 [ 0 => "patricia.garcia.soler.sspa@juntadeandalucia.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Camacho Alonso" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "González-Gómez" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Milano-Manso" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monitorización no invasiva transcutánea de la concentración de hemoglobina en pacientes críticos pediátricos con riesgo de sangrado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1300 "Ancho" => 1658 "Tamanyo" => 105036 ] ] "descripcion" => array:1 [ "en" => "Dispersion diagram between the Hb values of the core lab analyser and the pulse co-oximeter (SpHb)." ] ] ] "textoCompleto" => "IntroductionAnemia is a common complication in pediatric intensive care units (PICU) and amounts to up to 74% of hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0130">1</a> In critical patients anemia is the consequence of blood losses due to acute traumatic hemorrhages in the postoperative period, especially due to cardiac or trauma surgeries, repeated blood extractions, chronic disorders, iron and other deficiency disorders, liver dysfunction or disseminated intravascular clotting, among others. In one multicentre, observational, prospective study conducted in children admitted at pediatric intensive care units, Bateman et al.<a class="elsevierStyleCrossRef" href="#bib0130">1</a>, found that 96% of these patients had their blood test analyzed, and 74% exhibited daily blood losses. Patients with anemia had longer hospital stays and spent more days on mechanical ventilation. Forty-one percent of children with anemia developed it during their hospital stay while only 33% had anemia at the moment of hospital admission. Conducting repeated blood test analyses can cause iatrogenic anemia that is present in up to 90% of patients during the third day of admission in adult intensive care units.<a class="elsevierStyleCrossRefs" href="#bib0135">2,3</a> This fact becomes more important in younger patients since the blood volume needed for extraction is not related to the child's weight, which means that larger volumes will be associated with the patient's blood volume.<a class="elsevierStyleCrossRef" href="#bib0145">4</a> Thus, the more serious the patient's condition is, the more blood losses due to blood extractions will occur.<a class="elsevierStyleCrossRef" href="#bib0140">3</a>However, the diagnosis of anemia cannot be clinically validated and requires confirmation through blood sample analysis. The setback of trying to determine the blood hemoglobin concentration using conventional methods is that obtaining lab results can delay therapy.The capacity to rapidly and accurately determine a patient's blood hemoglobin concentration may be useful and critical in various clinical settings, especially in intensive medicine, which has led to the development of point-of-care (POC) devices, that is, devices available at the patient's bedside so that there is no need to bring the blood sample to the core lab. Nevertheless, the accuracy of these methods has been questioned in some studies.<a class="elsevierStyleCrossRefs" href="#bib0150">5–9</a>These are the non-invasive modalities available today: pulse Co-oximetry (Pulse CO-Oximetry™; Masimo Corp., Irvine, CA, USA), occlusion spectroscopy (OrSense™, Ness Ziona, Israel) and transcutaneous reflectance spectroscopy (Haemospect, MBR Optical Systems, Herdecke, Germany).<a class="elsevierStyleCrossRef" href="#bib0175">10</a>The technology behind pulse co-oximetry is based on pulse oximetry and provides a continuous non-invasive monitoring of the blood hemoglobin concentration. This method allows us to distinguish between the different characteristics of light absorption and the different subtypes of hemoglobin, and through the implementation of certain algorithms is capable of determining the total blood hemoglobin concentration.<a class="elsevierStyleCrossRef" href="#bib0180">11</a> Theoretically speaking, one device capable of continuously measuring the blood hemoglobin concentration would have results earlier and alert clinicians on any drops in all those cases of hidden hemorrhages–all this added to the advantages of non-invasive measurements.There are some studies conducted in the pediatric population, most of them in the surgical setting and with hemodynamically stable patients.<a class="elsevierStyleCrossRefs" href="#bib0185">12–14</a>This is why we decided to conduct one study aimed at determining the validity and accuracy of this monitoring method in relation to the determination achieved at the core lab in PICU-hospitalized patients at risk of bleeding.Material and methodsGoalDetermine the validity and accuracy of one continuous transcutaneous method for measuring the blood hemoglobin (Hb) concentration in critical patients at risk of bleeding.DesignProspective observational design.Field of studyPICU of a third-level referral academic hospital.Study populationThe study included patients admitted at the PICU with risk of bleeding (postoperative cardiac or trauma surgery patients, polytraumatized patients and patients with serious coagulopathy in the context of systemic inflammatory syndrome response), weighting >3kg for a period of twelve (12) months.Study protocolWhen each blood sample was extracted, the concentration of Hb at the core lab (Siemens ADVIA 2120i) was compared to the concentration of Hb shown by the Radical/7.8.0.1 pulse co-oximeter (Masimo Corp., Irvine, CA). Several epidemiological variables were recorded (genre, age in months, weight, race), reason for hospital admission together with the following parameters: perfusion index (PI), plethysmographic variability index (PVI), heart rate (HR), SaO2, rectal temperature (RT), the Richmond Agitation Sedation Scale (RASS), low signal quality detected by the monitor, and all those situations that might affect measurement (Vasoactive-Inotropic Score [VIS score], mechanical ventilation).The PI is defined as the coefficient of pulse blood flow in relation to the non-pulsed or static flow in peripheral tissue and is one non-invasive way to measure peripheral perfusion. The PVI measures dynamic changes occurring in the PI during the respiratory cycle, which are expressed in percentages and calculated by the device following this formula: [(maximum PI−minimum PI)×100]/maximum PI.Based on the manufacturer's specifications, the finger of the hand (ringer finger, middle finger, and index finger of the non-dominant hand) and the hallux of the foot were the locations used, while limbs with recent lesions, surgeries or vascular catheters–mainly arterial catheters were avoided. The sphygmomanometer was always placed in a limb different to where the sensor had been placed. After its placement the explored area was covered with an opaque bag supplied by the manufacturer in order to avoid pollution and light interference. If there was no stable measurement after two (2) attempts another measurement was attempted in a different location before recording the case as non-detectable. Likewise, the low signal quality alarm was recorded, which according to the manufacturer's specifications, goes off in situations of excessive environmental light pollution, shunt between photo emitter and photo detector due to sensor misplacement, patients making moves, or between the placement site and the sensor.The R1 20L sensor was used in patients whose weight was between 3 and 10kg. For individuals over 10kg, the R2 20 sensor was used.Statistical analysisIn the descriptive analysis, data are expressed as mean and standard deviation for variables of normal distribution, and as mean and interquartile range (IQR) for variables that do not meet the conditions of normality. The categorical variables are described as absolute frequency and percentage.The Pearson correlation coefficient was obtained as well as the interclass correlation coefficient (ICC) that was calculated using a two-factor alpha model, random effects and absolute consensus with a 95% confidence interval and the Bland–Altman diagram in order to compare the hemoglobin concentration established by the pulse co-oximeter (SpHb) and the hemoglobin concentration established by the core lab analyser (tHb). Tolerance limits were established in differences of ±1g/dl. In order to calculate the difference between the two (2) methods, the absolute difference was used in the first place–including both negative and positive values. In the Bland–Altman analysis, positive and negative numbers were used to know these differences.Using the multivariate linear regression analysis, the influence exerted by the independent variables gathered on the absolute difference between both methods was analyzed. Using the multivariate logistic regression analysis, the correlation between low signal quality (yes/no) and different potential variables associated was studied. A 5% statistical-significance level was taken into account. For the selection of the final multivariate model in both cases, a backward step-wise regression proceeding (Wald test statistics) was used initially including all the variables that might have something to do with the dependent variables and the variables that exhibited statistical significance in the bivariate analysis. The Akaike information criterion (AIC) was used to confirm how good the adjustment of the model really was.For the statistical analysis, the IBM® SPSS® Statistics 20.0 software for Macintosh® was used. The Bland–Altman diagram was built using the R software–version 3.2.2.Ethical aspectsThis paper has been approved by the Regional Research Ethics Committee. Participation in this study was voluntary. The patients’ legal representatives were verbally informed and given one copy of the written informed consent. The study authors declare that they have followed the good clinical practice and principles contained in the Declaration of Helsinki.Results284 measurements were taken in 80 patients averaging 14.5 months of age (range 3–60 months) and 8.5kg of weight (range 4.35–18.5kg). In 15 determinations (5.2%), the SpHb could not be recorded due to poor peripheral hyperperfusion uptake, and in 36 determinations (12.7%) there was poor signal quality as the Radical7 station exhibited.The SaO2 was 98% (IQR 96–100%), the HR 123±24lpm, the RT 36±2°C, the PI 1.5 (IQR 0.93–3.32) and the PVI 17 (IQR 11–27.25).Most patients included were postoperative cardiac surgery patients (76.4%), and polytraumatized patients (14.8%), while 8.8% had been admitted to the hospital PICU for other reasons such as post-adenoidectomy bleeding (4), upper GI bleeding (2), or septic shock (1). Sixty-three percent (22 cases) of all measurements were taken during mechanical ventilation–all of them under continuous sedation with a mean RASS score of −3 (IQR from −2.8 to −4.1). Five (5) patients (6.25%) received therapy with alpha-adrenergic vasoactive drugs. The mean VIS score was 8 (RIQ 0–10).The average Hb concentration exhibited in the core lab analyser was 11.7±2.05g/dl (median 11.5, IQR 10.27–13). The average Hb concentration exhibited in the pulse-oximeter was 12.32±2g/dl (median 12.1g/dl, IQR 11–13.4) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The Pearson correlation coefficient was 0.72 (p<0.001), and the coefficient of determination R2, 0.52 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The overall ICC was 0.69 (95% CI: 0.55–0.78), p<0.001. The ICC in determinations with PI>1.5 was 0.70 (95% CI: 0.6–0.78), but when the PI was ≤1.5, the ICC was 0.68 (95% CI: 0.43–0.81)–being both values statistically significant (p<0.001). Concordance was higher in individuals over 6months (0.7, 95% CI: 0.59–0.78) compared to individuals under 6 months (0.59, 95% CI: 0.36–0.74). When the monitor exhibited low signal quality (12.7% of cases), the ICC was 0.45 (95% CI: 0.06–0.71), while in the remaining cases the ICC was 0.74 (95% CI: 0.62–0.81).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The average difference between lab values and pulse co-oximeter values was 0.66±1.46g/dl, with a median of 0.5g/dl (IQR from −0.2 to 1.4). The mean difference in absolute values was 0.8g/dl (IQR from 0.4 to 1.7). The mean difference between both methods was greater in postoperative cardiac surgery patients (0.8g/dl, IQR from 0.4 to 1.8) than in polytraumatized patients (0.6g/dl, IQR from 0.3 to 1) and in the remaining patients (0.45g/dl, IQR from 0.3 to 1.57), though these differences were not statistically significant in the Kruskal–Wallis test (p=0.065) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The Bland–Altman diagram (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) shows that most differences can be found within the concordance limits – being the upper limit (+2DE) 3.59g/dl, and the lower limit (−2DE) −2.26g/dl. As it can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, 60.9% of all measurements taken with the non-invasive pulse co-oximeter exhibited a ≤−1g/dl difference with respect to data exhibited by the core lab analyser.<elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Using a linear regression model, the correlation between the absolute difference of both measurements and the real Hb concentration could be studied, and a statistically significant correlation was found (p=0.007), with a β coefficient of −0.09 and a coefficient of determination R2 of 0.027.In the multivariate linear regression analysis, the absolute difference between both methods was used as the dependent variable, including the variables that had a statistically significant relation in the correlation matrix as well as race, reason for hospital admission and need for invasive mechanical ventilation. Using a backward step-wise proceeding, the multivariate model was built, maintaining both all significant variables and those variables enhancing the validity of the model as <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows. According to this model, the lower the Hb concentration is, the higher the HR and fetal Hb concentration are; the difference between both methods of measurement becomes greater in a statistically significant way.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>One multivariate logistic regression analysis (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) was carried out in order to determine the variables that could be associated with a greater risk of exhibiting low signal in the monitor and, therefore, lower correlation between the real value and the one exhibited by the Radical7 station, and it was found that the lower the PI and rectal temperature are, the higher the risk of low signal quality is (OR 0.531 [95% IC: 0.32–0.88] and 0.529 [95% IC: 0.33–0.85], respectively).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThis paper shows that the degree of concordance between the SpHb and the hemoglobin concentration obtained using the core lab analyser in patients admitted to the hospital PICU and at risk of bleeding is good and meets the manufacturer's technical specifications. However, we found wide limits of concordance. Very few pediatric studies have analyzed the precision and concordance of this innovative method of transcutaneous measurement and most have been conducted in hemodynamically stable patients, or patients at low risk of bleeding.<a class="elsevierStyleCrossRefs" href="#bib0185">12–14</a> Most papers published so far discuss adult patients,<a class="elsevierStyleCrossRefs" href="#bib0150">5,16,17</a> in whom the technology based on multiple wavelength absorption spectroscopy achieves better results probably due to the characteristics of the explored area, the lower heart rate and the higher systolic volume with respect to children.Phillips et al.<a class="elsevierStyleCrossRef" href="#bib0215">18</a> recently published the results of one prospective study–similar to this paper, and conducted among children hospitalized at one PICU; they found that the average difference between both methods was lower than the one reported in our series (0.07g/dl); however, the limits of concordance are wider than the ones found in our paper (from −5.11 to +5.25g/dl) and the Pearson correlation coefficient was lower (r=0.55). This difference may be partially due to the smaller size of the sample (53 patients, 83 measurements), since, on the other hand, they show a difference percentage ≤1g/dl (67% versus 61% in our series) similar to ours.Among the factors that may affect the precision of transcutaneous monitoring we find that the total Hb concentration, the HR and the fetal Hb concentration increase the difference with respect to the determination obtained in the core lab. On the other hand, the lower the temperature and PI values are, the more likely it is to achieve low signal qualities in the Radical7 station. In the manufacturer's technical documentation, hemoglobinopathies are described as a potential cause of errors when reading the hemoglobin concentration,<a class="elsevierStyleCrossRef" href="#bib0180">11</a> which might explain the influence of the fetal Hb concentration on the difference seen in the core lab concentration. Although anemia is not specifically mentioned, other authors also found worse correlations with extreme values of Hb.<a class="elsevierStyleCrossRefs" href="#bib0215">18,19</a> Most pediatric studies published so far have been conducted in healthy or hemodynamically stable patients – being this is the reason why the effect of low values of Hb, high values of HR or peripheral hypoperfusion has not been extensively studied yet.<a class="elsevierStyleCrossRefs" href="#bib0185">12,13,20,21</a> The proportion of cases where no measurements could be taken even after three (3) attempts (5.2%) is similar to the numbers found in medical literature,<a class="elsevierStyleCrossRefs" href="#bib0235">22,23</a> where percentages range from 2.6 to 12.3%. The fact of not being able to obtain SpHb measurements may be due to technical errors since yet despite the training of all the staff from the PICU in the correct placement of sensors and use of the device, the same clinician was not present in all the measurements. Nevertheless, in our opinion, the results from this paper show the utility of this device in daily clinical practice.The degree of concordance between the SpHb and Hb concentration exhibited by the core lab analyser shows the clinical utility of this device even though its exact role is not well defined yet. Two (2) recent meta-analysis mainly based on studies conducted in adult patients state that this technology is not accurate enough to be used as the sole indicator of transfusion.<a class="elsevierStyleCrossRefs" href="#bib0245">24,25</a> However, in studies that tested this method in surgical patients, this device seemed to be useful for monitoring the tendency of Hb values, optimize the moment to perform blood sample analysis, and avoid unnecessary venipunctures.<a class="elsevierStyleCrossRefs" href="#bib0185">12,13,15</a> On this regard, it would be interesting to conduct cost-effectiveness studies to assess the utility of this non-invasive method from this perspective.ConclusionsThe estimate of the Hb concentration using the non-invasive pulse co-oximetry shows good global correlation with the Hb concentration using the core lab analyser, though with wide limits of concordance. In our setting, the main advantage is the possibility of continuous non-invasive monitoring of the tendency in patients at risk of bleeding. The reliability of this method is limited in cases of poor peripheral perfusion.FinancingThis paper has not received any financial support.Conflicts of interestWe the authors declare that while conducting this paper there were no conflicts of interests linked whatsoever." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres838045" "titulo" => "Abstract" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Variables" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec833767" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres838046" "titulo" => "Resumen" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Variables" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec833766" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Goal" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Field of study" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Study population" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Study protocol" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical aspects" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Financing" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack281647" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-02-10" "fechaAceptado" => "2016-06-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec833767" "palabras" => array:5 [ 0 => "Hemoglobin" 1 => "Anemia" 2 => "Oximetry" 3 => "Pediatric intensive care" 4 => "Physiological monitoring" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec833766" "palabras" => array:5 [ 0 => "Hemoglobina" 1 => "Anemia" 2 => "Oximetría" 3 => "Cuidados intensivos pediátricos" 4 => "Monitorización fisiológica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo determine the accuracy and usefulness of noninvasive continuous hemoglobin (Hb) monitoring in critically ill patients at risk of bleeding. DesignAn observational prospective study was made, comparing core laboratory Hb measurement (LabHb) as the gold standard versus transcutaneous hemoglobin monitoring (SpHb). SettingPediatric Intensive Care Unit of a tertiary University Hospital. PatientsPatients weighing >3kg at risk of bleeding. InterventionsSpHb was measured using the Radical7 pulse co-oximeter (Masimo Corp., Irvine, CA, USA) each time a blood sample was drawn for core laboratory analysis (Siemens ADVIA 2120i). VariablesSociodemographic characteristics, perfusion index (PI), pleth variability index, heart rate, SaO2, rectal temperature, low signal quality and other events that can interfere with measurement. ResultsA total of 284 measurements were made (80 patients). Mean LabHb was 11.7±2.05g/dl. Mean SpHb was 12.32±2g/dl (Pearson 0.72, R2 0.52). The intra-class correlation coefficient was 0.69 (95%CI 0.55–0.78) (p<0.001). Bland–Altman analysis showed a mean difference of 0.07±1.46g/dl. A lower PI and higher temperature independently increased the risk of low signal quality (OR 0.531 [95% CI 0.32–0.88] and 0.529 [95% CI 0.33–0.85], respectively). ConclusionsSpHb shows a good overall correlation to LabHb, though with wide limits of agreement. Its main advantage is continuous monitoring of patients at risk of bleeding. The reliability of the method is limited in cases with poor peripheral perfusion." "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Variables" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoDeterminar la validez y precisión de un método de medición continua transcutánea de la concentración de hemoglobina (Hb) en pacientes críticos con riesgo de sangrado. DiseñoEstudio observacional prospectivo comparando el estándar de referencia con la determinación transcutánea de hemoglobina (SpHb). ÁmbitoUnidad de cuidados intensivos pediátricos de un hospital universitario de tercer nivel. PacientesMuestra consecutiva de pacientes con peso >3kg y riesgo de sangrado. IntervencionesMedición de SpHb mediante el cooxímetro de pulso Radical7 (Masimo Corp., Irvine, CA) en cada extracción sanguínea con determinación de Hb analizada con estándar de referencia (Siemens ADVIA 2120i). VariablesVariables epidemiológicas, índice de perfusión (IP), índice de variabilidad pletismográfica, frecuencia cardiaca, SaO2, temperatura rectal, baja calidad de señal, así como otros factores que pueden afectar a la medición. ResultadosSe realizaron 284 mediciones (80 pacientes). La media de Hb por el analizador central fue de 11,7±2,05g/dl. La media de SpHb fue de 12,32±2g/dl (Pearson 0,72, R2 0,52). El índice de correlación intraclase fue de 0,69 (IC95%: 0,55-0,78), p<0,001. El diagrama de Bland-Altman mostró una diferencia media entre ambos métodos de 0,66±1,46g/dl. Un menor IP y una mayor temperatura rectal incrementaron de forma independiente el riesgo de baja calidad de la señal (OR 0,531 [IC 95%: 0,32-0,88] y 0,529 [IC 95%: 0,33-0,85], respectivamente). ConclusionesLa SpHb presenta buena correlación con la obtenida por el analizador central, aunque los límites de concordancia son amplios. Su principal ventaja es la posibilidad de monitorización continua en pacientes con riesgo de sangrado. La fiabilidad de este método es limitada en casos de mala perfusión periférica." "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0045" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0050" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0055" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0060" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0065" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0070" "titulo" => "Variables" ] 6 => array:2 [ "identificador" => "abst0075" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0080" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García-Soler P, Camacho Alonso JM, González-Gómez JM, Milano-Manso G. Monitorización no invasiva transcutánea de la concentración de hemoglobina en pacientes críticos pediátricos con riesgo de sangrado. Med Intensiva. 2017;41:209–215." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1287 "Ancho" => 1619 "Tamanyo" => 41541 ] ] "descripcion" => array:1 [ "en" => "Box plot comparing the values obtained using the transcutaneous measurement (SpHb) and the core lab analyser." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1300 "Ancho" => 1658 "Tamanyo" => 105036 ] ] "descripcion" => array:1 [ "en" => "Dispersion diagram between the Hb values of the core lab analyser and the pulse co-oximeter (SpHb)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1299 "Ancho" => 1632 "Tamanyo" => 65924 ] ] "descripcion" => array:1 [ "en" => "Box plot showing the absolute differences between the methods for measuring hemoglobin concentrations based on reason for hospital admission. POCS: post-operative of cardiovascular surgery." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1192 "Ancho" => 1653 "Tamanyo" => 226708 ] ] "descripcion" => array:1 [ "en" => "Bland–Altman diagram. The continuous blue line represents the mean difference between both methods. The dotted red lines represent the upper and lower limits of concordance." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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">Absolute frequency \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">Percentage \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">Accumulated frequency \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">Accumulated percentage \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≤1g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">173 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">173 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1–2g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">220 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2–3g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">248 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥3g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">269 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No uptake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">284 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1414479.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Absolute differences between SpHb and Hb in the core lab expressed as intervals." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HR: heart rate; Hb: hemoglobin; RT: rectal temperature." "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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Model \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Unstandarized coefficients</th><th class="td" title="table-head " align="left" valign="top" scope="col">t \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI for B</th></tr><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">B \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">Typical error \t\t\t\t\t\t\n \t\t\t\t</th><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="" 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">Lower limit \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">Upper limit \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(Constant) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.884 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.706 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.863 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.525 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.244 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lab Hb (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.036 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−4.979 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.251 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.109 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.741 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.083 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HR (lpm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.747 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.016 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RT (°C) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.074 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.045 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.636 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fetal Hb (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.064 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.989 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.048 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.127 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1414478.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Multivariate linear regression analysis. Dependent variable: absolute difference between SpHb and Hb in the core lab." ] ] 6 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HR: heart rate; Hb: hemoglobin; PI: perfusion index; OR: odds ratio; RT: rectal temperature.Chi square (or Hosmer–Lemeshow) test=7.37 for eight degrees of freedom (p=0.497).AIC=160.15." "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"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="middle" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="middle" scope="col">β \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="middle" scope="col">OR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI for the OR</th></tr><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="" 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="" 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="" 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">Lower limit \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">Upper limit \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.388 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.944 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.016 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SpO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.058 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.943 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.879 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.012 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HR (lpm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.996 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.043 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lab Hb (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.412 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.091 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.913 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.734 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.135 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.632 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.531 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.320 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.884 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RT (°C) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.637 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.529 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.327 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.855 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1414480.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Multivariate logistic regression analysis. Dependent variable: low signal quality." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anemia, blood loss, and blood transfusions in North American children in the intensive care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.T. Bateman" 1 => "J. Lacroix" 2 => "K. Boven" 3 => "P. Forbes" 4 => "R. Barton" 5 => "N.J. 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Noninvasive hemoglobin monitoring in critically ill pediatric patients at risk of bleeding

Monitorización no invasiva transcutánea de la concentración de hemoglobina en pacientes críticos pediátricos con riesgo de sangrado

P. García-Soler

Corresponding author

patricia.garcia.soler.sspa@juntadeandalucia.es

Corresponding author.

, J.M. Camacho Alonso, J.M. González-Gómez, G. Milano-Manso

Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario, Málaga, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Anemia is a common complication in pediatric intensive care units &#40;PICU&#41; and amounts to up to 74&#37; of hospitalized patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> In critical patients anemia is the consequence of blood losses due to acute traumatic hemorrhages in the postoperative period&#44; especially due to cardiac or trauma surgeries&#44; repeated blood extractions&#44; chronic disorders&#44; iron and other deficiency disorders&#44; liver dysfunction or disseminated intravascular clotting&#44; among others&#46; In one multicentre&#44; observational&#44; prospective study conducted in children admitted at pediatric intensive care units&#44; Bateman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a>&#44; found that 96&#37; of these patients had their blood test analyzed&#44; and 74&#37; exhibited daily blood losses&#46; Patients with anemia had longer hospital stays and spent more days on mechanical ventilation&#46; Forty-one percent of children with anemia developed it during their hospital stay while only 33&#37; had anemia at the moment of hospital admission&#46; Conducting repeated blood test analyses can cause iatrogenic anemia that is present in up to 90&#37; of patients during the third day of admission in adult intensive care units&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;3</span></a> This fact becomes more important in younger patients since the blood volume needed for extraction is not related to the child&#39;s weight&#44; which means that larger volumes will be associated with the patient&#39;s blood volume&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> Thus&#44; the more serious the patient&#39;s condition is&#44; the more blood losses due to blood extractions will occur&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; the diagnosis of anemia cannot be clinically validated and requires confirmation through blood sample analysis&#46; The setback of trying to determine the blood hemoglobin concentration using conventional methods is that obtaining lab results can delay therapy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The capacity to rapidly and accurately determine a patient&#39;s blood hemoglobin concentration may be useful and critical in various clinical settings&#44; especially in intensive medicine&#44; which has led to the development of point-of-care &#40;POC&#41; devices&#44; that is&#44; devices available at the patient&#39;s bedside so that there is no need to bring the blood sample to the core lab&#46; Nevertheless&#44; the accuracy of these methods has been questioned in some studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5&#8211;9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">These are the non-invasive modalities available today&#58; pulse Co-oximetry &#40;Pulse CO-Oximetry&#8482;&#59; Masimo Corp&#46;&#44; Irvine&#44; CA&#44; USA&#41;&#44; occlusion spectroscopy &#40;OrSense&#8482;&#44; Ness Ziona&#44; Israel&#41; and transcutaneous reflectance spectroscopy &#40;Haemospect&#44; MBR Optical Systems&#44; Herdecke&#44; Germany&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The technology behind pulse co-oximetry is based on pulse oximetry and provides a continuous non-invasive monitoring of the blood hemoglobin concentration&#46; This method allows us to distinguish between the different characteristics of light absorption and the different subtypes of hemoglobin&#44; and through the implementation of certain algorithms is capable of determining the total blood hemoglobin concentration&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> Theoretically speaking&#44; one device capable of continuously measuring the blood hemoglobin concentration would have results earlier and alert clinicians on any drops in all those cases of hidden hemorrhages&#8211;all this added to the advantages of non-invasive measurements&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">There are some studies conducted in the pediatric population&#44; most of them in the surgical setting and with hemodynamically stable patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This is why we decided to conduct one study aimed at determining the validity and accuracy of this monitoring method in relation to the determination achieved at the core lab in PICU-hospitalized patients at risk of bleeding&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Goal</span><p id="par0060" class="elsevierStylePara elsevierViewall">Determine the validity and accuracy of one continuous transcutaneous method for measuring the blood hemoglobin &#40;Hb&#41; concentration in critical patients at risk of bleeding&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Design</span><p id="par0065" class="elsevierStylePara elsevierViewall">Prospective observational design&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Field of study</span><p id="par0070" class="elsevierStylePara elsevierViewall">PICU of a third-level referral academic hospital&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Study population</span><p id="par0075" class="elsevierStylePara elsevierViewall">The study included patients admitted at the PICU with risk of bleeding &#40;postoperative cardiac or trauma surgery patients&#44; polytraumatized patients and patients with serious coagulopathy in the context of systemic inflammatory syndrome response&#41;&#44; weighting &#62;3<span class="elsevierStyleHsp" style=""></span>kg for a period of twelve &#40;12&#41; months&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Study protocol</span><p id="par0080" class="elsevierStylePara elsevierViewall">When each blood sample was extracted&#44; the concentration of Hb at the core lab &#40;Siemens ADVIA 2120i&#41; was compared to the concentration of Hb shown by the Radical&#47;7&#46;8&#46;0&#46;1 pulse co-oximeter &#40;Masimo Corp&#46;&#44; Irvine&#44; CA&#41;&#46; Several epidemiological variables were recorded &#40;genre&#44; age in months&#44; weight&#44; race&#41;&#44; reason for hospital admission together with the following parameters&#58; perfusion index &#40;PI&#41;&#44; plethysmographic variability index &#40;PVI&#41;&#44; heart rate &#40;HR&#41;&#44; SaO<span class="elsevierStyleInf">2</span>&#44; rectal temperature &#40;RT&#41;&#44; the Richmond Agitation Sedation Scale &#40;RASS&#41;&#44; low signal quality detected by the monitor&#44; and all those situations that might affect measurement &#40;Vasoactive-Inotropic Score &#91;VIS score&#93;&#44; mechanical ventilation&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The PI is defined as the coefficient of pulse blood flow in relation to the non-pulsed or static flow in peripheral tissue and is one non-invasive way to measure peripheral perfusion&#46; The PVI measures dynamic changes occurring in the PI during the respiratory cycle&#44; which are expressed in percentages and calculated by the device following this formula&#58; &#91;&#40;maximum PI<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>minimum PI&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#93;&#47;maximum PI&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Based on the manufacturer&#39;s specifications&#44; the finger of the hand &#40;ringer finger&#44; middle finger&#44; and index finger of the non-dominant hand&#41; and the hallux of the foot were the locations used&#44; while limbs with recent lesions&#44; surgeries or vascular catheters&#8211;mainly arterial catheters were avoided&#46; The sphygmomanometer was always placed in a limb different to where the sensor had been placed&#46; After its placement the explored area was covered with an opaque bag supplied by the manufacturer in order to avoid pollution and light interference&#46; If there was no stable measurement after two &#40;2&#41; attempts another measurement was attempted in a different location before recording the case as non-detectable&#46; Likewise&#44; the low signal quality alarm was recorded&#44; which according to the manufacturer&#39;s specifications&#44; goes off in situations of excessive environmental light pollution&#44; shunt between photo emitter and photo detector due to sensor misplacement&#44; patients making moves&#44; or between the placement site and the sensor&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The R1 20L sensor was used in patients whose weight was between 3 and 10<span class="elsevierStyleHsp" style=""></span>kg&#46; For individuals over 10<span class="elsevierStyleHsp" style=""></span>kg&#44; the R2 20 sensor was used&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Statistical analysis</span><p id="par0105" class="elsevierStylePara elsevierViewall">In the descriptive analysis&#44; data are expressed as mean and standard deviation for variables of normal distribution&#44; and as mean and interquartile range &#40;IQR&#41; for variables that do not meet the conditions of normality&#46; The categorical variables are described as absolute frequency and percentage&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The Pearson correlation coefficient was obtained as well as the interclass correlation coefficient &#40;ICC&#41; that was calculated using a two-factor alpha model&#44; random effects and absolute consensus with a 95&#37; confidence interval and the Bland&#8211;Altman diagram in order to compare the hemoglobin concentration established by the pulse co-oximeter &#40;SpHb&#41; and the hemoglobin concentration established by the core lab analyser &#40;tHb&#41;&#46; Tolerance limits were established in differences of &#177;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; In order to calculate the difference between the two &#40;2&#41; methods&#44; the absolute difference was used in the first place&#8211;including both negative and positive values&#46; In the Bland&#8211;Altman analysis&#44; positive and negative numbers were used to know these differences&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Using the multivariate linear regression analysis&#44; the influence exerted by the independent variables gathered on the absolute difference between both methods was analyzed&#46; Using the multivariate logistic regression analysis&#44; the correlation between low signal quality &#40;yes&#47;no&#41; and different potential variables associated was studied&#46; A 5&#37; statistical-significance level was taken into account&#46; For the selection of the final multivariate model in both cases&#44; a backward step-wise regression proceeding &#40;Wald test statistics&#41; was used initially including all the variables that might have something to do with the dependent variables and the variables that exhibited statistical significance in the bivariate analysis&#46; The Akaike information criterion &#40;AIC&#41; was used to confirm how good the adjustment of the model really was&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">For the statistical analysis&#44; the IBM<span class="elsevierStyleSup">&#174;</span> SPSS<span class="elsevierStyleSup">&#174;</span> Statistics 20&#46;0 software for Macintosh<span class="elsevierStyleSup">&#174;</span> was used&#46; The Bland&#8211;Altman diagram was built using the R software&#8211;version 3&#46;2&#46;2&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Ethical aspects</span><p id="par0130" class="elsevierStylePara elsevierViewall">This paper has been approved by the Regional Research Ethics Committee&#46; Participation in this study was voluntary&#46; The patients&#8217; legal representatives were verbally informed and given one copy of the written informed consent&#46; The study authors declare that they have followed the good clinical practice and principles contained in the Declaration of Helsinki&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Results</span><p id="par0135" class="elsevierStylePara elsevierViewall">284 measurements were taken in 80 patients averaging 14&#46;5 months of age &#40;range 3&#8211;60 months&#41; and 8&#46;5<span class="elsevierStyleHsp" style=""></span>kg of weight &#40;range 4&#46;35&#8211;18&#46;5<span class="elsevierStyleHsp" style=""></span>kg&#41;&#46; In 15 determinations &#40;5&#46;2&#37;&#41;&#44; the SpHb could not be recorded due to poor peripheral hyperperfusion uptake&#44; and in 36 determinations &#40;12&#46;7&#37;&#41; there was poor signal quality as the Radical7 station exhibited&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The SaO<span class="elsevierStyleInf">2</span> was 98&#37; &#40;IQR 96&#8211;100&#37;&#41;&#44; the HR 123<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>lpm&#44; the RT 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; the PI 1&#46;5 &#40;IQR 0&#46;93&#8211;3&#46;32&#41; and the PVI 17 &#40;IQR 11&#8211;27&#46;25&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Most patients included were postoperative cardiac surgery patients &#40;76&#46;4&#37;&#41;&#44; and polytraumatized patients &#40;14&#46;8&#37;&#41;&#44; while 8&#46;8&#37; had been admitted to the hospital PICU for other reasons such as post-adenoidectomy bleeding &#40;4&#41;&#44; upper GI bleeding &#40;2&#41;&#44; or septic shock &#40;1&#41;&#46; Sixty-three percent &#40;22 cases&#41; of all measurements were taken during mechanical ventilation&#8211;all of them under continuous sedation with a mean RASS score of &#8722;3 &#40;IQR from &#8722;2&#46;8 to &#8722;4&#46;1&#41;&#46; Five &#40;5&#41; patients &#40;6&#46;25&#37;&#41; received therapy with alpha-adrenergic vasoactive drugs&#46; The mean VIS score was 8 &#40;RIQ 0&#8211;10&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The average Hb concentration exhibited in the core lab analyser was 11&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;05<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;median 11&#46;5&#44; IQR 10&#46;27&#8211;13&#41;&#46; The average Hb concentration exhibited in the pulse-oximeter was 12&#46;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;median 12&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; IQR 11&#8211;13&#46;4&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The Pearson correlation coefficient was 0&#46;72 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and the coefficient of determination <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span>&#44; 0&#46;52 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The overall ICC was 0&#46;69 &#40;95&#37; CI&#58; 0&#46;55&#8211;0&#46;78&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46; The ICC in determinations with PI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;5 was 0&#46;70 &#40;95&#37; CI&#58; 0&#46;6&#8211;0&#46;78&#41;&#44; but when the PI was &#8804;1&#46;5&#44; the ICC was 0&#46;68 &#40;95&#37; CI&#58; 0&#46;43&#8211;0&#46;81&#41;&#8211;being both values statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Concordance was higher in individuals over 6<span class="elsevierStyleHsp" style=""></span>months &#40;0&#46;7&#44; 95&#37; CI&#58; 0&#46;59&#8211;0&#46;78&#41; compared to individuals under 6 months &#40;0&#46;59&#44; 95&#37; CI&#58; 0&#46;36&#8211;0&#46;74&#41;&#46; When the monitor exhibited low signal quality &#40;12&#46;7&#37; of cases&#41;&#44; the ICC was 0&#46;45 &#40;95&#37; CI&#58; 0&#46;06&#8211;0&#46;71&#41;&#44; while in the remaining cases the ICC was 0&#46;74 &#40;95&#37; CI&#58; 0&#46;62&#8211;0&#46;81&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The average difference between lab values and pulse co-oximeter values was 0&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;46<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; with a median of 0&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;IQR from &#8722;0&#46;2 to 1&#46;4&#41;&#46; The mean difference in absolute values was 0&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;IQR from 0&#46;4 to 1&#46;7&#41;&#46; The mean difference between both methods was greater in postoperative cardiac surgery patients &#40;0&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; IQR from 0&#46;4 to 1&#46;8&#41; than in polytraumatized patients &#40;0&#46;6<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; IQR from 0&#46;3 to 1&#41; and in the remaining patients &#40;0&#46;45<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; IQR from 0&#46;3 to 1&#46;57&#41;&#44; though these differences were not statistically significant in the Kruskal&#8211;Wallis test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;065&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The Bland&#8211;Altman diagram &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; shows that most differences can be found within the concordance limits &#8211; being the upper limit &#40;&#43;2DE&#41; 3&#46;59<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; and the lower limit &#40;&#8722;2DE&#41; &#8722;2&#46;26<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; As it can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 60&#46;9&#37; of all measurements taken with the non-invasive pulse co-oximeter exhibited a &#8804;&#8722;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl difference with respect to data exhibited by the core lab analyser&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Using a linear regression model&#44; the correlation between the absolute difference of both measurements and the real Hb concentration could be studied&#44; and a statistically significant correlation was found &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#44; with a <span class="elsevierStyleItalic">&#946;</span> coefficient of &#8722;0&#46;09 and a coefficient of determination <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span> of 0&#46;027&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In the multivariate linear regression analysis&#44; the absolute difference between both methods was used as the dependent variable&#44; including the variables that had a statistically significant relation in the correlation matrix as well as race&#44; reason for hospital admission and need for invasive mechanical ventilation&#46; Using a backward step-wise proceeding&#44; the multivariate model was built&#44; maintaining both all significant variables and those variables enhancing the validity of the model as <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows&#46; According to this model&#44; the lower the Hb concentration is&#44; the higher the HR and fetal Hb concentration are&#59; the difference between both methods of measurement becomes greater in a statistically significant way&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">One multivariate logistic regression analysis &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; was carried out in order to determine the variables that could be associated with a greater risk of exhibiting low signal in the monitor and&#44; therefore&#44; lower correlation between the real value and the one exhibited by the Radical7 station&#44; and it was found that the lower the PI and rectal temperature are&#44; the higher the risk of low signal quality is &#40;OR 0&#46;531 &#91;95&#37; IC&#58; 0&#46;32&#8211;0&#46;88&#93; and 0&#46;529 &#91;95&#37; IC&#58; 0&#46;33&#8211;0&#46;85&#93;&#44; respectively&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">This paper shows that the degree of concordance between the SpHb and the hemoglobin concentration obtained using the core lab analyser in patients admitted to the hospital PICU and at risk of bleeding is good and meets the manufacturer&#39;s technical specifications&#46; However&#44; we found wide limits of concordance&#46; Very few pediatric studies have analyzed the precision and concordance of this innovative method of transcutaneous measurement and most have been conducted in hemodynamically stable patients&#44; or patients at low risk of bleeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#8211;14</span></a> Most papers published so far discuss adult patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5&#44;16&#44;17</span></a> in whom the technology based on multiple wavelength absorption spectroscopy achieves better results probably due to the characteristics of the explored area&#44; the lower heart rate and the higher systolic volume with respect to children&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Phillips et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> recently published the results of one prospective study&#8211;similar to this paper&#44; and conducted among children hospitalized at one PICU&#59; they found that the average difference between both methods was lower than the one reported in our series &#40;0&#46;07<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#59; however&#44; the limits of concordance are wider than the ones found in our paper &#40;from &#8722;5&#46;11 to &#43;5&#46;25<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41; and the Pearson correlation coefficient was lower &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;55&#41;&#46; This difference may be partially due to the smaller size of the sample &#40;53 patients&#44; 83 measurements&#41;&#44; since&#44; on the other hand&#44; they show a difference percentage &#8804;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;67&#37; versus 61&#37; in our series&#41; similar to ours&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Among the factors that may affect the precision of transcutaneous monitoring we find that the total Hb concentration&#44; the HR and the fetal Hb concentration increase the difference with respect to the determination obtained in the core lab&#46; On the other hand&#44; the lower the temperature and PI values are&#44; the more likely it is to achieve low signal qualities in the Radical7 station&#46; In the manufacturer&#39;s technical documentation&#44; hemoglobinopathies are described as a potential cause of errors when reading the hemoglobin concentration&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> which might explain the influence of the fetal Hb concentration on the difference seen in the core lab concentration&#46; Although anemia is not specifically mentioned&#44; other authors also found worse correlations with extreme values of Hb&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">18&#44;19</span></a> Most pediatric studies published so far have been conducted in healthy or hemodynamically stable patients &#8211; being this is the reason why the effect of low values of Hb&#44; high values of HR or peripheral hypoperfusion has not been extensively studied yet&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#44;13&#44;20&#44;21</span></a> The proportion of cases where no measurements could be taken even after three &#40;3&#41; attempts &#40;5&#46;2&#37;&#41; is similar to the numbers found in medical literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">22&#44;23</span></a> where percentages range from 2&#46;6 to 12&#46;3&#37;&#46; The fact of not being able to obtain SpHb measurements may be due to technical errors since yet despite the training of all the staff from the PICU in the correct placement of sensors and use of the device&#44; the same clinician was not present in all the measurements&#46; Nevertheless&#44; in our opinion&#44; the results from this paper show the utility of this device in daily clinical practice&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The degree of concordance between the SpHb and Hb concentration exhibited by the core lab analyser shows the clinical utility of this device even though its exact role is not well defined yet&#46; Two &#40;2&#41; recent meta-analysis mainly based on studies conducted in adult patients state that this technology is not accurate enough to be used as the sole indicator of transfusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">24&#44;25</span></a> However&#44; in studies that tested this method in surgical patients&#44; this device seemed to be useful for monitoring the tendency of Hb values&#44; optimize the moment to perform blood sample analysis&#44; and avoid unnecessary venipunctures&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#44;13&#44;15</span></a> On this regard&#44; it would be interesting to conduct cost-effectiveness studies to assess the utility of this non-invasive method from this perspective&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusions</span><p id="par0230" class="elsevierStylePara elsevierViewall">The estimate of the Hb concentration using the non-invasive pulse co-oximetry shows good global correlation with the Hb concentration using the core lab analyser&#44; though with wide limits of concordance&#46; In our setting&#44; the main advantage is the possibility of continuous non-invasive monitoring of the tendency in patients at risk of bleeding&#46; The reliability of this method is limited in cases of poor peripheral perfusion&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Financing</span><p id="par0235" class="elsevierStylePara elsevierViewall">This paper has not received any financial support&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">We the authors declare that while conducting this paper there were no conflicts of interests linked whatsoever&#46;</p></span></span>"
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    "fechaRecibido" => "2016-02-10"
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            0 => "Hemoglobin"
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            2 => "Oximetry"
            3 => "Pediatric intensive care"
            4 => "Physiological monitoring"
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            0 => "Hemoglobina"
            1 => "Anemia"
            2 => "Oximetr&#237;a"
            3 => "Cuidados intensivos pedi&#225;tricos"
            4 => "Monitorizaci&#243;n fisiol&#243;gica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine the accuracy and usefulness of noninvasive continuous hemoglobin &#40;Hb&#41; monitoring in critically ill patients at risk of bleeding&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An observational prospective study was made&#44; comparing core laboratory Hb measurement &#40;LabHb&#41; as the gold standard versus transcutaneous hemoglobin monitoring &#40;SpHb&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pediatric Intensive Care Unit of a tertiary University Hospital&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients weighing &#62;3<span class="elsevierStyleHsp" style=""></span>kg at risk of bleeding&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">SpHb was measured using the Radical7 pulse co-oximeter &#40;Masimo Corp&#46;&#44; Irvine&#44; CA&#44; USA&#41; each time a blood sample was drawn for core laboratory analysis &#40;Siemens ADVIA 2120i&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Sociodemographic characteristics&#44; perfusion index &#40;PI&#41;&#44; pleth variability index&#44; heart rate&#44; SaO<span class="elsevierStyleInf">2</span>&#44; rectal temperature&#44; low signal quality and other events that can interfere with measurement&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 284 measurements were made &#40;80 patients&#41;&#46; Mean LabHb was 11&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;05<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; Mean SpHb was 12&#46;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;Pearson 0&#46;72&#44; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span> 0&#46;52&#41;&#46; The intra-class correlation coefficient was 0&#46;69 &#40;95&#37;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">CI</span> 0&#46;55&#8211;0&#46;78&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Bland&#8211;Altman analysis showed a mean difference of 0&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;46<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; A lower PI and higher temperature independently increased the risk of low signal quality &#40;OR 0&#46;531 &#91;95&#37; CI 0&#46;32&#8211;0&#46;88&#93; and 0&#46;529 &#91;95&#37; CI 0&#46;33&#8211;0&#46;85&#93;&#44; respectively&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">SpHb shows a good overall correlation to LabHb&#44; though with wide limits of agreement&#46; Its main advantage is continuous monitoring of patients at risk of bleeding&#46; The reliability of the method is limited in cases with poor peripheral perfusion&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Determinar la validez y precisi&#243;n de un m&#233;todo de medici&#243;n continua transcut&#225;nea de la concentraci&#243;n de hemoglobina &#40;Hb&#41; en pacientes cr&#237;ticos con riesgo de sangrado&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo comparando el est&#225;ndar de referencia con la determinaci&#243;n transcut&#225;nea de hemoglobina &#40;SpHb&#41;&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos de un hospital universitario de tercer nivel&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Muestra consecutiva de pacientes con peso &#62;3<span class="elsevierStyleHsp" style=""></span>kg y riesgo de sangrado&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Medici&#243;n de SpHb mediante el coox&#237;metro de pulso Radical7 &#40;Masimo Corp&#46;&#44; Irvine&#44; CA&#41; en cada extracci&#243;n sangu&#237;nea con determinaci&#243;n de Hb analizada con est&#225;ndar de referencia &#40;Siemens ADVIA 2120i&#41;&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Variables epidemiol&#243;gicas&#44; &#237;ndice de perfusi&#243;n &#40;IP&#41;&#44; &#237;ndice de variabilidad pletismogr&#225;fica&#44; frecuencia cardiaca&#44; SaO<span class="elsevierStyleInf">2</span>&#44; temperatura rectal&#44; baja calidad de se&#241;al&#44; as&#237; como otros factores que pueden afectar a la medici&#243;n&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se realizaron 284 mediciones &#40;80 pacientes&#41;&#46; La media de Hb por el analizador central fue de 11&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;05<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; La media de SpHb fue de 12&#44;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;Pearson 0&#44;72&#44; R<span class="elsevierStyleSup">2</span> 0&#44;52&#41;&#46; El &#237;ndice de correlaci&#243;n intraclase fue de 0&#44;69 &#40;IC<span class="elsevierStyleHsp" style=""></span>95&#37;&#58; 0&#44;55-0&#44;78&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; El diagrama de Bland-Altman mostr&#243; una diferencia media entre ambos m&#233;todos de 0&#44;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;46<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; Un menor IP y una mayor temperatura rectal incrementaron de forma independiente el riesgo de baja calidad de la se&#241;al &#40;OR 0&#44;531 &#91;IC 95&#37;&#58; 0&#44;32-0&#44;88&#93; y 0&#44;529 &#91;IC 95&#37;&#58; 0&#44;33-0&#44;85&#93;&#44; respectivamente&#41;&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La SpHb presenta buena correlaci&#243;n con la obtenida por el analizador central&#44; aunque los l&#237;mites de concordancia son amplios&#46; Su principal ventaja es la posibilidad de monitorizaci&#243;n continua en pacientes con riesgo de sangrado&#46; La fiabilidad de este m&#233;todo es limitada en casos de mala perfusi&#243;n perif&#233;rica&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Soler P&#44; Camacho Alonso JM&#44; Gonz&#225;lez-G&#243;mez JM&#44; Milano-Manso G&#46; Monitorizaci&#243;n no invasiva transcut&#225;nea de la concentraci&#243;n de hemoglobina en pacientes cr&#237;ticos pedi&#225;tricos con riesgo de sangrado&#46; Med Intensiva&#46; 2017&#59;41&#58;209&#8211;215&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">284&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Absolute differences between SpHb and Hb in the core lab expressed as intervals&#46;</p>"
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      5 => array:8 [
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                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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Unstandarized coefficients</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">t</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI for B</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\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"><span class="elsevierStyleItalic">B</span>&nbsp;\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">Typical error&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\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">Lower limit&nbsp;\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">Upper limit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#40;Constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;884&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;706&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;863&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;525&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;244&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lab Hb &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;036&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;4&#46;979&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;251&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;1&#46;741&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;083&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HR &#40;lpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;747&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RT &#40;&#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;074&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;045&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;1&#46;636&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;164&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fetal Hb &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;064&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;989&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;048&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">HR&#58; heart rate&#59; Hb&#58; hemoglobin&#59; PI&#58; perfusion index&#59; OR&#58; odds ratio&#59; RT&#58; rectal temperature&#46;</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Chi square &#40;or Hosmer&#8211;Lemeshow&#41; test<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;37 for eight degrees of freedom &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;497&#41;&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">AIC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>160&#46;15&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="middle" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;944&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SpO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;943&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;879&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HR &#40;lpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;043&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lab Hb &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;412&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;091&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;913&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;734&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;632&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;531&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;320&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;884&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RT &#40;&#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;637&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;529&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;327&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;855&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "1"
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                0 => array:2 [
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2016.06.005

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Year/Month	Html	Pdf	Total

2024 November	6	3	9
2024 October	63	53	116
2024 September	70	42	112
2024 August	68	46	114
2024 July	86	43	129
2024 June	68	59	127
2024 May	50	34	84
2024 April	56	37	93
2024 March	48	39	87
2024 February	23	54	77
2024 January	35	49	84
2023 December	36	40	76
2023 November	54	46	100
2023 October	56	39	95
2023 September	61	44	105
2023 August	46	18	64
2023 July	55	35	90
2023 June	61	14	75
2023 May	70	41	111
2023 April	46	27	73
2023 March	69	38	107
2023 February	111	37	148
2023 January	75	58	133
2022 December	103	38	141
2022 November	89	50	139
2022 October	85	60	145
2022 September	87	43	130
2022 August	63	50	113
2022 July	51	35	86
2022 June	49	48	97
2022 May	62	53	115
2022 April	45	37	82
2022 March	70	71	141
2022 February	54	53	107
2022 January	90	44	134
2021 December	63	47	110
2021 November	44	54	98
2021 October	73	70	143
2021 September	51	35	86
2021 August	43	50	93
2021 July	33	43	76
2021 June	33	39	72
2021 May	79	49	128
2021 April	147	68	215
2021 March	116	40	156
2021 February	116	32	148
2021 January	114	29	143
2020 December	93	29	122
2020 November	73	24	97
2020 October	68	42	110
2020 September	52	36	88
2020 August	47	19	66
2020 July	41	37	78
2020 June	50	19	69
2020 May	61	32	93
2020 April	49	30	79
2020 March	49	18	67
2020 February	180	49	229
2020 January	82	44	126
2019 December	93	29	122
2019 November	69	40	109
2019 October	53	26	79
2019 September	46	33	79
2019 August	79	31	110
2019 July	79	30	109
2019 June	38	23	61
2019 May	77	45	122
2019 April	39	38	77
2019 March	40	29	69
2019 February	56	45	101
2019 January	48	35	83
2018 December	69	58	127
2018 November	135	135	270
2018 October	86	34	120
2018 September	28	10	38
2018 August	36	13	49
2018 July	26	7	33
2018 June	30	13	43
2018 May	19	12	31
2018 April	34	13	47
2018 March	24	8	32
2018 February	28	13	41
2018 January	45	23	68
2017 December	39	17	56
2017 November	36	26	62
2017 October	42	20	62
2017 September	43	5	48
2017 July	1	0	1
2017 June	1	0	1
2017 May	0	1	1

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