Perioperative management in cardiovascular surgery

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GEDVI: volumen telediastólico global de ventrículo izquierdo; PAM: presión arterial media; POAP: presión de oclusión arterial pulmonar; PVC: presión venosa central; SvO2: Saturación venosa mixta de oxígeno; SvcO2: Saturación venosa central de oxígeno; TDVI: telediastólica de ventrículo izquierdo; VD: ventrículo derecho; VI: ventrículo izquierdo; VSVI: volumen sistólico de ventrículo izquierdo. *Adaptado de Habicher M et al<a class="elsevierStyleCrossRef" href="#bib0320">18</a>." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.J. Jiménez Rivera, C. Llanos Jorge, M.J. López Gude, J.L. Pérez Vela" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.J." "apellidos" => "Jiménez Rivera" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Llanos Jorge" ] 2 => array:2 [ "nombre" => "M.J." "apellidos" => "López Gude" ] 3 => array:2 [ "nombre" => "J.L." 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Jiménez Rivera, C. Llanos Jorge, M.J. López Gude, J.L. Pérez Vela" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.J." "apellidos" => "Jiménez Rivera" "email" => array:1 [ 0 => "jjjimenezrivera@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Llanos Jorge" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.J." "apellidos" => "López Gude" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J.L." 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PO, postoperative; pre-OP, preoperative." ] ] ] "textoCompleto" => "IntroductionCardiovascular surgery is a highly complex procedure with good results for selected patients that increases both their quality of life and survival. In Spain, back in 2018,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> 34 318 procedures were performed in 62 different cardiac surgery intensive care units.The optimal management of these patients should be multidisciplinary, comprehensive, and patient-focused using the right protocols.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Intensive medicine plays a key role in this clinical setting thanks to its contributions, values, and overall approach of the entire process.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> Intensivists play a key role for their knowledge of the procedure and capacity to handle the quality of the process through healthcare registries, outcome assessments, and actions for improvement. It is of paramount importance to admit patients to the intensive care unit (ICU) who, due to their instability or complexity, require preoperative optimization. Similarly, postoperative management is essential here too, both at the ICU setting and at the hospitalization floor for the early detection of any possible complications.The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) strategic plan for 2018–2022<a class="elsevierStyleCrossRef" href="#bib0025">5</a> advocates for the quality of the surgical process by establishing specific actions aimed at improving the management of surgical patients and their families and working collaboratively with other medical specialties to achieve an effective, efficient, and safe process.Advances in cardiac surgeryOver the last few years, cardiovascular surgery has evolved significantly thanks to the advances made in myocardial protection, systemic perfusion during extracorporeal circulation, and cerebral protection in situations of circulatory arrest, the implementation of safe surgical protocols during the intervention, the transesophageal echocardiography monitorization of technical complications, new minimally invasive surgical techniques, sutureless percutaneous heart valve implantation, and the development of multimodal recovery (ERAS) in cardiac surgery.Enhanced recovery after surgery and fast-track surgeryERAS protocols reduce the impact of perioperative stress and speed up the patients’ recovery time. They include pre-, intra-, and postoperative indications; they obtain as much information as possible and preparation prior to the surgery, empower the patient, standardize certain processes, and optimize resources to reduce complications, hospital stays, and down times. These recommendations<a class="elsevierStyleCrossRef" href="#bib0030">6</a> are shown on <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Preoperative optimizationPrehabilitation in frail patients<a class="elsevierStyleCrossRef" href="#bib0035">7</a> by correcting nutritional deficits<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and preoperative anemia,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and withdrawing certain drugs (antiplatelet drugs, anticoagulants, renin-angiotensin system inhibitors) improves postoperative results and reduces hemorrhagic, hemodynamic, and renal complications.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a>Prophylaxis of de novo atrial fibrillation with beta-blockers or amiodarone is capable of reducing its incidence rate.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Preconditioning with levosimendan in coronary patients with moderate-to-severe systolic dysfunction is a useful and cost-effective strategy to reduce the incidence rate of postoperative low cardiac output syndrome.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>Standard management of the uncomplicated postoperative courseThe early management of patients during postoperative cardiac surgery care (PCSC) requires a thorough physical examination and, at least, basic hemodynamic monitorization.<a class="elsevierStyleCrossRefs" href="#bib0075">15–17</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) Afterwards, the homeostasis of the internal medium needs to be reestablished, normothermia needs to be reached, the correct functioning of the epicardial pacemaker guaranteed, and antibiotic prophylaxis continued. It is essential to establish a multimodal analgesic strategy by combining different types of analgesics to reduce the doses of opioids, thus facilitating the patient’s extubation, rehabilitation, and early mobilization. Weaning from mechanical ventilation should start when the proper conditions of clinical stability are met. As it occurs in most critically ill patients, an adequate glycemic control should be kept followed by the detection and prevention of acute kidney injury, early administration of thromboprophylaxis (mechanical and, when possible, pharmacological), and prevention of delirium.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Resuscitation and hemodynamic management should be guided by objective targets<a class="elsevierStyleCrossRef" href="#bib0090">18</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Advanced monitorization is indicated in unstable patients, in those in whom the pathophysiology of the process needs to be deciphered or in patients who, due to their baseline characteristics, intraoperative evolution or type of intervention are considered of high surgical risk. Advanced hemodynamic monitoring systems allow us to obtain ongoing information on cardiac output (CO) and its determinants: preload or preload-dependency, contractility, and afterload.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Contractility is reduced during the immediate PCSC compared to the preoperative course. The magnitude and duration of this stage will depend on the previous cardiac dysfunction, existence of ischemic events, preoperative complications, and intraoperative evolution. The components that impact cardiac dysfunction the most are an increased left ventricular (LV) mass, hypothermia, the volume and route of cardioplegia administration, and prolonged ECC time.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>During the postoperative course we should take into account the presence of 2 hemodynamic patterns: pressure overload (left hypertrophy and impaired lusitropy) that affects the measurement of filling pressures, thus underestimating the volume needs and associated with possible tachycardia intolerance. The other one being volume overload (typical of valvular regurgitation) that also alters the measurement of preload-dependency and where the dynamic variables of response to volume have not been validated. In this context a continuous assessment of the response to the volume administered is required as well as its repercussion on the target parameters to avoid inadequate resuscitations.Added to CO and its determinants, the pulmonary artery catheterization is the only system that provides us with information on SvO2 and pulmonary pressures. Systems based on transpulmonary thermodilution have been developed as an alternative to provide CO continuous measurements (and other parameters of great utility). These systems have recently been validated in patients with cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> However, they have limitations like the need for frequent recalibration in the presence of significant hemodynamic variations or loss of accuracy in the presence of arrhythmias or work of breathing.<a class="elsevierStyleCrossRefs" href="#bib0075">15–17</a> Echocardiography has been playing a key role during PCSC and, to this date, it is considered an essential imaging modality. Its utility lies in how fast it provides us with functional and anatomical information. It allows us to assess the ejection fraction, the CO through systolic volume assessment, the response to fluids, inotropes or vasoactive drugs, speed up the early diagnosis of complications (tamponade, valve failure…), and facilitate the appropriate therapeutic decision-making process.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>ComplicationsThe risk of perioperative complications depends on the patient’s baseline coronary artery disease, his functional reserve, the prevalence of comorbidities, type and character of the surgery, and duration of the entire surgical procedure. These are some of the most common postoperative complications:De novo atrial fibrillation and other arrhythmiasAtrial fibrillation (AF) is the most common arrhythmia during PCSC.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Its peak incidence rate occurs within 48 h–72 h and it usually subsides spontaneously within the first 24 h or with drug therapy. Beta-blockers and amiodarone are the cornerstone of prophylaxis and treatment of de novo postoperative AF. Here the strategy of monitoring heart rate and that of monitoring heart rhythm are equally valid. Antithrombotic therapy should be based on the individual assessment of risk of thromboembolism using scales like the CHA2DS2-VASc and the HAS-BLED.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> In presence of AF with hemodynamic instability we should consider the use of biphasic waveform synchronized shocks, initially at 100 joules, (200 joules in obese patients). For the management of sustained monomorphic ventricular tachycardias synchronized shocks at 50−100 joules should be used. Regarding disorganized or pulseless ventricular tachycardias non-synchronized shocks at maximum energy should be used.The rate of complete postoperative atrioventricular block is between 4%<a class="elsevierStyleCrossRef" href="#bib0120">24</a> and 11%.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> It is often transient, and the indications for definitive pacemaker implantation are the same ones as in non-operated patients.Postoperative low cardiac output syndromeManagement of right-sided heart diseaseIt is defined as that hemodynamic situation where CO cannot fully satisfy the tissue metabolic demand. However, the triggers, clinical presentation, disease progression, and treatment are different to heart failure of medical origin. Its incidence rate is somewhere between 3% and 45%, and it is associated with a higher morbidity and mortality rate, ICU stays, and use of resources.<a class="elsevierStyleCrossRefs" href="#bib0130">26–29</a> Its clinical signs are varied and go from mild myocardial stunning that may require the transient use of inotropes with full recovery within 24 h–48 h to serious cases with cardiogenic shock, multiorgan failure, and death. The early identification of clinical signs and the proper management are essential to achieve good results.Added to the aforementioned measures, we should also:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Rule out mechanical and/or reversible causes: pneumothorax, hemothorax, excessive bleeding, cardiac tamponade, and coronary graft spasm or occlusion, prosthetic valve dysfunction, and arrhythmias (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</li><li class="elsevierStyleListItem" id="lsti0010">2Use a stepped approach following gradual sequencies of action. First, preload should be optimized, and rhythm should be kept under control by reversing tachyarrhythmias through cardioversion and/or over-pacing in the presence of hemodynamic repercussions. In the presence of bradyarrhythmias, relative bradycardias or atrioventricular block, epicardial cardiac pacing wires should be used. Afterwards, inotropes, vasoconstrictors and/or vasodilators should be used. The last step is circulatory assist devices like the intra-aortic balloon pump, venoarterial extracorporeal oxygenation or any other types of mechanical circulatory support ventricular assist devices (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</li></ul>Management of right-sided heart disease and pulmonary hypertensionIn the context of cardiac surgery, right ventricular (RV) failure is more prevalent in<a class="elsevierStyleCrossRef" href="#bib0150">30</a> high-risk coronary artery disease with right coronary artery lesion, valvular heart disease—especially in the mitral valve—, the postoperative course of heart transplant, congenital coronary artery disease, pulmonary thromboendarterectomy due to chronic thromboembolic pulmonary hypertension (TPH), and patients with LV assist devices.Its management requires optimizing preload, afterload, contractility, rhythm, and rate<a class="elsevierStyleCrossRef" href="#bib0080">16</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The RV cardiac output is influenced by the contraction of interventricular septum, based on the LV function, which is why in the presence of associated LV dysfunction, inotropes should be used. It is essential to avoid arterial hypotension to secure the correct perfusion of both ventricles.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In order to reduce the RV afterload, pulmonary vasodilators (PVD) can be administered locally (inhaled or nebulized) or systemically (oral and intravenous) (<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>).<a class="elsevierStyleCrossRef" href="#bib0155">31</a> Systemic vasodilation can cause arterial hypotension and create respiratory failure due to ventilation/perfusion (V/Q ratio) mismatch. Inhaled PVD cause less systemic hypotension and improve the V/Q ratio. Therefore, they are useful to treat chronic TPH, improve the V/Q ratio, and reduce the afterload of a dysfunctional RV.<a class="elsevierStyleCrossRef" href="#bib0160">32</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The type of drug that should be used depends on the clinical context.<a class="elsevierStyleCrossRefs" href="#bib0160">32–38</a> In patients with predominant respiratory failure and residual TPH, locally-acting drugs (inhaled nitric oxide [iNO] and/or inhaled prostacyclin) should be used to treat both entities simultaneously. In presence of hemodynamic instability, we should start with inodilators (dobutamine or milrinone) together with inhaled PVD (iNO and prostacyclin) to reduce the afterload thanks to the lower hemodynamic impairment associated. Once the situation has stabilized (significant reduction or withdrawal of vasoactive support) phosphodiesterase-5 inhibitors or prostaglandins can be started IV and at low doses. Based on the patient’s tolerance, the withdrawal of iNO and then prostacyclin can be considered (since the latter can still be used in extubated patients).In hemodynamically stable patients without respiratory failure but significant residual TPH, home medication can be suggested and introduced gradually.There are times that despite the optimal medical therapy, the patient’s cardiac output remains low. In these cases, it is required to initiate mechanical support measures.Vasoplegic syndrome after cardiac surgeryIt has been reported that during PCSC up to half of the patients can develop vasoplegia (low systemic vascular resistances with CI > 2.2 L/kg/min) accompanied by distributive shock in up to 5% of them.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> Pathophysiology is similar to that of the vasoplegic shock reported in sepsis. It is important to recognize the situation early and start vasopressor therapy to achieve the proper organ perfusion. The most commonly used drug is noradrenaline. In cases that require high doses, vasopressin can be used as well.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> The role of angiotensin ii seems promising in these patients.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Excessive postoperative bleedingExcessive postoperative bleeding is one the most common complications of cardiac surgery. It can be defined as bleeding over 1 L of blood within the first 24 h. Its incidence rate is around 33% and requires surgical reassessment in 3% to 7% of the cases.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Proper management is a priority in this context since in up to 50% of the patients with reinterventions there is no surgical cause for the bleeding, and reassessment becomes an independent risk factor for the appearance of postoperative adverse events.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> Bleeding during PCSC is multifactorial and somehow triggered by the characteristics of the patient,<a class="elsevierStyleCrossRefs" href="#bib0220">44,45</a> the perioperative drugs used, and surgery per se.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> ECC causes a procoagulant state that triggers a pro-hemorrhagic situation (since it consumes coagulation and platelet factors) aggravated by hemodilution and the activation of the fibrinolytic system. The transfusion of hemoderivatives is directly associated with an increased morbidity and mortality rate in patients treated with cardiac surgery. It should be individualized based on clinical and functional parameters like tissue oxygenation rather than hemoglobin values. Nevertheless, without perioperative ischemic data, hemoglobin values between 7 g/dL and 8 g/dL are well tolerated during PCSC.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> Bleeding prophylaxis with tranexamic acid during the entire cardiac surgery is recommended. The management of postoperative bleeding should be conducted using target-guided algorithms. The first step is to eliminate the factors that exacerbate coagulopathy (correcting hypothermia and acidosis), reverse residual heparin induced anemia through a protamine booster shot and optimize primary hemostasis (platelet levels > 100 000 cells/cc). The first thing target-guided therapy based on viscoelastic testing recommends is to correct hyperfibrinolysis (tranexamic acid), and then the firmness of the blood clot (fibrinogen). Finally, if the synthesis of thrombin is still compromised, a prothrombin complex concentrate should be administered.ConclusionsThe optimal perioperative management of patients treated with cardiovascular surgery requires a comprehensive and multidisciplinary approach including the proper medical-surgical training. Preoperative optimization, minimally invasive techniques, the prophylaxis of arrhythmias and postoperative bleeding, target-guided hemodynamic management, and multimodal analgesia to facilitate extubation and early mobilization are key elements in the intensified recovery of these patients. The high level of complexity reported turns the intensive medicine unit into the optimal environment to achieve the best results possible.AuthorsJJJR, CLJ, MJLG, and JLPV participated in the writing and final approval of this manuscript.Conflicts of interestNone reported." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1489471" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1352571" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1489470" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1352572" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Advances in cardiac surgery" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Enhanced recovery after surgery and fast-track surgery" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Preoperative optimization" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Standard management of the uncomplicated postoperative course" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Complications" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "De novo atrial fibrillation and other arrhythmias" ] 1 => array:3 [ "identificador" => "sec0040" "titulo" => "Postoperative low cardiac output syndrome" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Management of right-sided heart disease" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Management of right-sided heart disease and pulmonary hypertension" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Vasoplegic syndrome after cardiac surgery" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Excessive postoperative bleeding" ] ] ] ] ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Authors" ] 12 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-27" "fechaAceptado" => "2020-10-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1352571" "palabras" => array:3 [ 0 => "Perioperative medicine" 1 => "Cardiovascular surgery" 2 => "Critical care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1352572" "palabras" => array:3 [ 0 => "Medicina perioperatoria" 1 => "Cirugía cardiovascular" 2 => "Medicina intensiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Cardio-surgical patient care requires a comprehensive and multidisciplinary approach to develop strategies to improve patient safety and outcomes. In the preoperative period, prophylaxis for frequent postoperative complications, such as de novo atrial fibrillation or bleeding, and prehabilitation based on exercise training, respiratory physiotherapy and nutritional and cognitive therapy, especially in fragile patients, stand out. There have been great advances, during the intraoperative phase, such as minimally invasive surgery, improved myocardial preservation, enhanced systemic perfusion and brain protection during extracorporeal circulation, or implementation of Safe Surgery protocols. Postoperative care should include goal-directed hemodynamic theraphy, a correct approach to coagulation disorders, and a multimodal analgesic protocol to facilitate early extubation and mobilization. Finally, optimal management of postoperative complications is key, including arrhythmias, vasoplegia, bleeding, and myocardial stunning that can lead to low cardiac output syndrome or, in extreme cases, cardiogenic shock. This global approach and the high degree of complexity require highly specialised units where intensive care specialists add value and are key to obtain more effective and efficient clinical results." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La atención al paciente cardioquirúrgico requiere una aproximación integral y multidisciplinar para desarrollar estrategias que mejoren la seguridad y el pronóstico de los pacientes. En la fase preoperatoria destacan la implantación de medidas de prevención de las complicaciones postoperatorias más frecuentes, como la fibrilación auricular de novo o el sangrado, y la prehabilitación basada en ejercicio físico, fisioterapia respiratoria y terapia nutricional y cognitiva, especialmente en aquellos pacientes más frágiles. En la fase quirúrgica se han producido grandes avances como el desarrollo de procedimientos mínimamente invasivos, las mejoras en la preservación miocárdica, la perfusión sistémica durante la circulación extracorpórea y la protección cerebral, o la implantación de los protocolos de Cirugía Segura. En el postoperatorio se debe establecer un manejo hemodinámico guiado por objetivos, un correcto abordaje de los trastornos de la coagulación y el uso de analgesia multimodal que posibilite la extubación y movilización precoz de los pacientes. Por último, es clave un óptimo manejo de las complicaciones postoperatorias, entre las que destacan las arritmias, la vasoplejia, el sangrado postquirúrgico y el aturdimiento miocárdico que puede derivar en bajo gasto o, en su caso más extremo, en shock cardiogénico. Este enfoque global y el elevado nivel de complejidad hacen necesario el ingreso del paciente en unidades de alto nivel de asistencia siendo clave el valor aportado a este proceso por los Servicios de Medicina Intensiva para obtener unos resultados clínicos más eficaces y eficientes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Jiménez Rivera JJ, Llanos Jorge C, López Gude MJ, Pérez Vela JL. Manejo perioperatorio en cirugía cardiovascular. Med Intensiva. 2021;45:175–183." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2228 "Ancho" => 2501 "Tamanyo" => 474101 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Different perioperative stages based on the recommendations established. PO, postoperative; pre-OP, preoperative." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3655 "Ancho" => 2513 "Tamanyo" => 678522 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm proposal for the management of postoperative low cardiac output syndrome. CVP, central venous pressure; GLVEDV, global left ventricular end-diastolic volume; LV, left ventricle; LVEDP, left ventricular end-diastolic pressure; LVSV, left ventricular systolic volume; MAP, mean arterial pressure; PAOP, pulmonary artery occlusion pressure; RV, right ventricle; SvO2, mixed venous oxygen saturation; SvcO2, central venous oxygen saturation. *Adapted from Habicher M et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive arterial pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous electrocardiogram \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temperature \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydric balance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mixed oxygen venous saturation (SvO2) or central venous oxygen saturation (SvcO2) (if not monitored through pulmonary artery catheterization): marker of the balance between oxygen supply and demand. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gasometry: upon admission every 4 h–8 h and only as long as there is a change in the patient’s clinical situation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central venous pressure: it should be monitored because it is useful for tendency assessment or in the presence of extreme values. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2558374.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommended basic hemodynamic monitorization." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "DAP, diastolic arterial pressure; IPVD, inhaled pulmonary vasodilators; LCOS: low cardiac output syndrome; PEEP, positive end-expiratory pressure; PH, pulmonary hypertension; PSP, pulmonary systolic pressure; SAP, systolic arterial pressure; SPVD, systemic pulmonary vasodilators; VA/VV ECMO, venoarterial/venovenous extracorporeal membrane oxygenation; VAD, vasoactive drugs." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preload optimization \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume resuscitation in patients with bleeding or overt fluid loss \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume response assessment. Single or repeated bolus of 250 cc \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If high DAP levels use renal diuretics or renal replacement therapy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimization of heart rhythm and heart rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maintain sinus rhythm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Be aggressive with the management of tachycardias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the presence of atrioventricular block use a pacemaker \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimization of ventricular arterial coupling and perfusion pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of vasoactive drugs to achieve SAP > PSP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Noradrenaline, adrenaline or vasopressin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inotropes or inodilators + pulmonary vasodilators \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shock or LCOS ( VAD + inotropes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LCOS + PH ( VAD + inotropes + SPVD or IPVD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LCOS + ARF ( VAD + inotropes + IPVD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shock + PH ( VAD + inotropes + IPVD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shock due to PH ( VAD + inotropes + SPVD + IPVD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If failure: consider mechanical support (ventricular assist devices, VA-ECMO)/transplant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If accompanied by pulmonary disease use inhaled pulmonary vasodilators \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimizing breathing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjust PEEP. Avoid atelectasis and hyperinflation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider using pulmonary vasodilators to improve respiratory failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Avoid: hypercapnia, hypoxemia, and metabolic acidosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If failure: consider extracorporeal membrane oxygenation. VV-ECMO \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2558375.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Management of right ventricular failure while taking into consideration the patient’s hemodynamic situation, presence of pulmonary hypertension, and appearance of acute respiratory failure." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "cGMP, cyclic guanosine monophosphate." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drugs \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mechanism \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Doses and delivery systems \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adverse events \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nitric oxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inhaled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased cGMP levels (relaxation of smooth muscle fibers) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doses: 10–40 ppm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Methemoglobinemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rebound TPH after withdrawal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epoprostenol (Flolan®) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inhaled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostaglandin analogues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doses of 50–80 ng/kg/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dizziness, headache, hypotension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Requires an ultrasonic aerosol delivery system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Iloprost \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inhaled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostaglandin analogues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doses: 2.5–5 μg 6−9 times/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypotension and headache \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administer with a patented system or using a nebulizer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Milrinone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inhaled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Phosphodiesterase inhibitor increasing cAMP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 mg/4 mL every 8 h through an ultrasonic aerosol delivery system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypotension and headache \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2558376.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Inhaled pulmonary vasodilators." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "cGMP, cyclic guanosine monophosphate." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drugs \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mechanism \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Doses and delivery systems \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adverse events \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sildenafil (Revatio®) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increasing cGMP levels cause the relaxation of smooth muscle fibers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral dose: 5–80 mg every 8 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypotension, headache \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intravenous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When administered intravenously use half a dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Teprostinil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostaglandin analogues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 mg very 12 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dizziness, headache, hypotension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Up-titrate 0.25 mg every 4 days if well tolerated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epoprostenol (Veletri®) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intravenous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostaglandin analogues \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initially: 2 ng/kg/min with 1 ng/kg/min increases based on tolerance every 15−20 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache, hypotension, flushing, jaw pain \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiplatelet effect \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Riociguat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct stimulator of guanylate-cyclase \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 mg every 8 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypotension, headache, dizziness, gastrointestinal discomfort \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Up-titrate 0.5 mg every 2 weeks to a maximum of 2.5 mg every 8 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2558377.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Systemic pulmonary vasodilators." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:46 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugía cardiovascular en España en el año 2018. 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Update in Perioperative Intensive Medicine

Perioperative management in cardiovascular surgery

Manejo perioperatorio en cirugía cardiovascular

J.J. Jiménez Riveraa,

Corresponding author

jjjimenezrivera@gmail.com

Corresponding author.

, C. Llanos Jorgeb, M.J. López Gudec, J.L. Pérez Velad, on behalf of the GTCICYRCP

a Servicio de Medicina Intensiva, Hospital Universitario de Canarias, La Laguna, Spain

b Servicio de Medicina Intensiva, Hospital Quirón Salud Tenerife, Santa Cruz de Tenerife, Spain

c Servicio de Cirugía Cardiovascular, Hospital Universitario Doce de Octubre, Madrid, Spain

d Servicio de Medicina Intensiva, Hospital Universitario Doce de Octubre, Madrid, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Different perioperative stages based on the recommendations established&#46; PO&#44; postoperative&#59; pre-OP&#44; preoperative&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular surgery is a highly complex procedure with good results for selected patients that increases both their quality of life and survival&#46; In Spain&#44; back in 2018&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> 34 318 procedures were performed in 62 different cardiac surgery intensive care units&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The optimal management of these patients should be multidisciplinary&#44; comprehensive&#44; and patient-focused using the right protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Intensive medicine plays a key role in this clinical setting thanks to its contributions&#44; values&#44; and overall approach of the entire process&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Intensivists play a key role for their knowledge of the procedure and capacity to handle the quality of the process through healthcare registries&#44; outcome assessments&#44; and actions for improvement&#46; It is of paramount importance to admit patients to the intensive care unit &#40;ICU&#41; who&#44; due to their instability or complexity&#44; require preoperative optimization&#46; Similarly&#44; postoperative management is essential here too&#44; both at the ICU setting and at the hospitalization floor for the early detection of any possible complications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;SEMICYUC&#41; strategic plan for 2018&#8211;2022<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> advocates for the quality of the surgical process by establishing specific actions aimed at improving the management of surgical patients and their families and working collaboratively with other medical specialties to achieve an effective&#44; efficient&#44; and safe process&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Advances in cardiac surgery</span><p id="par0020" class="elsevierStylePara elsevierViewall">Over the last few years&#44; cardiovascular surgery has evolved significantly thanks to the advances made in myocardial protection&#44; systemic perfusion during extracorporeal circulation&#44; and cerebral protection in situations of circulatory arrest&#44; the implementation of safe surgical protocols during the intervention&#44; the transesophageal echocardiography monitorization of technical complications&#44; new minimally invasive surgical techniques&#44; sutureless percutaneous heart valve implantation&#44; and the development of multimodal recovery &#40;ERAS&#41; in cardiac surgery&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Enhanced recovery after surgery and fast-track surgery</span><p id="par0025" class="elsevierStylePara elsevierViewall">ERAS protocols reduce the impact of perioperative stress and speed up the patients&#8217; recovery time&#46; They include pre-&#44; intra-&#44; and postoperative indications&#59; they obtain as much information as possible and preparation prior to the surgery&#44; empower the patient&#44; standardize certain processes&#44; and optimize resources to reduce complications&#44; hospital stays&#44; and down times&#46; These recommendations<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> are shown on <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Preoperative optimization</span><p id="par0030" class="elsevierStylePara elsevierViewall">Prehabilitation in frail patients<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> by correcting nutritional deficits<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and preoperative anemia&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and withdrawing certain drugs &#40;antiplatelet drugs&#44; anticoagulants&#44; renin-angiotensin system inhibitors&#41; improves postoperative results and reduces hemorrhagic&#44; hemodynamic&#44; and renal complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Prophylaxis of <span class="elsevierStyleItalic">de novo</span> atrial fibrillation with beta-blockers or amiodarone is capable of reducing its incidence rate&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Preconditioning with levosimendan in coronary patients with moderate-to-severe systolic dysfunction is a useful and cost-effective strategy to reduce the incidence rate of postoperative low cardiac output syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Standard management of the uncomplicated postoperative course</span><p id="par0040" class="elsevierStylePara elsevierViewall">The early management of patients during postoperative cardiac surgery care &#40;PCSC&#41; requires a thorough physical examination and&#44; at least&#44; basic hemodynamic monitorization&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; Afterwards&#44; the homeostasis of the internal medium needs to be reestablished&#44; normothermia needs to be reached&#44; the correct functioning of the epicardial pacemaker guaranteed&#44; and antibiotic prophylaxis continued&#46; It is essential to establish a multimodal analgesic strategy by combining different types of analgesics to reduce the doses of opioids&#44; thus facilitating the patient&#8217;s extubation&#44; rehabilitation&#44; and early mobilization&#46; Weaning from mechanical ventilation should start when the proper conditions of clinical stability are met&#46; As it occurs in most critically ill patients&#44; an adequate glycemic control should be kept followed by the detection and prevention of acute kidney injury&#44; early administration of thromboprophylaxis &#40;mechanical and&#44; when possible&#44; pharmacological&#41;&#44; and prevention of delirium&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Resuscitation and hemodynamic management should be guided by objective targets<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Advanced monitorization is indicated in unstable patients&#44; in those in whom the pathophysiology of the process needs to be deciphered or in patients who&#44; due to their baseline characteristics&#44; intraoperative evolution or type of intervention are considered of high surgical risk&#46; Advanced hemodynamic monitoring systems allow us to obtain ongoing information on cardiac output &#40;CO&#41; and its determinants&#58; preload or preload-dependency&#44; contractility&#44; and afterload&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Contractility is reduced during the immediate PCSC compared to the preoperative course&#46; The magnitude and duration of this stage will depend on the previous cardiac dysfunction&#44; existence of ischemic events&#44; preoperative complications&#44; and intraoperative evolution&#46; The components that impact cardiac dysfunction the most are an increased left ventricular &#40;LV&#41; mass&#44; hypothermia&#44; the volume and route of cardioplegia administration&#44; and prolonged ECC time&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">During the postoperative course we should take into account the presence of 2 hemodynamic patterns&#58; pressure overload &#40;left hypertrophy and impaired lusitropy&#41; that affects the measurement of filling pressures&#44; thus underestimating the volume needs and associated with possible tachycardia intolerance&#46; The other one being volume overload &#40;typical of valvular regurgitation&#41; that also alters the measurement of preload-dependency and where the dynamic variables of response to volume have not been validated&#46; In this context a continuous assessment of the response to the volume administered is required as well as its repercussion on the target parameters to avoid inadequate resuscitations&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Added to CO and its determinants&#44; the pulmonary artery catheterization is the only system that provides us with information on SvO<span class="elsevierStyleInf">2</span> and pulmonary pressures&#46; Systems based on transpulmonary thermodilution have been developed as an alternative to provide CO continuous measurements &#40;and other parameters of great utility&#41;&#46; These systems have recently been validated in patients with cardiogenic shock&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> However&#44; they have limitations like the need for frequent recalibration in the presence of significant hemodynamic variations or loss of accuracy in the presence of arrhythmias or work of breathing&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> Echocardiography has been playing a key role during PCSC and&#44; to this date&#44; it is considered an essential imaging modality&#46; Its utility lies in how fast it provides us with functional and anatomical information&#46; It allows us to assess the ejection fraction&#44; the CO through systolic volume assessment&#44; the response to fluids&#44; inotropes or vasoactive drugs&#44; speed up the early diagnosis of complications &#40;tamponade&#44; valve failure&#8230;&#41;&#44; and facilitate the appropriate therapeutic decision-making process&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Complications</span><p id="par0065" class="elsevierStylePara elsevierViewall">The risk of perioperative complications depends on the patient&#8217;s baseline coronary artery disease&#44; his functional reserve&#44; the prevalence of comorbidities&#44; type and character of the surgery&#44; and duration of the entire surgical procedure&#46; These are some of the most common postoperative complications&#58;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055"><span class="elsevierStyleItalic">De novo</span> atrial fibrillation and other arrhythmias</span><p id="par0070" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; is the most common arrhythmia during PCSC&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Its peak incidence rate occurs within 48&#8239;h&#8211;72&#8239;h and it usually subsides spontaneously within the first 24&#8239;h or with drug therapy&#46; Beta-blockers and amiodarone are the cornerstone of prophylaxis and treatment of <span class="elsevierStyleItalic">de novo</span> postoperative AF&#46; Here the strategy of monitoring heart rate and that of monitoring heart rhythm are equally valid&#46; Antithrombotic therapy should be based on the individual assessment of risk of thromboembolism using scales like the CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc and the HAS-BLED&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In presence of AF with hemodynamic instability we should consider the use of biphasic waveform synchronized shocks&#44; initially at 100&#8239;joules&#44; &#40;200&#8239;joules in obese patients&#41;&#46; For the management of sustained monomorphic ventricular tachycardias synchronized shocks at 50&#8722;100&#8239;joules should be used&#46; Regarding disorganized or pulseless ventricular tachycardias non-synchronized shocks at maximum energy should be used&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The rate of complete postoperative atrioventricular block is between 4&#37;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and 11&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It is often transient&#44; and the indications for definitive pacemaker implantation are the same ones as in non-operated patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Postoperative low cardiac output syndrome</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Management of right-sided heart disease</span><p id="par0080" class="elsevierStylePara elsevierViewall">It is defined as that hemodynamic situation where CO cannot fully satisfy the tissue metabolic demand&#46; However&#44; the triggers&#44; clinical presentation&#44; disease progression&#44; and treatment are different to heart failure of medical origin&#46; Its incidence rate is somewhere between 3&#37; and 45&#37;&#44; and it is associated with a higher morbidity and mortality rate&#44; ICU stays&#44; and use of resources&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#8211;29</span></a> Its clinical signs are varied and go from mild myocardial stunning that may require the transient use of inotropes with full recovery within 24&#8239;h&#8211;48&#8239;h to serious cases with cardiogenic shock&#44; multiorgan failure&#44; and death&#46; The early identification of clinical signs and the proper management are essential to achieve good results&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Added to the aforementioned measures&#44; we should also&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0090" class="elsevierStylePara elsevierViewall">Rule out mechanical and&#47;or reversible causes&#58; pneumothorax&#44; hemothorax&#44; excessive bleeding&#44; cardiac tamponade&#44; and coronary graft spasm or occlusion&#44; prosthetic valve dysfunction&#44; and arrhythmias &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0095" class="elsevierStylePara elsevierViewall">Use a stepped approach following gradual sequencies of action&#46; First&#44; preload should be optimized&#44; and rhythm should be kept under control by reversing tachyarrhythmias through cardioversion and&#47;or over-pacing in the presence of hemodynamic repercussions&#46; In the presence of bradyarrhythmias&#44; relative bradycardias or atrioventricular block&#44; epicardial cardiac pacing wires should be used&#46; Afterwards&#44; inotropes&#44; vasoconstrictors and&#47;or vasodilators should be used&#46; The last step is circulatory assist devices like the intra-aortic balloon pump&#44; venoarterial extracorporeal oxygenation or any other types of mechanical circulatory support ventricular assist devices &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Management of right-sided heart disease and pulmonary hypertension</span><p id="par0100" class="elsevierStylePara elsevierViewall">In the context of cardiac surgery&#44; right ventricular &#40;RV&#41; failure is more prevalent in<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> high-risk coronary artery disease with right coronary artery lesion&#44; valvular heart disease&#8212;especially in the mitral valve&#8212;&#44; the postoperative course of heart transplant&#44; congenital coronary artery disease&#44; pulmonary thromboendarterectomy due to chronic thromboembolic pulmonary hypertension &#40;TPH&#41;&#44; and patients with LV assist devices&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Its management requires optimizing preload&#44; afterload&#44; contractility&#44; rhythm&#44; and rate<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The RV cardiac output is influenced by the contraction of interventricular septum&#44; based on the LV function&#44; which is why in the presence of associated LV dysfunction&#44; inotropes should be used&#46; It is essential to avoid arterial hypotension to secure the correct perfusion of both ventricles&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">In order to reduce the RV afterload&#44; pulmonary vasodilators &#40;PVD&#41; can be administered locally &#40;inhaled or nebulized&#41; or systemically &#40;oral and intravenous&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Systemic vasodilation can cause arterial hypotension and create respiratory failure due to ventilation&#47;perfusion &#40;V&#47;Q ratio&#41; mismatch&#46; Inhaled PVD cause less systemic hypotension and improve the V&#47;Q ratio&#46; Therefore&#44; they are useful to treat chronic TPH&#44; improve the V&#47;Q ratio&#44; and reduce the afterload of a dysfunctional RV&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The type of drug that should be used depends on the clinical context&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#8211;38</span></a> In patients with predominant respiratory failure and residual TPH&#44; locally-acting drugs &#40;inhaled nitric oxide &#91;iNO&#93; and&#47;or inhaled prostacyclin&#41; should be used to treat both entities simultaneously&#46; In presence of hemodynamic instability&#44; we should start with inodilators &#40;dobutamine or milrinone&#41; together with inhaled PVD &#40;iNO and prostacyclin&#41; to reduce the afterload thanks to the lower hemodynamic impairment associated&#46; Once the situation has stabilized &#40;significant reduction or withdrawal of vasoactive support&#41; phosphodiesterase-5 inhibitors or prostaglandins can be started IV and at low doses&#46; Based on the patient&#8217;s tolerance&#44; the withdrawal of iNO and then prostacyclin can be considered &#40;since the latter can still be used in extubated patients&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In hemodynamically stable patients without respiratory failure but significant residual TPH&#44; home medication can be suggested and introduced gradually&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">There are times that despite the optimal medical therapy&#44; the patient&#8217;s cardiac output remains low&#46; In these cases&#44; it is required to initiate mechanical support measures&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Vasoplegic syndrome after cardiac surgery</span><p id="par0130" class="elsevierStylePara elsevierViewall">It has been reported that during PCSC up to half of the patients can develop vasoplegia &#40;low systemic vascular resistances with CI&#8239;&#62;&#8239;2&#46;2&#8239;L&#47;kg&#47;min&#41; accompanied by distributive shock in up to 5&#37; of them&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Pathophysiology is similar to that of the vasoplegic shock reported in sepsis&#46; It is important to recognize the situation early and start vasopressor therapy to achieve the proper organ perfusion&#46; The most commonly used drug is noradrenaline&#46; In cases that require high doses&#44; vasopressin can be used as well&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The role of angiotensin <span class="elsevierStyleSmallCaps">ii</span> seems promising in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Excessive postoperative bleeding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Excessive postoperative bleeding is one the most common complications of cardiac surgery&#46; It can be defined as bleeding over 1&#8239;L of blood within the first 24&#8239;h&#46; Its incidence rate is around 33&#37; and requires surgical reassessment in 3&#37; to 7&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Proper management is a priority in this context since in up to 50&#37; of the patients with reinterventions there is no surgical cause for the bleeding&#44; and reassessment becomes an independent risk factor for the appearance of postoperative adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Bleeding during PCSC is multifactorial and somehow triggered by the characteristics of the patient&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a> the perioperative drugs used&#44; and surgery <span class="elsevierStyleItalic">per se</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> ECC causes a procoagulant state that triggers a pro-hemorrhagic situation &#40;since it consumes coagulation and platelet factors&#41; aggravated by hemodilution and the activation of the fibrinolytic system&#46; The transfusion of hemoderivatives is directly associated with an increased morbidity and mortality rate in patients treated with cardiac surgery&#46; It should be individualized based on clinical and functional parameters like tissue oxygenation rather than hemoglobin values&#46; Nevertheless&#44; without perioperative ischemic data&#44; hemoglobin values between 7&#8239;g&#47;dL and 8&#8239;g&#47;dL are well tolerated during PCSC&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Bleeding prophylaxis with tranexamic acid during the entire cardiac surgery is recommended&#46; The management of postoperative bleeding should be conducted using target-guided algorithms&#46; The first step is to eliminate the factors that exacerbate coagulopathy &#40;correcting hypothermia and acidosis&#41;&#44; reverse residual heparin induced anemia through a protamine booster shot and optimize primary hemostasis &#40;platelet levels &#62; 100 000 cells&#47;cc&#41;&#46; The first thing target-guided therapy based on viscoelastic testing recommends is to correct hyperfibrinolysis &#40;tranexamic acid&#41;&#44; and then the firmness of the blood clot &#40;fibrinogen&#41;&#46; Finally&#44; if the synthesis of thrombin is still compromised&#44; a prothrombin complex concentrate should be administered&#46;</p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">The optimal perioperative management of patients treated with cardiovascular surgery requires a comprehensive and multidisciplinary approach including the proper medical-surgical training&#46; Preoperative optimization&#44; minimally invasive techniques&#44; the prophylaxis of arrhythmias and postoperative bleeding&#44; target-guided hemodynamic management&#44; and multimodal analgesia to facilitate extubation and early mobilization are key elements in the intensified recovery of these patients&#46; The high level of complexity reported turns the intensive medicine unit into the optimal environment to achieve the best results possible&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authors</span><p id="par0145" class="elsevierStylePara elsevierViewall">JJJR&#44; CLJ&#44; MJLG&#44; and JLPV participated in the writing and final approval of this manuscript&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">None reported&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Advances in cardiac surgery"
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          "identificador" => "sec0015"
          "titulo" => "Enhanced recovery after surgery and fast-track surgery"
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          "titulo" => "Preoperative optimization"
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          "identificador" => "sec0025"
          "titulo" => "Standard management of the uncomplicated postoperative course"
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          "titulo" => "Complications"
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              "identificador" => "sec0035"
              "titulo" => "De novo atrial fibrillation and other arrhythmias"
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              "titulo" => "Postoperative low cardiac output syndrome"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0045"
                  "titulo" => "Management of right-sided heart disease"
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                  "titulo" => "Management of right-sided heart disease and pulmonary hypertension"
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                  "identificador" => "sec0055"
                  "titulo" => "Vasoplegic syndrome after cardiac surgery"
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                  "titulo" => "Excessive postoperative bleeding"
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          "titulo" => "Conclusions"
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          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2020-10-27"
    "fechaAceptado" => "2020-10-29"
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          "palabras" => array:3 [
            0 => "Medicina perioperatoria"
            1 => "Cirug&#237;a cardiovascular"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cardio-surgical patient care requires a comprehensive and multidisciplinary approach to develop strategies to improve patient safety and outcomes&#46; In the preoperative period&#44; prophylaxis for frequent postoperative complications&#44; such as de novo atrial fibrillation or bleeding&#44; and prehabilitation based on exercise training&#44; respiratory physiotherapy and nutritional and cognitive therapy&#44; especially in fragile patients&#44; stand out&#46; There have been great advances&#44; during the intraoperative phase&#44; such as minimally invasive surgery&#44; improved myocardial preservation&#44; enhanced systemic perfusion and brain protection during extracorporeal circulation&#44; or implementation of Safe Surgery protocols&#46; Postoperative care should include goal-directed hemodynamic theraphy&#44; a correct approach to coagulation disorders&#44; and a multimodal analgesic protocol to facilitate early extubation and mobilization&#46; Finally&#44; optimal management of postoperative complications is key&#44; including arrhythmias&#44; vasoplegia&#44; bleeding&#44; and myocardial stunning that can lead to low cardiac output syndrome or&#44; in extreme cases&#44; cardiogenic shock&#46; This global approach and the high degree of complexity require highly specialised units where intensive care specialists add value and are key to obtain more effective and efficient clinical results&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La atenci&#243;n al paciente cardioquir&#250;rgico requiere una aproximaci&#243;n integral y multidisciplinar para desarrollar estrategias que mejoren la seguridad y el pron&#243;stico de los pacientes&#46; En la fase preoperatoria destacan la implantaci&#243;n de medidas de prevenci&#243;n de las complicaciones postoperatorias m&#225;s frecuentes&#44; como la fibrilaci&#243;n auricular de novo o el sangrado&#44; y la prehabilitaci&#243;n basada en ejercicio f&#237;sico&#44; fisioterapia respiratoria y terapia nutricional y cognitiva&#44; especialmente en aquellos pacientes m&#225;s fr&#225;giles&#46; En la fase quir&#250;rgica se han producido grandes avances como el desarrollo de procedimientos m&#237;nimamente invasivos&#44; las mejoras en la preservaci&#243;n mioc&#225;rdica&#44; la perfusi&#243;n sist&#233;mica durante la circulaci&#243;n extracorp&#243;rea y la protecci&#243;n cerebral&#44; o la implantaci&#243;n de los protocolos de Cirug&#237;a Segura&#46; En el postoperatorio se debe establecer un manejo hemodin&#225;mico guiado por objetivos&#44; un correcto abordaje de los trastornos de la coagulaci&#243;n y el uso de analgesia multimodal que posibilite la extubaci&#243;n y movilizaci&#243;n precoz de los pacientes&#46; Por &#250;ltimo&#44; es clave un &#243;ptimo manejo de las complicaciones postoperatorias&#44; entre las que destacan las arritmias&#44; la vasoplejia&#44; el sangrado postquir&#250;rgico y el aturdimiento mioc&#225;rdico que puede derivar en bajo gasto o&#44; en su caso m&#225;s extremo&#44; en shock cardiog&#233;nico&#46; Este enfoque global y el elevado nivel de complejidad hacen necesario el ingreso del paciente en unidades de alto nivel de asistencia siendo clave el valor aportado a este proceso por los Servicios de Medicina Intensiva para obtener unos resultados cl&#237;nicos m&#225;s eficaces y eficientes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Jim&#233;nez Rivera JJ&#44; Llanos Jorge C&#44; L&#243;pez Gude MJ&#44; P&#233;rez Vela JL&#46; Manejo perioperatorio en cirug&#237;a cardiovascular&#46; Med Intensiva&#46; 2021&#59;45&#58;175&#8211;183&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Algorithm proposal for the management of postoperative low cardiac output syndrome&#46; CVP&#44; central venous pressure&#59; GLVEDV&#44; global left ventricular end-diastolic volume&#59; LV&#44; left ventricle&#59; LVEDP&#44; left ventricular end-diastolic pressure&#59; LVSV&#44; left ventricular systolic volume&#59; MAP&#44; mean arterial pressure&#59; PAOP&#44; pulmonary artery occlusion pressure&#59; RV&#44; right ventricle&#59; SvO<span class="elsevierStyleInf">2</span>&#44; mixed venous oxygen saturation&#59; SvcO<span class="elsevierStyleInf">2</span>&#44; central venous oxygen saturation&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#42;Adapted from Habicher M et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Invasive arterial pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Continuous electrocardiogram&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Temperature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hydric balance&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Mixed oxygen venous saturation &#40;SvO<span class="elsevierStyleInf">2</span>&#41; or central venous oxygen saturation &#40;SvcO<span class="elsevierStyleInf">2</span>&#41; &#40;if not monitored through pulmonary artery catheterization&#41;&#58; marker of the balance between oxygen supply and demand&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Gasometry&#58; upon admission every 4&#8239;h&#8211;8&#8239;h and only as long as there is a change in the patient&#8217;s clinical situation&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Central venous pressure&#58; it should be monitored because it is useful for tendency assessment or in the presence of extreme values&#46;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">DAP&#44; diastolic arterial pressure&#59; IPVD&#44; inhaled pulmonary vasodilators&#59; LCOS&#58; low cardiac output syndrome&#59; PEEP&#44; positive end-expiratory pressure&#59; PH&#44; pulmonary hypertension&#59; PSP&#44; pulmonary systolic pressure&#59; SAP&#44; systolic arterial pressure&#59; SPVD&#44; systemic pulmonary vasodilators&#59; VA&#47;VV ECMO&#44; venoarterial&#47;venovenous extracorporeal membrane oxygenation&#59; VAD&#44; vasoactive drugs&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>If high DAP levels use renal diuretics or renal replacement therapy&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Optimization of heart rhythm and heart rate</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maintain sinus rhythm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Be aggressive with the management of tachycardias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In the presence of atrioventricular block use a pacemaker&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Optimization of ventricular arterial coupling and perfusion pressure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Use of vasoactive drugs to achieve SAP&#8239;&#62;&#8239;PSP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Noradrenaline&#44; adrenaline or vasopressin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inotropes or inodilators&#8239;&#43;&#8239;pulmonary vasodilators&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Shock or LCOS&#8239;&#40;&#8239;VAD&#8239;&#43;&#8239;inotropes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LCOS&#8239;&#43;&#8239;PH&#8239;&#40;&#8239;VAD&#8239;&#43;&#8239;inotropes&#8239;&#43;&#8239;SPVD or IPVD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LCOS&#8239;&#43;&#8239;ARF&#8239;&#40;&#8239;VAD&#8239;&#43;&#8239;inotropes&#8239;&#43;&#8239;IPVD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Shock&#8239;&#43;&#8239;PH&#8239;&#40;&#8239;VAD&#8239;&#43;&#8239;inotropes&#8239;&#43;&#8239;IPVD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Shock due to PH&#8239;&#40;&#8239;VAD&#8239;&#43;&#8239;inotropes&#8239;&#43;&#8239;SPVD&#8239;&#43;&#8239;IPVD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>If failure&#58; consider mechanical support &#40;ventricular assist devices&#44; VA-ECMO&#41;&#47;transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>If accompanied by pulmonary disease use inhaled pulmonary vasodilators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Optimizing breathing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adjust PEEP&#46; Avoid atelectasis and hyperinflation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consider using pulmonary vasodilators to improve respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Avoid&#58; hypercapnia&#44; hypoxemia&#44; and metabolic acidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>If failure&#58; consider extracorporeal membrane oxygenation&#46; VV-ECMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Management of right ventricular failure while taking into consideration the patient&#8217;s hemodynamic situation&#44; presence of pulmonary hypertension&#44; and appearance of acute respiratory failure&#46;</p>"
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      ]
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        "etiqueta" => "Table 3"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">cGMP&#44; cyclic guanosine monophosphate&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mechanism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Doses and delivery systems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nitric oxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhaled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased cGMP levels &#40;relaxation of smooth muscle fibers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Doses&#58; 10&#8211;40&#8239;ppm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Methemoglobinemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rebound TPH after withdrawal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epoprostenol &#40;Flolan&#174;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhaled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prostaglandin analogues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Doses of 50&#8211;80&#8239;ng&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dizziness&#44; headache&#44; hypotension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Requires an ultrasonic aerosol delivery system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Iloprost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhaled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prostaglandin analogues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Doses&#58; 2&#46;5&#8211;5&#8239;&#956;g 6&#8722;9&#8239;times&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypotension and headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Administer with a patented system or using a nebulizer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Milrinone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhaled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phosphodiesterase inhibitor increasing cAMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#8239;mg&#47;4&#8239;mL every 8&#8239;h through an ultrasonic aerosol delivery system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypotension and headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Inhaled pulmonary vasodilators&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">cGMP&#44; cyclic guanosine monophosphate&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mechanism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Doses and delivery systems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sildenafil &#40;Revatio&#174;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increasing cGMP levels cause the relaxation of smooth muscle fibers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral dose&#58; 5&#8211;80&#8239;mg every 8&#8239;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypotension&#44; headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intravenous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">When administered intravenously use half a dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Teprostinil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prostaglandin analogues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&#8239;mg very 12&#8239;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dizziness&#44; headache&#44; hypotension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up-titrate 0&#46;25&#8239;mg every 4 days if well tolerated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epoprostenol &#40;Veletri&#174;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intravenous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prostaglandin analogues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initially&#58; 2&#8239;ng&#47;kg&#47;min with 1&#8239;ng&#47;kg&#47;min increases based on tolerance every 15&#8722;20&#8239;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Headache&#44; hypotension&#44; flushing&#44; jaw pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antiplatelet effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Riociguat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Direct stimulator of guanylate-cyclase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#8239;mg every 8&#8239;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypotension&#44; headache&#44; dizziness&#44; gastrointestinal discomfort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up-titrate 0&#46;5&#8239;mg every 2 weeks to a maximum of 2&#46;5&#8239;mg every 8&#8239;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "imagenFichero" => array:1 [
                0 => "xTab2558377.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Systemic pulmonary vasodilators&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:46 [
            0 => array:3 [
              "identificador" => "bib0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                          "etal" => true
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                  "host" => array:1 [
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                      "Revista" => array:5 [
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            1 => array:3 [
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                      "titulo" => "Cirug&#237;a cardiovascular&#46; Abordaje integral"
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                        0 => array:2 [
                          "etal" => false
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                            1 => "J&#46;J&#46; Jim&#233;nez Rivera"
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                          "etal" => false
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                            0 => "M&#46;C&#46; Mart&#237;n Delgado"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2018.02.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva&#46;"
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                        "link" => array:1 [
                          0 => array:2 [
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            3 => array:3 [
              "identificador" => "bib0020"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medicina Intensiva Perioperatoria&#46; Aportando valor al proceso quir&#250;rgico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; Gordo Vidal"
                            1 => "M&#46;C&#46; Mart&#237;n Delgado"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2020.01.009"
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                        "tituloSerie" => "Med Intensiva"
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                        "paginaFinal" => "311"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32093970"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
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              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Documento sobre la situaci&#243;n del modelo espa&#241;ol de Medicina Intensiva Plan estrat&#233;gico SEMICYUC 2018-2022"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;M&#46; Olaechea Astigarraga"
                            1 => "M&#46; Bod&#237; Saera"
                            2 => "M&#46;C&#46; Mart&#237;n Delgado"
                            3 => "M&#46;S&#46; Holanda Pe&#241;a"
                            4 => "A&#46; Garc&#237;a de Lorenzo"
                            5 => "A&#46;A&#46; Mateos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2018.04.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva&#46;"
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                        "volumen" => "43"
                        "paginaInicial" => "47"
                        "paginaFinal" => "51"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29898831"
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                        ]
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              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for perioperative care in cardiac surgery&#58; enhanced recovery after surgery society recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "D&#46;T&#46; Engelman"
                            1 => "W&#46; Ben Ali"
                            2 => "J&#46;B&#46; Williams"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jamasurg.2019.1153"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA Surg"
                        "fecha" => "2019"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31054241"
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fragility and perioperative outcomes&#58; a narrative review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "T&#46; Beggs"
                            1 => "A&#46; Sepehri"
                            2 => "A&#46; Szwajcer"
                            3 => "N&#46; Tangri"
                            4 => "R&#46;C&#46; Arora"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12630-014-0273-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Anesth"
                        "fecha" => "2015"
                        "volumen" => "62"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25420470"
                            "web" => "Medline"
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              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Malnutrition in cardiac surgery&#58; food for thought"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46; Chermesh"
                            1 => "J&#46; Hajos"
                            2 => "T&#46; Mashiach"
                            3 => "M&#46; Bozhko"
                            4 => "L&#46; Shani"
                            5 => "R&#46;-R&#46; Nir"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/2047487312452969"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2020.10.005

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Year/Month	Html	Pdf	Total

2024 November	9	11	20
2024 October	146	119	265
2024 September	222	98	320
2024 August	237	99	336
2024 July	254	81	335
2024 June	245	121	366
2024 May	227	89	316
2024 April	180	83	263
2024 March	259	74	333
2024 February	290	91	381
2024 January	286	114	400
2023 December	246	91	337
2023 November	323	129	452
2023 October	317	126	443
2023 September	269	155	424
2023 August	202	63	265
2023 July	242	103	345
2023 June	254	81	335
2023 May	262	98	360
2023 April	197	63	260
2023 March	338	124	462
2023 February	332	124	456
2023 January	205	71	276
2022 December	181	58	239
2022 November	203	76	279
2022 October	235	71	306
2022 September	172	70	242
2022 August	169	91	260
2022 July	162	97	259
2022 June	148	97	245
2022 May	154	70	224
2022 April	209	174	383
2022 March	221	94	315
2022 February	158	74	232
2022 January	169	71	240
2021 December	158	68	226
2021 November	134	62	196
2021 October	169	137	306
2021 September	134	84	218
2021 August	130	86	216
2021 July	78	56	134
2021 April	274	18	292
2021 March	1	0	1

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