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o el Documento C&#243;digo Sepsis &#40;DCS&#41; en Espa&#241;a han intentado homogeneizar el tratamiento diagn&#243;stico-terap&#233;utico<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a>&#44; y se ha demostrado que la introducci&#243;n del concepto de los <span class="elsevierStyleItalic">bundles</span> o paquetes de medidas mejora la atenci&#243;n e incluso la morbimortalidad<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a>&#46; La SSC enfatiza la importancia del <span class="elsevierStyleItalic">bundle</span> de la primera hora&#58; obtener hemocultivos &#40;y otros cultivos&#41;&#44; determinar el lactato plasm&#225;tico&#44; el r&#225;pido inicio de una adecuada antibioticoterapia emp&#237;rica y fluidoterapia y administraci&#243;n precoz de vasopresores<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; El DCS ampl&#237;a estos <span class="elsevierStyleItalic">bundles</span> hasta 4 y destaca la importancia del tratamiento integral e indivi-dualizado en las diferentes fases de la sepsis<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En los &#250;ltimos 15 a&#241;os&#44; una serie de estudios observacionales&#44; ensayos cl&#237;nicos y consensos han mantenido importantes controversias sobre la reanimaci&#243;n con fluidos en la sepsis&#46; Estas se basan en qu&#233; tipo de fluido es el m&#225;s adecuado&#44; qu&#233; cantidad&#44; cu&#225;nto tiempo se debe administrar o c&#243;mo se debe monitorizar la respuesta hemodin&#225;mica&#46; Tiene importancia capital evitar balances h&#237;dricos positivos por el aumento de la morbimortalidad&#46; Otra cuesti&#243;n importante es el inicio m&#225;s precoz de los vasopresores<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;10</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Por ello&#44; en este art&#237;culo se revisan los principales conceptos&#44; estudios y controversias de la reanimaci&#243;n con fluidos en enfermos s&#233;pticos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0030">Justificaci&#243;n fisiopatol&#243;gica del papel de la fluidoterapia en la sepsis y el <span class="elsevierStyleItalic">shock</span> s&#233;ptico</span><p id="par0020" class="elsevierStylePara elsevierViewall">El SS se caracteriza por una distribuci&#243;n anormal del flujo sangu&#237;neo en los diferentes tejidos&#44; con la consiguiente ca&#237;da de la presi&#243;n arterial media &#40;PAM&#41;&#44; as&#237; como la disminuci&#243;n del retorno venoso&#46; La vasodilataci&#243;n venosa da lugar a un aumento del volumen intravascular a expensas de volumen no estresado &#40;incapaz de generar presi&#243;n que venza la distensibilidad y la capacitancia de la pared venosa&#41;&#44; lo que produce una disminuci&#243;n del retorno venoso y el gasto cardiaco &#40;GC&#41; del ventr&#237;culo derecho &#40;VD&#41;&#44; que se transmite posteriormente al ventr&#237;culo izquierdo &#40;VI&#41; disminuyendo su precarga y el GC<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6&#8211;11</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Simult&#225;neamente a la vasodilataci&#243;n arterial y venosa por vasoplej&#237;a&#44; se incrementan los mediadores de la respuesta inmunitaria innata&#44; que puede resultar en lesi&#243;n microvascular&#44; un suministro inadecuado de ox&#237;geno a los tejidos y un metabolismo celular inadecuado<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Hay varios factores asociados con el descenso del retorno venoso&#46; El m&#225;s importante es la inmovilizaci&#243;n venosa &#40;en peque&#241;os y grandes vasos&#41; que puede complicarse a&#250;n m&#225;s por la escasa ingesta&#47;administraci&#243;n de l&#237;quidos o el aumento de las p&#233;rdidas intravasculares durante la fase inicial de la sepsis&#46; Otro mecanismo importante&#44; que puede empeorar a&#250;n m&#225;s dicho retorno venoso y consecuentemente la microcirculaci&#243;n&#44; es el da&#241;o endotelial que genera fuga capilar hacia el intersticio<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;9&#8211;11</span></a>&#46; Este puede generar un s&#237;ndrome compartimental celular y estimular la producci&#243;n de citocinas proinflamatorias&#44; que mantiene un ciclo y p&#233;rdida de la homeostasis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Las manifestaciones cl&#237;nicas y anal&#237;ticas precoces m&#225;s importantes del SS son hipotensi&#243;n arterial &#40;PAM<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; mala perfusi&#243;n &#40;disminuci&#243;n de la diuresis y alteraci&#243;n cut&#225;nea o de conciencia&#41;&#44; empeoramiento de la saturaci&#243;n venosa mixta de ox&#237;geno &#40;SatVO<span class="elsevierStyleInf">2</span>&#41; y el aumento del lactato plasm&#225;tico&#46; El SS es una entidad m&#225;s compleja que la hipotensi&#243;n arterial&#44; pues puede haber <span class="elsevierStyleItalic">shock</span> tisular sin hipotensi&#243;n arterial<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La administraci&#243;n de fluidos en el SS se basa en intentar que aumente el volumen intravascular y en consecuencia el retorno venoso para contrarrestar la &#8220;hipovolemia&#8221; relativa&#46; De esta forma se favorece el aumento de la precarga del VD y&#44; en ausencia de fallo de este&#44; la precarga y el GC del VI y&#44; por tanto&#44; la mejor&#237;a de la perfusi&#243;n tisular y del trasporte de ox&#237;geno<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;7&#44;9</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Los principales elementos para una reanimaci&#243;n eficaz con fluidos depender&#225;n del tipo de fluido elegido&#44; as&#237; como el volumen y el tiempo de administraci&#243;n&#46; Pero tambi&#233;n es un factor determinante la monitorizaci&#243;n de la respuesta hemodin&#225;mica&#44; tanto para evaluar su respuesta como para evitar la sobrecarga h&#237;drica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#8211;13</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">Tabla 1</a> se describen las 4 fases de fluidoterapia en la reanimaci&#243;n del SS seg&#250;n distintos par&#225;metros&#58; <span class="elsevierStyleItalic">a&#41;</span> fase 1&#58; reanimaci&#243;n&#59; <span class="elsevierStyleItalic">b&#41;</span> fase 2&#58; optimizaci&#243;n&#59; <span class="elsevierStyleItalic">c&#41;</span> fase 3&#58; estabilizaci&#243;n o consolidaci&#243;n&#44; y <span class="elsevierStyleItalic">d&#41;</span> fase 4&#58; evacuaci&#243;n o desescalada terap&#233;utica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#8211;9&#44;12&#44;13</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">La fase 1 o de reanimaci&#243;n tiene como principal objetivo salvar el paciente&#46; Para ello se debe alcanzar una PAM y un GC m&#237;nimos para mantener la perfusi&#243;n tisular&#46; No es necesaria una monitorizaci&#243;n sofisticada&#44; pero s&#237; vigilar los signos vitales&#46; Tambi&#233;n se deben considerar intervenciones&#47;tratamientos concomitantes&#44; como drenajes o revascularizaci&#243;n&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">La fase 2 es la de optimizaci&#243;n de la terapia y el principal objetivo es mejorar la disponibilidad intracelular de ox&#237;geno&#46; Adem&#225;s de incrementar la PAM y el GC&#44; se puede necesitar un aumento de la hemoglobina con trasfusiones&#46; La respuesta a la fluidoterapia se monitoriza eficaz y r&#225;pidamente con el lactato plasm&#225;tico y&#47;o la SatVO<span class="elsevierStyleInf">2</span>&#44; as&#237; como con los par&#225;metros de la precarga&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La fase 3 o de estabilizaci&#243;n es un momento de consolidaci&#243;n de la terapia con fluidos e intenta prevenir la disfunci&#243;n org&#225;nica &#40;DO&#41;&#44; incluso en pacientes que ya han llegado a la estabilidad hemodin&#225;mica&#46; Se debe asistir a los diferentes &#243;rganos para evitar sus respectivas disfunciones&#44; que son un factor independiente de mayor morbimortalidad&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; la fase 4&#44; denominada de evacuaci&#243;n o desescalada terap&#233;utica h&#237;drica&#44; es clave para la eficacia global de la reanimaci&#243;n por fluidos&#46; Su principal objetivo es alcanzar balances h&#237;dricos negativos&#46; Destaca la desresucitaci&#243;n&#44; con lo que se busca la desescalada&#44; la disminuci&#243;n de los fluidos y forzar el balance h&#237;drico negativo proporcionados previamente en la resucitaci&#243;n&#46; Para ello&#44; se busca facilitar la eliminaci&#243;n espont&#225;nea o forzada de l&#237;quidos a trav&#233;s de diur&#233;ticos o t&#233;cnicas de reemplazo renal &#40;TRR&#41; y reducir&#47;suspender los f&#225;rmacos vasoactivos&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Las principales complicaciones asociadas con la sobrecarga h&#237;drica se exponen en la <a class="elsevierStyleCrossRef" href="#tbl0010">Tabla 2</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;7&#8211;15</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0035">Cantidad de fluidos en la resucitaci&#243;n de la sepsis y monitorizaci&#243;n de la respuesta</span><p id="par0080" class="elsevierStylePara elsevierViewall">La cantidad de fluidos en la resucitaci&#243;n de la sepsis&#44; tanto en su fase inicial como las horas y d&#237;as posteriores&#44; sigue siendo un tema controvertido<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;6</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Con el objetivo de proponer un tratamiento unificado la SSC&#44; tanto en 2016 como en 2021&#44; aconsej&#243;&#44; con d&#233;bil grado de recomendaci&#243;n y baja evidencia cient&#237;fica&#44; administrar cristaloides a 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg de peso ideal v&#237;a endovenosa en las primeras 3<span class="elsevierStyleHsp" style=""></span>h de la resucitaci&#243;n inicial con fluidos<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; No obstante&#44; dicha cantidad de l&#237;quido se basa exclusivamente en estudios observacionales y no en ensayos prospectivos que comparen resultados de la administraci&#243;n de diferentes vol&#250;menes de fluidos<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Esto dio lugar a una correcci&#243;n en la nueva gu&#237;a de 2021&#44; en la que reaparecen los 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg como recomendaci&#243;n de bajo grado y nivel de evidencia<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En cuanto a la velocidad de la administraci&#243;n&#44; tambi&#233;n hay controversias&#46; El reciente ensayo cl&#237;nico aleatorizado con m&#225;s de 10&#46;000 pacientes cr&#237;ticos realizado en Brasil&#44; Basics&#44; no encontr&#243; diferencia significativa en la mortalidad a los 90 d&#237;as entre una administraci&#243;n lenta &#40;333<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41; y una r&#225;pida &#40;999<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Dados el posible deterioro org&#225;nico y el aumento de la mortalidad asociado con un exceso de volumen&#44; es necesario individualizar el tratamiento&#46; Para ello se requiere una evaluaci&#243;n inicial exhaustiva y una revaluaci&#243;n continua de la respuesta al tratamiento basada en par&#225;metros hemodin&#225;micos est&#225;ticos o&#44; preferentemente&#44; din&#225;micos<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;12&#44;13&#44;15&#44;17</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="sect0040">&#205;ndices est&#225;ticos</span><p id="par0100" class="elsevierStylePara elsevierViewall">Cl&#225;sicamente&#44; se han utilizado los &#237;ndices est&#225;ticos para determinar si el paciente responde a los l&#237;quidos y guiar as&#237; la fluidoterapia&#46; La determinaci&#243;n de la precarga del VD a trav&#233;s de la presi&#243;n venosa central &#40;PVC&#41;&#44; la precarga del VI a trav&#233;s de la presi&#243;n de oclusi&#243;n de la arteria pulmonar &#40;PAOP&#41;&#44; la determinaci&#243;n de par&#225;metros volum&#233;tricos por termodiluci&#243;n transpulmonar o la medici&#243;n de los vol&#250;menes telediast&#243;licos ventriculares por ecocardiograf&#237;a son los par&#225;metros est&#225;ticos m&#225;s utilizados para determinar el estado intravascular del paciente<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;11</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No obstante&#44; los par&#225;metros est&#225;ticos se han demostrado malos predictores de la volemia de la respuesta al volumen con valor predictivo moderado y con predicci&#243;n aceptable tan solo en valores extremos&#46; Son m&#225;s &#250;tiles para determinar el riesgo potencial de administrar m&#225;s l&#237;quidos que para predecir de manera fiable la respuesta al volumen&#44; por lo que son marcadores de precarga y no de la respuesta a esta<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a>&#46; A pesar de ello&#44; los marcadores est&#225;ticos de precarga siguen siendo ampliamente utilizados para guiar el tratamiento con fluidos&#44; tal y como muestra el estudio observacional FENICE<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5</span><span class="elsevierStyleSectionTitle" id="sect0045">&#205;ndices din&#225;micos</span><p id="par0110" class="elsevierStylePara elsevierViewall">Se ha demostrado una mejor precisi&#243;n diagn&#243;stica de los &#237;ndices din&#225;micos para predecir la capacidad de respuesta a los fluidos<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6&#44;21</span></a>&#46; As&#237;&#44; tanto el DCS como la SCC sugieren el uso de &#237;ndices din&#225;micos frente est&#225;ticos para predecir la respuesta a la administraci&#243;n de fluidos<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a>&#46; A continuaci&#243;n se describen algunos de ellos&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0050">Variaci&#243;n de volumen sist&#243;lico &#40;VVS&#41; y variaci&#243;n de la presi&#243;n de pulso &#40;VPP&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Probablemente los par&#225;metros m&#225;s utilizados&#44; se basan en la repercusi&#243;n de la positiva intrat&#243;racica secundaria a la ventilaci&#243;n mec&#225;nica en la precarga y&#44; por consiguiente&#44; en el GC&#46; La presi&#243;n positiva reduce la precarga en el VD&#59; si esto se transmite a la precarga del VI y&#44; por ende&#44; disminuye el volumen sist&#243;lico del VI de forma c&#237;clica con la presi&#243;n positiva&#44; indicar&#237;a que ambos ventr&#237;culos son dependientes <span class="elsevierStyleInf">de</span><span class="elsevierStyleInf">la</span> precarga<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;9&#44;16&#44;20&#44;21</span></a><span class="elsevierStyleInf">&#46;</span></p><p id="par0120" class="elsevierStylePara elsevierViewall">No obstante&#44; el VVS y el VPP presentan limitaciones importantes&#46; Requieren de ventilaci&#243;n mec&#225;nica y son poco fiables en caso de respiraci&#243;n espont&#225;nea&#46; Su fiabilidad tambi&#233;n disminuye en caso de arritmia cardiaca&#44; bajos vol&#250;menes tidales &#40;Vt&#41; o baja distensibilidad pulmonar &#40;p&#46; ej&#46;&#44; en el s&#237;ndrome de distr&#233;s respiratorio agudo &#91;SDRA&#93;&#41;&#44; esternotom&#237;a&#44; aumento de la presi&#243;n intraabdominal&#44; frecuencias respiratorias altas o insuficiencia card&#237;aca derecha<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0055">Colapsabilidad o distensibilidad de la vena cava</span><p id="par0125" class="elsevierStylePara elsevierViewall">Los cambios de la presi&#243;n intrator&#225;cica inducidos por la ventilaci&#243;n mec&#225;nica generan variaciones en las venas cavas cuando la precarga es baja&#44; lo que permite estimar la respuesta a la administraci&#243;n de volumen&#44; tanto la variaci&#243;n del di&#225;metro de la vena cava inferior&#44; por ecograf&#237;a transtor&#225;cica&#44; como la colapsabilidad de la vena cava superior por ecograf&#237;a transesof&#225;gica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;23</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Su fiabilidad para predecir la respuesta ha sido cuestionada por sus limitaciones<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Al igual que en el caso de la VVS y la VPP&#44; la precisi&#243;n de dichas mediciones disminuye considerablemente en pacientes en respiraci&#243;n espont&#225;nea &#8212;en cuyo caso parece que solo las variaciones de gran amplitud predicen buena respuesta a los l&#237;quidos<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;24</span></a>&#8212; y los casos de Vt bajos o baja distensibilidad pulmonar<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;24</span></a>&#46; Adem&#225;s&#44; requiere pericia con la ecograf&#237;a transtor&#225;cica o transesof&#225;gica &#40;en el caso de la vena cava superior&#41;&#46; A diferencia de la VPP y la VVS&#44; los &#237;ndices de colapsabilidad y distensibilidad de la vena cava s&#237; son fiables en pacientes con arritmias cardiacas<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;20&#44;24&#8211;26</span></a><span class="elsevierStyleInf">&#46;</span></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0060">Fluid challenge</span><p id="par0135" class="elsevierStylePara elsevierViewall">Cl&#225;sicamente esta prueba se basa en la administraci&#243;n de un volumen de 250&#8211;500<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido en 30<span class="elsevierStyleHsp" style=""></span>min&#44; y si produce un aumento del GC &#8805; 15&#37;&#44; se considera dependiente de precarga y&#44; por lo tanto&#44; respuesta a la administraci&#243;n de flui<span class="elsevierStyleSup">dos</span><span class="elsevierStyleSup">2</span><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">0&#44;6&#8211;9</span></a><span class="elsevierStyleInf">&#46;</span></p><p id="par0140" class="elsevierStylePara elsevierViewall">No obstante&#44; tiene principalmente dos limitaciones&#46; Por un lado&#44; requiere la medici&#243;n continua del GC&#59; por otro&#44; la administraci&#243;n deliberada de fluidos para predecir la respuesta es en s&#237; misma un tratamiento que contribuye a la sobrecarga de l&#237;quidos y la hemodiluci&#243;n&#46; Esto &#250;ltimo ha dado lugar al desarrollo de una provocaci&#243;n con minifluidos&#44; en la que se administran solo 100<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido en corto tiempo&#44; con una fiabilidad de predicci&#243;n de respuesta a fluidos incluso mejor que la VPP&#46; No obstante&#44; como ya se ha comentado&#44; requiere una medici&#243;n precisa del GC<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;27&#44;28</span></a>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0065">Elevaci&#243;n pasiva de las piernas</span><p id="par0145" class="elsevierStylePara elsevierViewall">Se trata de un <span class="elsevierStyleItalic">fluid challenge</span> &#8220;interno&#8221;&#44; reversible&#44; reproducible y de aproximadamente 300<span class="elsevierStyleHsp" style=""></span>ml de sangre&#44; suficiente para inducir un aumento significativo del GC que predice de manera fiable la respuesta a la administraci&#243;n ex&#243;gena de l&#237;quidos&#46; Se trata de una prueba fiable en pacientes en respiraci&#243;n espont&#225;nea&#44; con bajos vol&#250;menes o baja distensibilidad pulmonar&#44; as&#237; como en caso de hipertensi&#243;n intraabdominal&#46; Pese a que puede producir un aumento de la PAM en situaciones de dependencia de precarga y&#44; por consiguiente&#44; respuesta a los l&#237;quidos&#44; los cambios de la presi&#243;n arterial no permiten determinar con fiabilidad si los pacientes responden a los l&#237;quidos&#46; Por ello se requiere la medici&#243;n continua del GC con t&#233;cnicas invasivas o no invasivas<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9&#44;29&#44;30</span></a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0070">Prueba de oclusi&#243;n al final de espiraci&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Consiste en realizar una pausa espiratoria durante al menos 15 s&#46; Si el GC aumenta m&#225;s del 5&#37;&#44; indica que ambos ventr&#237;culos son dependientes de la precarga&#46; Requiere medici&#243;n continua del GC &#40;tanto invasiva como no invasiva&#41; y es fiable en caso de Vt bajo y baja distensibilidad pulmonar&#59; por lo tanto&#44; en el SDRA&#46; Una posible limitaci&#243;n es la ventilaci&#243;n en dec&#250;bito prono y no se puede realizar con pacientes que no se encuentren intubados o no toleren pausas espiratorias &#8805; 15 s<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;9&#44;21&#44;22</span></a>&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6</span><span class="elsevierStyleSectionTitle" id="sect0075">Otros &#237;ndices de respuesta a volumen</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0080">Aclaramiento de lactato s&#233;rico</span><p id="par0155" class="elsevierStylePara elsevierViewall">Se ha propuesto normalizar su concentraci&#243;n como objetivo de la reanimaci&#243;n inicial en el SS&#46; Sin embargo&#44; las cifras de lactato s&#233;rico han de interpretarse en el contexto cl&#237;nico y tras descartar otras causas de incremento&#46; En cualquier caso&#44; en una estrategia guiada por el lactato se ha de tener cautela y solo para las primeras horas del SS&#44; en las que la hiperlactacidemia es secundaria a disfunci&#243;n tisular por hipoperfusi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;6</span></a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0085">Normalizaci&#243;n del tiempo de llenado capilar</span><p id="par0160" class="elsevierStylePara elsevierViewall">Medida alternativa y no invasiva cuando no se dispone de monitorizaci&#243;n hemodin&#225;mica&#46; Permite evaluar con seguridad y eficacia la administraci&#243;n de fluidos seg&#250;n la perfusi&#243;n tisular&#46; Se ha demostrado una eficacia similar a la del tratamiento guiado por el aclaramiento de lactato<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Los &#237;ndices y par&#225;metros hemodin&#225;micos nunca deben considerarse de manera aislada y con valores predeterminados&#44; sino como un dato m&#225;s que apoya una sospecha fundada en una correcta y completa valoraci&#243;n del enfermo&#44; y siempre se debe individualizar cada caso<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;9</span></a>&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">7</span><span class="elsevierStyleSectionTitle" id="sect0090">Caracter&#237;sticas de los distintos tipos de fluidos</span><p id="par0170" class="elsevierStylePara elsevierViewall">Los fluidos se clasifican seg&#250;n su comportamiento frente a la membrana capilar y hay de 2 tipos&#58; cristaloides y coloides &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabla 3</a> y <a class="elsevierStyleCrossRef" href="#tbl0020">Tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8</span><span class="elsevierStyleSectionTitle" id="sect0095">Cristaloides</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los cristaloides generalmente est&#225;n constituidos por agua y sales minerales&#44; que se diluyen y difunden junto con el disolvente&#46; La mayor&#237;a de las soluciones cristaloides se distribuyen bien en el l&#237;quido intracelular y extracelular&#44; con un alto &#237;ndice de eliminaci&#243;n&#58; a los 60<span class="elsevierStyleHsp" style=""></span>min de la infusi&#243;n&#44; solamente permanece el 20&#37; del volumen infundido en el espacio intravascular<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11</span></a>&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0100">Soluciones no balanceadas</span><p id="par0180" class="elsevierStylePara elsevierViewall">Las soluciones no balanceadas son todas las que tienen osmolaridad&#44; tonicidad y contenido electrol&#237;tico distinto del plasma&#46; La m&#225;s utilizada es la soluci&#243;n salina al 0&#44;9&#37;&#44; &#40;SS0&#44;9&#37;&#41; mal denominada &#8220;fisiol&#243;gica&#8221;&#44; pues es hipert&#243;nica y &#225;cida respecto al plasma y contiene una cantidad supranormal de sodio y cloro&#46; Su capacidad de expandir la volemia depende de la concentraci&#243;n de sodio&#58; cuanto mayor concentraci&#243;n&#44; m&#225;s incremento de la volemia<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; No existe evidencia para administrar suero hipert&#243;nico para la resucitaci&#243;n en la sepsis<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#8211;8</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Las soluciones glucosadas tambi&#233;n tienen una osmolaridad diferente&#44; y cuanto mayor concentraci&#243;n de glucosa&#44; mayor osmolaridad&#46; Sin embargo&#44; las soluciones glucosadas no contienen electrolitos y tienen un coeficiente de Staverman extremo bajo&#44; de ah&#237; que se conozcan como agua libre&#46; Su permanencia en el espacio intravascular es muy corta<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a>&#46; Las soluciones no balanceadas tienen en com&#250;n varios efectos adversos&#46; Todas hacen un efecto de diluci&#243;n&#44; mientras que las de alto contenido en NaCl generan hipercloremia y eventualmente acidosis<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0105">Soluciones balanceadas</span><p id="par0190" class="elsevierStylePara elsevierViewall">Las soluciones balanceadas son las m&#225;s parecidas al plasma y tienen un amortiguador como lactato&#44; acetato o malato&#44; y cloro &#8804; 110 mEq&#47;l&#59; tambi&#233;n se las llama bajas en cloro&#44; en lugar de balanceadas&#46; Por ejemplo&#44; la soluci&#243;n de Hartmann tiene como variante el Ringer lactato como amortiguador&#46; La soluci&#243;n Plasmalyte&#174; tiene una osmolaridad cercana a la del plasma&#59; adem&#225;s contiene acetato y malato como amortiguador&#44; lo cual genera menor desequilibrio acidob&#225;sico<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a>&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">9</span><span class="elsevierStyleSectionTitle" id="sect0110">Coloides</span><p id="par0195" class="elsevierStylePara elsevierViewall">Los coloides son suspensiones de part&#237;culas s&#243;lidas muy finas&#44; de 10<span class="elsevierStyleSup">&#8722;9</span> a 10<span class="elsevierStyleSup">&#8722;5</span><span class="elsevierStyleHsp" style=""></span>m&#44; que no se difunden con su disolvente cuando este tiene que atravesar una membrana porosa&#46; Las macromol&#233;culas pueden estar elaboradas a partir de prote&#237;nas o carbohidratos&#44; por lo que todos los coloides en el mercado son sint&#233;ticos &#40;dextranos&#44; hidroxi-etil-almid&#243;n &#91;HEA&#93; y gelatinas&#41; con excepci&#243;n de la alb&#250;mina&#46; El HEA y las gelatinas tienen similar capacidad de expansi&#243;n plasm&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7&#44;11</span></a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Aunque los coloides tienen tendencia a permanecer m&#225;s tiempo en el espacio intravascular&#44; depende en gran parte de la integridad del glucoc&#225;liz&#59; en la sepsis&#44; como otros s&#237;ndromes&#44; hay una p&#233;rdida&#44; lo que aumenta el paso de los coloides a trav&#233;s de la membrana capilar&#44; o sea&#44; fuga capilar al intersticio<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">El gran peso molecular&#44; te&#243;ricamente&#44; confiere un alto coeficiente de reflexi&#243;n de Staverman&#59; sin embargo&#44; en la pr&#225;ctica cl&#237;nica el l&#237;quido en el que estas macromol&#233;culas est&#225;n suspendidas puede difundir pasivamente al intersticio o por medio de gradientes de presi&#243;n onc&#243;tica<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9</span></a>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">La alb&#250;mina es la prote&#237;na m&#225;s abundante en el plasma humano &#40;50&#8211;60&#37;&#41; y aporta el 80&#37; de la presi&#243;n onc&#243;tica del plasma&#46; Regula la presi&#243;n coloidonc&#243;tica&#44; trasporta f&#225;rmacos&#44; es antioxidante y modula el &#243;xido n&#237;trico<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9&#44;11</span></a>&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10</span><span class="elsevierStyleSectionTitle" id="sect0115">Evidencias en fluidoterapia en la resucitaci&#243;n de la sepsis</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0120">Cristaloides</span><p id="par0215" class="elsevierStylePara elsevierViewall">Los cristaloides siguen siendo los fluidos m&#225;s indicados parael tratamiento inicial de la sepsis y el SS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;13</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">En 2014&#44; un estudio retrospectivo observ&#243; menor mortalidad dependiente de la dosis en pacientes con SS reanimados en las primeras 48<span class="elsevierStyleHsp" style=""></span>h con una combinaci&#243;n de cristaloides cl&#225;sicos y balanceados&#44; comparados con los que hab&#237;an recibido solo SS0&#44;9&#37;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Otro estudio con <span class="elsevierStyleItalic">propensity score</span> compar&#243; el SS0&#44;9&#37; con 2 soluciones balanceadas &#40;Plasmalyte&#174; y Normosol&#174;&#41; en m&#225;s de 3&#46;000 pacientes con criterios de SRIS que hab&#237;an recibido m&#225;s de 500<span class="elsevierStyleHsp" style=""></span>ml en las primeras 48<span class="elsevierStyleHsp" style=""></span>h&#46; Se observ&#243; que el SS0&#44;9&#37; incrementaba la mortalidad&#44; las complicaciones cardiacas&#44; respiratorias y hem&#225;ticas&#44; la necesidad de reemplazo de electrolitos e infecciones&#44; pero no en los ri&#241;ones<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; El ensayo aleatorizado SMART&#44; con m&#225;s de 15&#46;000 pacientes cr&#237;ticos&#44; compar&#243; la SS0&#44;9&#37; con cristaloides balanceados &#40;Ringer lactato o Plasmalyte&#174;&#41;&#46; El objetivo combinado era&#58; mortalidad a los 30 d&#237;as y&#47;o aparici&#243;n de insuficiencia renal aguda con necesidad de TRR&#46; Hubo un mayor beneficio en el grupo de cristaloides balanceados&#44; pero al analizar el subgrupo con 1&#46;600 pacientes s&#233;pticos&#44; estos resultados eran m&#225;s marcados&#46; Incluso hab&#237;a una disminuci&#243;n significativa de la mortalidad a los 30 d&#237;as<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Sin embargo&#44; en un reciente estudio aleatorizado con 10&#46;520 pacientes cr&#237;ticos que compar&#243; la SS0&#44;9&#37; con soluci&#243;n balanceada&#44; no hubo diferencia significativa en la mortalidad a los 90 d&#237;as &#40;el 27&#44;2 frente al 26&#44;4&#37; respectivamente&#41;&#46; Hay que destacar que el 48&#44;4&#37; eran pacientes de cirug&#237;a programada&#44; aunque el 60&#37; ten&#237;a hipotensi&#243;n o tomaba vasopresores&#44; pero solamente alrededor del 18&#37; estaban s&#233;pticos<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Otro reciente estudio aleatorizado&#44; controlado y a doble ciego en 53 unidades de cuidados intensivos &#40;UCI&#41; de Australia y Nueva Zelanda compar&#243; una soluci&#243;n balanceada &#40;Plasmalyte&#174; 148&#41; con la SS0&#44;9&#37; en 5&#46;037 pacientes&#46; Los autores no observaron diferencias significativas entre los 2 grupos en la mortalidad a los 90 d&#237;as&#44; la aparici&#243;n de insuficiencia renal aguda o el n&#250;mero de otros efectos secundarios<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0125">Coloides sint&#233;ticos</span><p id="par0240" class="elsevierStylePara elsevierViewall">El uso de coloides tipo almidones &#40;HEA&#41; se han asociado a distintos efectos secundarios&#44; tales como anafilaxia&#44; coagulopat&#237;a o insuficiencia renal&#46; El HEA tiene mayor poder onc&#243;tico cuanto mayor peso molecular &#40;PM&#41; tenga y un efecto m&#225;s duradero cuanto mayor sea su &#237;ndice de sustituci&#243;n &#40;IS&#41;&#46; Hace varios a&#241;os&#44; el ensayo VISEP asoci&#243; la dosis de HEA &#40;PM&#44; 200&#59; IS&#44; 0&#44;5&#41; con insuficiencia renal aguda&#44; necesidad de TRR y mayor mortalidad<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&#46; Posteriormente&#44; el 6<span class="elsevierStyleHsp" style=""></span>S tambi&#233;n describi&#243; una mayor mortalidad dependiente de la necesidad de TRR a los 90 d&#237;as en los pacientes s&#233;pticos reanimados con HEA 130&#47;04 comparados con el Ringer acetato<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>&#46; En 2013&#44; un metan&#225;lisis incluy&#243; a 3&#46;456 pacientes s&#233;pticos para comparar HES 130&#47;0&#44;38-0&#44;45 frente a cristaloides o albumina&#46; Los autores no encontraron diferencias en mortalidad&#44; pero en el grupo de HEA se increment&#243; significativamente el riesgo de TRR y administraci&#243;n de hemoderivados<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46; Estos resultados se confirmaron en 2 metan&#225;lisis posteriores<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a>&#46; Uno de ellos incluy&#243; 38 ensayos con m&#225;s de 10&#46;800 pacientes diagnosticados de sepsis&#44; traumatismos o hipovolemias en Urgencias o UCI entre 1982 y 2012&#46; Se compar&#243; HEA con cristaloides&#44; gelatinas y alb&#250;mina&#46; No hubo diferencias en la mortalidad y la estancia en UCI u hospitalaria entre los grupos&#46; Sin embargo&#44; en el an&#225;lisis de subgrupos los pacientes tratados con HES presentaban un significativo aumento de la insuficiencia renal aguda y necesidad de TRR<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Un estudio con 7&#46;000 pacientes de 34 UCI compar&#243; la SS0&#44;9&#37; con coloides frente a HEA&#46; La dosis m&#225;xima de HEA fue 50<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;d&#237;a&#46; No hubo diferencias de mortalidad a los 90 d&#237;as&#44; pero s&#237; un incremento estad&#237;sticamente significativo de la necesidad de TRR en el grupo de HEA&#44; con un incremento relativo del 21&#37;&#46; Este grupo tambi&#233;n presentaba m&#225;s insuficiencia renal aguda&#44; eritema y prurito&#44; insuficiencia hep&#225;tica y necesidad de trasfusiones&#44; aunque en el grupo de HEA mejor&#243; la insuficiencia cardiaca y disminuy&#243; la necesidad y el tiempo de vasopresores<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46; Por todo ello&#44; desde 2013 las autoridades sanitarias espa&#241;olas han restringido el uso de coloides tipo HEA por los potenciales efectos secundarios graves en pacientes s&#233;pticos<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11</span></a>&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Sobre las gelatinas hay menos estudios&#44; aunque la mayor&#237;a no aporta beneficios comparadas con los cristaloides&#44; y varios de ellos describen mayor riesgo de anafilaxia&#44; hemorragias&#44; insuficiencia renal o mortalidad hospitalaria<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;45&#44;46</span></a>&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Una revisi&#243;n sistematizada de la literatura y metan&#225;lisis de 40 estudios prospectivos y ensayos cl&#237;nicos con 3&#46;275 pacientes evalu&#243; la seguridad de las gelatinas comparadas con un grupo de control que inclu&#237;a a pacientes tratados con SS0&#44;9&#37;&#44; Ringer lactato&#44; plasma y alb&#250;mina&#46; La dosis media de las gelatinas fue 17<span class="elsevierStyleHsp" style=""></span>ml&#47;kg en las primeras 24<span class="elsevierStyleHsp" style=""></span>h&#44; una media de 1 l&#46; Los autores concluyen que eran heterog&#233;neos los grupos de pacientes y los estudios&#46; No observaron aumento de trasfusiones&#44; insuficiencia renal o mortalidad entre gelatinas y el grupo de control con una dosis de 17<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#46; Sin embargo&#44; cuando la dosis de gelatinas era<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#44; aumentaba el riesgo de mortalidad y de trasfusiones<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">11</span><span class="elsevierStyleSectionTitle" id="sect0130">Alb&#250;mina</span><p id="par0260" class="elsevierStylePara elsevierViewall">El coloide natural que genera mucho debate es la alb&#250;mina&#46; El ensayo SAFE incluy&#243; a casi 7&#46;000 pacientes cr&#237;ticos y compar&#243; los tratamientos con SS0&#44;9&#37; y con alb&#250;mina al 4&#37; en la reanimaci&#243;n inicial&#46; La principal conclusi&#243;n fue que no se observaron diferencias en la mortalidad<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#44; pero al analizar el subgrupo de pacientes s&#233;pticos de la serie&#44; los tratados con alb&#250;mina al 4&#37; presentaban una mortalidad significativamente menor &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;71&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; Otro in teresante estudio&#44; EARSS&#44; administr&#243; aleatoriamente 10<span class="elsevierStyleHsp" style=""></span>ml de alb&#250;mina al 20&#37; o 100<span class="elsevierStyleHsp" style=""></span>ml de SS0&#44;9&#37; cada 8<span class="elsevierStyleHsp" style=""></span>h durante 3 d&#237;as a 798 pacientes cr&#237;ticos&#46; No encontraron diferencias en estancia en UCI u hospitalaria o en mortalidad&#44; pero los tratados con alb&#250;mina al 20&#37; ten&#237;an significativamente menos d&#237;as con vasopresores<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; Un estudio que ha sido importante para los defensores de la alb&#250;mina en la sepsis es el ensayo cl&#237;nico ALBIOS&#46; Este aleatoriz&#243; a 2 grupos de pacientes con sepsis graves&#58; cristaloides frente a alb&#250;mina al 20&#37;&#44; para alcanzar un objetivo de alb&#250;mina plasm&#225;tica<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>g&#47;l&#46; No hubo diferencias en mortalidad a los 28 y a los 90 d&#237;as&#44; pero los pacientes con SS que recibieron alb&#250;mina al 20&#37; presentaban una mortalidad a los 90 d&#237;as significativamente menor &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a>&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Infecci&#243;n y potencial inicio de los fen&#243;menos fisiopatog&#233;nicos de la sepsis&#58; tiempo muy variable&#44; desde horas hasta d&#237;as despu&#233;s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Ya empiezan los signos&#47;s&#237;ntomas de alteraciones cl&#237;nicas&#47;anal&#237;ticas&#47;radiol&#243;gicas compatibles con inflamaci&#243;n y DO de sepsis&#46; Estos son muy variables y dependen de la interacci&#243;n entre pat&#243;geno y hu&#233;sped&#46; Por ejemplo&#44; la variabilidad fenot&#237;pica de presentaci&#243;n de una sepsis depende de varios factores&#58; gen&#243;micos del paciente&#44; del tipo de pat&#243;geno &#40;virus o bacteria&#41;&#44; ambientales&#44; administraci&#243;n de otros f&#225;rmacos &#40;p&#46; ej&#46;&#44; quimioterapia&#41;&#44; etc&#46; En este momento de detecci&#243;n hay que proceder al <span class="elsevierStyleItalic">bundle</span> inicial&#58; toma de hemocultivos&#44; iniciar ATB&#44; lactato plasm&#225;tico&#44; e iniciar tratamiento hemodin&#225;mico con fluidoterapia y considerar VP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Una tercera fase precoz &#40;primeras 3<span class="elsevierStyleHsp" style=""></span>h&#41; del proceso s&#233;ptico&#44; en que se valora espec&#237;ficamente la HD&#44; est&#225; solapada a la previa&#44; que es la monitorizaci&#243;n utilizando criterios cl&#237;nicos &#40;PAM&#44; FC&#41;&#44; de laboratorio &#40;lactato&#44; SatVO2&#41;&#44; par&#225;metros est&#225;ticos &#40;PVC&#41; y&#44; por supuesto&#44; tambi&#233;n din&#225;micos&#46; La nueva SSC de 2021 no incluye la SatVO2 para monitorizaci&#243;n&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">La cuarta fase de la evoluci&#243;n de la sepsis&#44; que puede desarrollarse desde las primeras horas hasta d&#237;as&#44; la monitorizaci&#243;n HD utilizando par&#225;metros din&#225;micos es crucial para evaluar la respuesta cl&#237;nica y los potenciales ajustes del tratamiento HD&#46; Se ha demostrado que las maniobras como elevar pasivamente las piernas o minifluidos&#44; ecocardiograf&#237;a o los par&#225;metros VVS y VVP aportan m&#225;s y mejores datos para el tratamiento HD&#46; Y el lactato&#44; principalmente en las primeras 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; considerando sus limitaciones&#44; tambi&#233;n aporta una r&#225;pida informaci&#243;n de la respuesta HD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Hay que destacar que actualmente&#44; seg&#250;n la mayor&#237;a de consensos&#44; la indicaci&#243;n es iniciar el tratamiento HD con fluidos tipo cristaloides a dosis de 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#44; pero hay muchas controversias en este punto&#46; Uno&#44; la dosis&#58; la tendencia actual es ajustar&#47;personalizar esta dosis&#46; Dos&#44; la posibilidad de sustituir por cristaloides balanceados que podr&#237;an tener m&#225;s eficacia y menos efectos secundarios &#40;p&#46; ej&#46;&#44; hipercloremia&#41;&#46; Tres&#44; la posibilidad de tratamiento con fluidos combinado &#40;p&#46; ej&#46;&#44; con alb&#250;mina&#41; con varios estudios muy favorables&#44; incluso con menor mortalidad asociada en enfermos s&#233;pticos&#46; Cuatro&#44; hay que considerar el inicio precoz de los VP &#161;siempre&#33;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Esta fase&#44; que tambi&#233;n es muy variable&#44; pero ser&#225;n d&#237;as&#44; hasta semanas&#44; es cuando puede haber soluci&#243;n cl&#237;nica del proceso s&#233;ptico&#44; pero tambi&#233;n se puede observar los efectos delet&#233;reos de los distintos tratamientos&#44; como ATB&#44; VP o fluidos&#46; En este caso&#44; uno de vital importancia es la sobrecarga h&#237;drica con aumento de DO &#40;que puede ocurrir desde las fases iniciales en las primeras horas de la resucitaci&#243;n HD&#41;&#46; Se trata de un factor asociado con la mayor morbimortalidad del paciente s&#233;ptico&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Por ello&#44; para evitar la sobrecarga h&#237;drica&#44; se debe ser proactivos en el ajuste&#47;desescalada de fluidos y el balance h&#237;drico negativo evaluando de manera continua&#44; principalmente con una monitorizaci&#243;n HD basada en par&#225;metros din&#225;micos&#46; Por ello&#44; la atenci&#243;n continuada es crucial para una resucitaci&#243;n HD eficaz y con m&#237;nimos efectos secundarios para el paciente&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Todo el proceso s&#233;ptico&#44; espec&#237;ficamente el tratamiento HD&#44; siempre se debe considerar individualizadamente&#44; tanto el tipo como la dosis&#44; las cantidades y la desescalada de fluidos&#44; as&#237; como su monitorizaci&#243;n de respuesta cl&#237;nica HD&#46; La medicina personalizada es un reto en la atenci&#243;n de la sepsis&#44; y el tratamiento HD es un reto complejo que necesita experiencia y flexibilidad durante las diferentes fases de la sepsis&#46;</p></li></ul></p><p id="par0305" class="elsevierStylePara elsevierViewall">ATB&#58; antibi&#243;ticos&#59; DO&#58; difunci&#243;n org&#225;nica&#59; EF&#58; exploraci&#243;n f&#237;sica&#59; HD&#58; hemodin&#225;mica&#59; SS&#58; <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#59; VP&#58; vasopresores&#59; VPP&#58; variaci&#243;n de la presi&#243;n de pulso&#59; VVS&#58; variaci&#243;n de volumen sist&#243;lico&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">El ensayo multic&#233;ntrico internacional CRISTAL compar&#243; la reanimaci&#243;n con cristaloides frente a coloides en 2&#46;857 pacientes en <span class="elsevierStyleItalic">shock</span> hipovol&#233;mico&#44; includos s&#233;pticos&#46; El grupo de control con cristaloides bajo SS0&#44;9&#37; y Ringer lactato frente a coloides hipoonc&#243;ticos &#40;gelatinas&#44; albumina al 4&#37;&#41; e hiperonc&#243;ticos &#40;dextranos&#44; alb&#250;mina al 20&#37; y HEA en dosis &#60; 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41;&#46; La media de volumen de cristaloides administrado fue 3&#46;000<span class="elsevierStyleHsp" style=""></span>ml y depend&#237;a del facultativo&#46; El volumen medio de coloides administrado fue 2&#46;000<span class="elsevierStyleHsp" style=""></span>ml&#46; El tiempo promedio de administraci&#243;n fue menos de 2 d&#237;as&#46; No hubo diferencias de mortalidad entre uno y otro grupo a los 28 d&#237;as&#44; pero s&#237; a los 90 d&#237;as&#44; cuando fue significativamente mayor en el grupo de cristaloides&#44; motivo por el que se suspendi&#243; el estudio&#46; Tampoco hubo diferencias en los d&#237;as de estancia en UCI u hospitalaria&#44; SOFA a los 28 d&#237;as o necesidad de TRR a los 7 y 28 d&#237;as&#46; Los pacientes con coloides ten&#237;an menos d&#237;as de ventilaci&#243;n mec&#225;nica y vasopresores<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a>&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Sobre el empleo de alb&#250;minas al 4-5&#37; frente al 20&#37;&#44; el estudio SWIPE las compar&#243; en la reanimaci&#243;n en pacientes cr&#237;ticos&#46; El grupo con alb&#250;mina al 20&#37; recibi&#243; una media de 600<span class="elsevierStyleHsp" style=""></span>ml &#40;65&#37;&#41; menos de fluidos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y un balance h&#237;drico acumulado a las 48<span class="elsevierStyleHsp" style=""></span>h significativamente menor&#44; alrededor de 576<span class="elsevierStyleHsp" style=""></span>ml &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Se observ&#243; menos sodio y potasio en el grupo de alb&#250;mina al 20&#37;&#46; Por &#250;ltimo&#44; no se han observado diferencias en anafilaxia&#44; aparici&#243;n de insuficiencia renal aguda o mortalidad en UCI u hospitalaria<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">12</span><span class="elsevierStyleSectionTitle" id="sect0135">Combinaci&#243;n de fluidos</span><p id="par0320" class="elsevierStylePara elsevierViewall">De la combinaci&#243;n de cristaloides y albumina hay nueva evidencia&#44; incluso la SSC de 2021 indica considerar esta posibilidad en pacientes que hayan recibido gran cantidad de volumen<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; En un reciente an&#225;lisis retrospectivo de reanimaci&#243;n con fluidos en pacientes s&#233;pticos de la base MIMIC-IV&#44; 6&#46;597 pacientes recibieron solo cristaloides frente a 920 con una combinaci&#243;n precoz de cristaloides m&#225;s albumina&#46; Se objetiv&#243; que los pacientes con la combinaci&#243;n administrada en las primeras 24<span class="elsevierStyleHsp" style=""></span>h ten&#237;an una mortalidad a los 28 d&#237;as significativamente menor &#40;el 12&#44;5 frente al 16&#44;4&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#44; aunque ten&#237;an una estancia en UCI significativamente m&#225;s larga &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">13</span><span class="elsevierStyleSectionTitle" id="sect0140">Comentarios finales</span><p id="par0325" class="elsevierStylePara elsevierViewall">Aunque sigue habiendo controversias en la reanimaci&#243;n con fluidos en la sepsis y el SS&#44; hay algunos puntos de la pr&#225;ctica cl&#237;nica basada en la &#8220;poca&#8221; evidencia que se siguen en la actualidad<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;53</span></a>&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">La fluidoterapia es&#44; por lo tanto&#44; un elemento clave en el tratamiento de la sepsis&#44; y su inicio inmediato en la resucitaci&#243;n precoz es imprescindible con el objetivo de restaurar el volumen intravascular para mejorar el GC y&#44; por ende&#44; la perfusi&#243;n tisular&#46; En la <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> se resume el papel de la fluidoterapia y c&#243;mo plantearla en las diferentes fases de la resucitaci&#243;n en la sepsis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0335" class="elsevierStylePara elsevierViewall">En principio&#44; para los pacientes s&#233;pticos se debe iniciar la reanimaci&#243;n con cristaloides<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a>&#44; pero hay que valorar la posibilidad de reanimar con los cristaloides balanceados en determinados casos &#40;p&#46; ej&#46;&#44; que ya hayan recibido SS0&#44;9&#37; o tengan cifras elevadas de cloro plasm&#225;tico&#41; por sus potenciales ventajas&#44; como menor incidencia de acidosis metab&#243;lica hiperclor&#233;mica o insuficiencia renal<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;9</span></a>&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">La tendencia actual es considerar la posibilidad de reanimaci&#243;n con fluidos mixta con cristaloides &#40;considerando la posibilidad de los balanceados&#41;&#44; con alb&#250;mina &#40;m&#225;s al 20&#37; que al 4&#37;&#41;&#44; para los pacientes que necesiten altas cantidades de los primeros o ya est&#233;n en tratamiento con dosis elevadas de vasopresores y tengan la alb&#250;mina plasm&#225;tica<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>g&#47;l<span class="elsevierStyleSup">4</span><a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">0&#44;7&#8211;9</span></a>&#46; Otro factor determinante es alcanzar una reanimaci&#243;n con fluidos eficaz&#44; pero restrictiva para evitar la sobrecarga h&#237;drica&#46; Para ello&#44; la monitorizaci&#243;n din&#225;mica &#40;m&#225;s que la est&#225;tica&#41;&#44; principalmente en las fases de optimizaci&#243;n y estabilizaci&#243;n&#44; son cruciales para disminuir la potencial morbimortalidad de balances h&#237;dricos positivos acumulados&#46; Ensayos cl&#237;nicos como de Douglas et al&#46; han demostrado que las medidas din&#225;micas &#40;como el aumento de la precarga durante la movilizaci&#243;n de las extremidades inferiores&#41; pueden orientar una resucitaci&#243;n con fluidos y vasopresores m&#225;s eficaz&#44; segura y restrictiva en cuanto a evitar la sobrecarga h&#237;drica<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a>&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Por todo ello&#44; actualmente se recomienda individualizar la terapia con fluidos y una monitorizaci&#243;n hemodin&#225;mica adecuada de cada paciente<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#8211;9</span></a>&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">14</span><span class="elsevierStyleSectionTitle" id="sect0145">Conflicto de intereses</span><p id="par0350" class="elsevierStylePara elsevierViewall">Marcio Borges Sa&#44; ha sido ponente de simposos de MSD&#44; Pfizer y Biomerieux&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Los dem&#225;s autores declaran no tener conflictos de intereses&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">15</span><span class="elsevierStyleSectionTitle" id="sect0150">Nota al suplemento</span><p id="par0360" class="elsevierStylePara elsevierViewall">Este art&#237;culo forma parte del suplemento &#171;Resucitaci&#243;n del paciente con sepsis y <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#187;&#44; que cuenta con el patrocinio de AOP HEALTH IBERIA&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La reanimaci&#243;n con fluidos es una parte crucial en el tratamiento de la hipotensi&#243;n y el <span class="elsevierStyleItalic">shock</span> de cualquier etiolog&#237;a y&#44; particularmente en el <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#44; un elemento esencial del <span class="elsevierStyleItalic">bundle</span> de atenci&#243;n inicial&#46; Como todos los tratamientos en sepsis&#44; tambi&#233;n est&#225; expuesto a m&#250;ltiples controversias&#58; qu&#233; tipo de fluido&#44; qu&#233; cantidad&#44; en cu&#225;nto tiempo se administra&#44; cu&#225;les son los potenciales riesgos y la toxicidad&#46; La principal gu&#237;a&#44; la <span class="elsevierStyleItalic">Surviving Sepsis Campaign&#44;</span> sigue indicando los cristaloides como principal fluido en la reanimaci&#243;n&#46; Pero la posibilidad de cristaloides balanceados sobre el suero salino al 0&#44;9&#37; o el uso combinado con alb&#250;mina en la reanimaci&#243;n del paciente s&#233;ptico siguen en debate&#46; Probablemente estemos delante de otro punto en que deber&#237;amos considerar siempre individualizar tanto el tipo como la cantidad de fluidos que se administran en las fases inicial y de mantenimiento en el tratamiento de la sepsis y el <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fluid resuscitation is a crucial part of the treatment of hypotension and shock of any etiology&#46; Particularly in septic shock&#44; it is an essential element of the initial care bundle&#46; Like all treatments in sepsis&#44; it is also subject to multiple controversies&#58; what type of fluid&#44; how much&#44; how long to administer it&#44; potential risks&#44; toxicity&#63; The main guideline&#44; the Surviving Sepsis Campaign&#44; continues to indicate crystalloids as the main fluid in resuscitation&#46; But the possibility of crystalloids balanced on 0&#46;9&#37; saline or combined use with albumin in the resuscitation of the septic patient is still under debate&#46; This is probably another point where we should always consider individualizing both the type and amount of fluids to be administered in both the initial and maintenance phases of the management of sepsis and septic shock&#46;</p></span>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tiempo de presentaci&#243;n&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">Minutos&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">Horas&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">Horas-d&#237;as&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">D&#237;as-semanas&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">Forma de presentaci&#243;n&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">Sepsis o <span class="elsevierStyleItalic">shock</span> s&#233;ptico&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">Inestabilidad hemodin&#225;mica o <span class="elsevierStyleItalic">shock</span>&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">Ausencia de <span class="elsevierStyleItalic">shock</span>&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">Recuperaci&#243;n del <span class="elsevierStyleItalic">shock</span> o persistencia de permeabilidad capilar aumentada&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">Mecanismode inestabilidad&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">Primera se&#241;al&#58; inflamaci&#243;n&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">Segunda se&#241;al&#58; isquemia-reperfusi&#243;n&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">Segunda se&#241;al&#58;isquemia-reperfusi&#243;n&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">Tercera se&#241;al&#58; permeabilidad capilar aumentada&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">C&#243;mo se aplica la terapiacon fluidos&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">Bolo de 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#46; Monitorizaci&#243;n de respuesta a la fluidoterapia basada en par&#225;metros dependientesde la precarga&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">Bolo basado en par&#225;metros dependientes de la precarga&#44; preferentemente din&#225;micos&#44; de respuesta a los fluidos&#46; Tb con lactato y SatvO2&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">Solamente para mantenimientoy&#47;o como reposici&#243;n de otras p&#233;rdidas&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">Reversi&#243;n del balance h&#237;drico positivo&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">Resultado&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">Supervivencia inmediata del paciente&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">Rescate o asistencia de &#243;rganos&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">Rescate o asistencia de &#243;rganos&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">Recuperaci&#243;n de la disfunci&#243;n org&#225;nica&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">Riesgos&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">Reanimaci&#243;n insuficiente&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">Reanimaci&#243;n insuficienteo sobrecarga h&#237;drica &#40;edema pulmonar&#44; s&#237;ndrome compartimental celular&#44; hipertensi&#243;n abdominal&#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">Sobrecarga h&#237;drica &#40;edema pulmonar&#44; s&#237;ndrome compartimental celular&#44; hipertensi&#243;n abdominal&#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">Eliminaci&#243;n excesiva de l&#237;quidosy posibilidad de hipotensi&#243;ny&#47;o hipoperfusi&#243;ntisular&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">Balance h&#237;drico&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">Positivo&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">Neutral&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">Neutral o negativo&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">Negativo&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">Objetivo principalModificada de las r&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">Administraci&#243;n de fluidosguiada por objetivoseferencias 1&#44; 4&#44; 6&#44; 7 y 8&#46;&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">Basada en asistencia de &#243;rganos y mantenimiento de la perfusi&#243;n tisular&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">Tratamiento de fluidos conservador y tard&#237;o&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">Eliminaci&#243;n tard&#237;a de l&#237;quidos basada en objetivos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AV&#58; auriculoventricular&#59; CP450&#58; citpcromo 450&#59; FE&#58; fracci&#243;n de eyecci&#243;n&#59; GC&#58; gasto cardiaco&#59; GI&#58; gastrointestinal&#59; NAVM&#58; neu- mon&#237;a asociada con VM&#59; POAP&#58; presi&#243;n de oclusi&#243;n de la arteria pulmonar&#59; PVC&#58; presi&#243;n venosa central&#59; VI&#58; ventr&#237;culo izquierdo&#59; VM&#58; ventilaci&#243;n mec&#225;nica&#59; F&#58; aumento&#59; f&#58; reducci&#243;n&#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">Cardiovascular&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">Pulmonar&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">Abdominal&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">Renal&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">SNC&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">Piel-muslo&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">Edema pulmonar&#44;&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">Edema pulmonar&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">Edema GI&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">Edema renal&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">Edema cerebral&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">Edema tisular&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">disfunci&#243;n del VI&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">Hipoxemia&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">Ascitis&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">f Filtrado&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">Alteraci&#243;n&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">f Perfusi&#243;n&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">f Retorno venoso&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">Derrame pleural&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">Hipertensi&#243;n abdominal&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">glomerular&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">de la conciencia&#44;&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">perif&#233;rica&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">f FE&#44; GC&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">Alteraci&#243;n de la&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">F Presi&#243;n&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">F Presi&#243;n venosa&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">confusi&#243;n&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">F &#218;lceras&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">F PVC&#44; POAP&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">distensibilidad&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">intraabdominal&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">renal&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">Delirio&#44; coma&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">de presi&#243;n&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">Depresi&#243;n&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">pulmonar&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">F Permeabilidad&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">F Presi&#243;n intersticial&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">f Presi&#243;n de&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">f Masa&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">mioc&#225;rdica&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">f Volumen&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">intestinal&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">Insuficiencia renal&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">perfusi&#243;n cerebral&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">muscular&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">Dilataci&#243;n del VI&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">pulmonar&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">F Traslocaci&#243;n&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">agudo&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">F Presi&#243;n&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">f Movilidad&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">Disfunci&#243;n&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">f Gradiente&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">bacteriana&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">F Creatinina&#44; uremia&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">intracraneal&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">Peor&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">diast&#243;lica&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">alveoloarterial&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">S&#237;ndrome&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">F Resistencia&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">Hipertensi&#243;n&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">evoluci&#243;n&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">Edema miorc&#225;rdico&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">F Trabajo&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">compartimental&#58;&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">vascular renal&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">intracraneal&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">de las heridas&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">Derrame&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">respiratorio&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">GI&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">Retenci&#243;n de agua&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">S&#237;ndrome&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">F Infecci&#243;n&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">peric&#225;rdico&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">Dificultad&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">Hep&#225;tico&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">y solutos&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">compartimental&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">de heridas&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">Alteraci&#243;n de&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">destete VM&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">Pared abdominal&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">S&#237;ndrome&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">intracraneal&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="" 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">la conducci&#243;n AV&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">F NAVM&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">f Perfusi&#243;n espl&#225;cnica&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">compartimental&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">F Presi&#243;n intraocular&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="" 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">Arritmias&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="" 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">f pH intrag&#225;strico&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">renal&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">S&#237;ndrome&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" 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">Colestasis&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="" 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">compartimental&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" 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">f Actividad de CP450&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="" 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">ocular&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" 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">Intolerancia digestiva&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="" 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="" 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="" 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>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3456032.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diferentes complicaciones de la sobrecarga h&#237;drica</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de soluciones</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Soluciones balanceadas</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Soluciones no balanceadas</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">Ringer&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">Ringer&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">Plasmalyte&#174; &#40;Baxter&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">Isolyte S&#174; &#40;B&#46; Braun&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">NaCl&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">NaCl 0&#44;18&#37;&#47;&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">NaCl 0&#44;45&#37;&#47;&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">Glucosa&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">NaHCO3&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">NaHCO3&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">NaHCO3&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">Par&#225;metro&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">Plasma&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">lactato&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">acetato&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">International&#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">Medical Inc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;9&#37;&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">glucosa 4&#37;&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">glucosa 4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37;&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">Hartmann&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&#44;26&#37;&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&#44;4&#37;&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">8&#44;4&#37;&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">Na<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#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">135-145&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">130&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">130&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">140&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">141&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">154&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">31&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">77&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="" 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">131&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">23<span class="elsevierStyleHsp" style=""></span>mmol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">23<span class="elsevierStyleHsp" style=""></span>mmol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fosfato &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Glucosa &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5-5&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#44;0-7&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;0-8&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;0-8&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;0-8&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Osmolaridad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</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">273&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">277&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">295&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">295&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">308&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">284&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">406&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">278&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">278&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">301&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">333&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">2&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">&#40;mOsmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" 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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" 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>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3456034.png"
              ]
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        "descripcion" => array:1 [
          "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Composici&#243;n de los principales tipos de cristaloides frente al plasma</p>"
        ]
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      4 => array:8 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">HES&#58; hidroxietilalmid&#243;n&#59; PM&#58; peso molecular&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&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="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Gelofusine&#174;&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">Geloplasma&#174;&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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">Hetastarch&#174; 6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">P&#225;rametro&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">Plasma&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">Alb&#250;mina 5&#37;&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">Alb&#250;mina 20&#37;&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">Haemacel&#174;&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">&#40;B&#46; Braun Medical Inc&#46;&#41;&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">&#40;Fresenius Kabi&#41;&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">Dextran&#174; 40&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">Dextran&#174; 70 en NaCl&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">HES130&#47;0&#46;4 &#40;B&#46; Braun Medical Inc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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">Donante&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">Donante&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">Gelatina&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">Gelatina&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">Gelatina&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><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">Fuente&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">humano&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">humano&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">bovina&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">bovina&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">bovina&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">Sucrosa&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">Sucrosa&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">Almid&#243;n de ma&#237;z&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">Na<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#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">135-145&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">148&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">130&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">145&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">154&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">150&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">154&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">154&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">154&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">K<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5-4&#44;5&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="" 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="" 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">5&#44;1&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="" 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">5&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="" 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="" 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="" 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">Cl<span class="elsevierStyleSup">&#8211;</span>&#40;mmol&#47;l&#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">95-105&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">128&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">77&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">120&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">120&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">100&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">154&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">154&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">154&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">Ca2<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#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">2&#44;2-2&#44;6&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="" 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="" 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">6&#44;25&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="" 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="" valign="\n
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                  \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="" 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="" 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="" 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">Mg2<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;8-1&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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">HCO3<span class="elsevierStyleSup">&#8211;</span>&#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">24-32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;como&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">lactato&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">Lactato &#40;mmol&#47;l&#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">1&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&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="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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">Glucosa &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5-6&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">252&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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">Acetato&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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">Malato&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" 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="" valign="\n
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                  \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">Octanotato&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="" valign="\n
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                  \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">8&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">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">PH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;35-7&#44;45&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">6&#44;4-7&#44;4&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">6&#44;7-7&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;0-7&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;5-7&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;0-5&#44;5&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">PM &#40;kD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63-77&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">130&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">Osmolaridad &#40;mOsmol&#47;l&#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">275-295&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">309&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">130&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">274-300&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">274&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Resucitación del paciente con sepsis y shock séptico
Fluidoterapia en la sepsis y el shock séptico
Fluid therapy in sepsis and septic shock
Marcio Borges Saa,
Corresponding author
mborges1967@yahoo.es

Autor para correspondencia.
, Iñigo Salaverríab,c, Antonio Couto Cabasa,d
a Unidad Multidisciplinar de Sepsis, Servicio Medicina Intensiva, Hospital Universitario Son Llàtzer, Palma de Mallorca, España
b Grupo Multidisciplinar de Sepsis. Instituto de Investigación Sanitaria de las Islas Baleares (IDISBA), Palma de Mallorca, España
c Director del Comité de Sepsis, Federación Ibérica y Panamericana de Medicina Intensiva (FEPIMCTI)
d Servicio de Medicina Intensiva, Hospital General, León, México
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o el Documento C&#243;digo Sepsis &#40;DCS&#41; en Espa&#241;a han intentado homogeneizar el tratamiento diagn&#243;stico-terap&#233;utico<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a>&#44; y se ha demostrado que la introducci&#243;n del concepto de los <span class="elsevierStyleItalic">bundles</span> o paquetes de medidas mejora la atenci&#243;n e incluso la morbimortalidad<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a>&#46; La SSC enfatiza la importancia del <span class="elsevierStyleItalic">bundle</span> de la primera hora&#58; obtener hemocultivos &#40;y otros cultivos&#41;&#44; determinar el lactato plasm&#225;tico&#44; el r&#225;pido inicio de una adecuada antibioticoterapia emp&#237;rica y fluidoterapia y administraci&#243;n precoz de vasopresores<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; El DCS ampl&#237;a estos <span class="elsevierStyleItalic">bundles</span> hasta 4 y destaca la importancia del tratamiento integral e indivi-dualizado en las diferentes fases de la sepsis<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En los &#250;ltimos 15 a&#241;os&#44; una serie de estudios observacionales&#44; ensayos cl&#237;nicos y consensos han mantenido importantes controversias sobre la reanimaci&#243;n con fluidos en la sepsis&#46; Estas se basan en qu&#233; tipo de fluido es el m&#225;s adecuado&#44; qu&#233; cantidad&#44; cu&#225;nto tiempo se debe administrar o c&#243;mo se debe monitorizar la respuesta hemodin&#225;mica&#46; Tiene importancia capital evitar balances h&#237;dricos positivos por el aumento de la morbimortalidad&#46; Otra cuesti&#243;n importante es el inicio m&#225;s precoz de los vasopresores<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;10</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Por ello&#44; en este art&#237;culo se revisan los principales conceptos&#44; estudios y controversias de la reanimaci&#243;n con fluidos en enfermos s&#233;pticos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0030">Justificaci&#243;n fisiopatol&#243;gica del papel de la fluidoterapia en la sepsis y el <span class="elsevierStyleItalic">shock</span> s&#233;ptico</span><p id="par0020" class="elsevierStylePara elsevierViewall">El SS se caracteriza por una distribuci&#243;n anormal del flujo sangu&#237;neo en los diferentes tejidos&#44; con la consiguiente ca&#237;da de la presi&#243;n arterial media &#40;PAM&#41;&#44; as&#237; como la disminuci&#243;n del retorno venoso&#46; La vasodilataci&#243;n venosa da lugar a un aumento del volumen intravascular a expensas de volumen no estresado &#40;incapaz de generar presi&#243;n que venza la distensibilidad y la capacitancia de la pared venosa&#41;&#44; lo que produce una disminuci&#243;n del retorno venoso y el gasto cardiaco &#40;GC&#41; del ventr&#237;culo derecho &#40;VD&#41;&#44; que se transmite posteriormente al ventr&#237;culo izquierdo &#40;VI&#41; disminuyendo su precarga y el GC<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6&#8211;11</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Simult&#225;neamente a la vasodilataci&#243;n arterial y venosa por vasoplej&#237;a&#44; se incrementan los mediadores de la respuesta inmunitaria innata&#44; que puede resultar en lesi&#243;n microvascular&#44; un suministro inadecuado de ox&#237;geno a los tejidos y un metabolismo celular inadecuado<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Hay varios factores asociados con el descenso del retorno venoso&#46; El m&#225;s importante es la inmovilizaci&#243;n venosa &#40;en peque&#241;os y grandes vasos&#41; que puede complicarse a&#250;n m&#225;s por la escasa ingesta&#47;administraci&#243;n de l&#237;quidos o el aumento de las p&#233;rdidas intravasculares durante la fase inicial de la sepsis&#46; Otro mecanismo importante&#44; que puede empeorar a&#250;n m&#225;s dicho retorno venoso y consecuentemente la microcirculaci&#243;n&#44; es el da&#241;o endotelial que genera fuga capilar hacia el intersticio<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;9&#8211;11</span></a>&#46; Este puede generar un s&#237;ndrome compartimental celular y estimular la producci&#243;n de citocinas proinflamatorias&#44; que mantiene un ciclo y p&#233;rdida de la homeostasis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Las manifestaciones cl&#237;nicas y anal&#237;ticas precoces m&#225;s importantes del SS son hipotensi&#243;n arterial &#40;PAM<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; mala perfusi&#243;n &#40;disminuci&#243;n de la diuresis y alteraci&#243;n cut&#225;nea o de conciencia&#41;&#44; empeoramiento de la saturaci&#243;n venosa mixta de ox&#237;geno &#40;SatVO<span class="elsevierStyleInf">2</span>&#41; y el aumento del lactato plasm&#225;tico&#46; El SS es una entidad m&#225;s compleja que la hipotensi&#243;n arterial&#44; pues puede haber <span class="elsevierStyleItalic">shock</span> tisular sin hipotensi&#243;n arterial<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La administraci&#243;n de fluidos en el SS se basa en intentar que aumente el volumen intravascular y en consecuencia el retorno venoso para contrarrestar la &#8220;hipovolemia&#8221; relativa&#46; De esta forma se favorece el aumento de la precarga del VD y&#44; en ausencia de fallo de este&#44; la precarga y el GC del VI y&#44; por tanto&#44; la mejor&#237;a de la perfusi&#243;n tisular y del trasporte de ox&#237;geno<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;7&#44;9</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Los principales elementos para una reanimaci&#243;n eficaz con fluidos depender&#225;n del tipo de fluido elegido&#44; as&#237; como el volumen y el tiempo de administraci&#243;n&#46; Pero tambi&#233;n es un factor determinante la monitorizaci&#243;n de la respuesta hemodin&#225;mica&#44; tanto para evaluar su respuesta como para evitar la sobrecarga h&#237;drica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#8211;13</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">Tabla 1</a> se describen las 4 fases de fluidoterapia en la reanimaci&#243;n del SS seg&#250;n distintos par&#225;metros&#58; <span class="elsevierStyleItalic">a&#41;</span> fase 1&#58; reanimaci&#243;n&#59; <span class="elsevierStyleItalic">b&#41;</span> fase 2&#58; optimizaci&#243;n&#59; <span class="elsevierStyleItalic">c&#41;</span> fase 3&#58; estabilizaci&#243;n o consolidaci&#243;n&#44; y <span class="elsevierStyleItalic">d&#41;</span> fase 4&#58; evacuaci&#243;n o desescalada terap&#233;utica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#8211;9&#44;12&#44;13</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">La fase 1 o de reanimaci&#243;n tiene como principal objetivo salvar el paciente&#46; Para ello se debe alcanzar una PAM y un GC m&#237;nimos para mantener la perfusi&#243;n tisular&#46; No es necesaria una monitorizaci&#243;n sofisticada&#44; pero s&#237; vigilar los signos vitales&#46; Tambi&#233;n se deben considerar intervenciones&#47;tratamientos concomitantes&#44; como drenajes o revascularizaci&#243;n&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">La fase 2 es la de optimizaci&#243;n de la terapia y el principal objetivo es mejorar la disponibilidad intracelular de ox&#237;geno&#46; Adem&#225;s de incrementar la PAM y el GC&#44; se puede necesitar un aumento de la hemoglobina con trasfusiones&#46; La respuesta a la fluidoterapia se monitoriza eficaz y r&#225;pidamente con el lactato plasm&#225;tico y&#47;o la SatVO<span class="elsevierStyleInf">2</span>&#44; as&#237; como con los par&#225;metros de la precarga&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La fase 3 o de estabilizaci&#243;n es un momento de consolidaci&#243;n de la terapia con fluidos e intenta prevenir la disfunci&#243;n org&#225;nica &#40;DO&#41;&#44; incluso en pacientes que ya han llegado a la estabilidad hemodin&#225;mica&#46; Se debe asistir a los diferentes &#243;rganos para evitar sus respectivas disfunciones&#44; que son un factor independiente de mayor morbimortalidad&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; la fase 4&#44; denominada de evacuaci&#243;n o desescalada terap&#233;utica h&#237;drica&#44; es clave para la eficacia global de la reanimaci&#243;n por fluidos&#46; Su principal objetivo es alcanzar balances h&#237;dricos negativos&#46; Destaca la desresucitaci&#243;n&#44; con lo que se busca la desescalada&#44; la disminuci&#243;n de los fluidos y forzar el balance h&#237;drico negativo proporcionados previamente en la resucitaci&#243;n&#46; Para ello&#44; se busca facilitar la eliminaci&#243;n espont&#225;nea o forzada de l&#237;quidos a trav&#233;s de diur&#233;ticos o t&#233;cnicas de reemplazo renal &#40;TRR&#41; y reducir&#47;suspender los f&#225;rmacos vasoactivos&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Las principales complicaciones asociadas con la sobrecarga h&#237;drica se exponen en la <a class="elsevierStyleCrossRef" href="#tbl0010">Tabla 2</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;7&#8211;15</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0035">Cantidad de fluidos en la resucitaci&#243;n de la sepsis y monitorizaci&#243;n de la respuesta</span><p id="par0080" class="elsevierStylePara elsevierViewall">La cantidad de fluidos en la resucitaci&#243;n de la sepsis&#44; tanto en su fase inicial como las horas y d&#237;as posteriores&#44; sigue siendo un tema controvertido<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;6</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Con el objetivo de proponer un tratamiento unificado la SSC&#44; tanto en 2016 como en 2021&#44; aconsej&#243;&#44; con d&#233;bil grado de recomendaci&#243;n y baja evidencia cient&#237;fica&#44; administrar cristaloides a 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg de peso ideal v&#237;a endovenosa en las primeras 3<span class="elsevierStyleHsp" style=""></span>h de la resucitaci&#243;n inicial con fluidos<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; No obstante&#44; dicha cantidad de l&#237;quido se basa exclusivamente en estudios observacionales y no en ensayos prospectivos que comparen resultados de la administraci&#243;n de diferentes vol&#250;menes de fluidos<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Esto dio lugar a una correcci&#243;n en la nueva gu&#237;a de 2021&#44; en la que reaparecen los 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg como recomendaci&#243;n de bajo grado y nivel de evidencia<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En cuanto a la velocidad de la administraci&#243;n&#44; tambi&#233;n hay controversias&#46; El reciente ensayo cl&#237;nico aleatorizado con m&#225;s de 10&#46;000 pacientes cr&#237;ticos realizado en Brasil&#44; Basics&#44; no encontr&#243; diferencia significativa en la mortalidad a los 90 d&#237;as entre una administraci&#243;n lenta &#40;333<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41; y una r&#225;pida &#40;999<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Dados el posible deterioro org&#225;nico y el aumento de la mortalidad asociado con un exceso de volumen&#44; es necesario individualizar el tratamiento&#46; Para ello se requiere una evaluaci&#243;n inicial exhaustiva y una revaluaci&#243;n continua de la respuesta al tratamiento basada en par&#225;metros hemodin&#225;micos est&#225;ticos o&#44; preferentemente&#44; din&#225;micos<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;12&#44;13&#44;15&#44;17</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="sect0040">&#205;ndices est&#225;ticos</span><p id="par0100" class="elsevierStylePara elsevierViewall">Cl&#225;sicamente&#44; se han utilizado los &#237;ndices est&#225;ticos para determinar si el paciente responde a los l&#237;quidos y guiar as&#237; la fluidoterapia&#46; La determinaci&#243;n de la precarga del VD a trav&#233;s de la presi&#243;n venosa central &#40;PVC&#41;&#44; la precarga del VI a trav&#233;s de la presi&#243;n de oclusi&#243;n de la arteria pulmonar &#40;PAOP&#41;&#44; la determinaci&#243;n de par&#225;metros volum&#233;tricos por termodiluci&#243;n transpulmonar o la medici&#243;n de los vol&#250;menes telediast&#243;licos ventriculares por ecocardiograf&#237;a son los par&#225;metros est&#225;ticos m&#225;s utilizados para determinar el estado intravascular del paciente<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;11</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No obstante&#44; los par&#225;metros est&#225;ticos se han demostrado malos predictores de la volemia de la respuesta al volumen con valor predictivo moderado y con predicci&#243;n aceptable tan solo en valores extremos&#46; Son m&#225;s &#250;tiles para determinar el riesgo potencial de administrar m&#225;s l&#237;quidos que para predecir de manera fiable la respuesta al volumen&#44; por lo que son marcadores de precarga y no de la respuesta a esta<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a>&#46; A pesar de ello&#44; los marcadores est&#225;ticos de precarga siguen siendo ampliamente utilizados para guiar el tratamiento con fluidos&#44; tal y como muestra el estudio observacional FENICE<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5</span><span class="elsevierStyleSectionTitle" id="sect0045">&#205;ndices din&#225;micos</span><p id="par0110" class="elsevierStylePara elsevierViewall">Se ha demostrado una mejor precisi&#243;n diagn&#243;stica de los &#237;ndices din&#225;micos para predecir la capacidad de respuesta a los fluidos<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6&#44;21</span></a>&#46; As&#237;&#44; tanto el DCS como la SCC sugieren el uso de &#237;ndices din&#225;micos frente est&#225;ticos para predecir la respuesta a la administraci&#243;n de fluidos<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a>&#46; A continuaci&#243;n se describen algunos de ellos&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0050">Variaci&#243;n de volumen sist&#243;lico &#40;VVS&#41; y variaci&#243;n de la presi&#243;n de pulso &#40;VPP&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Probablemente los par&#225;metros m&#225;s utilizados&#44; se basan en la repercusi&#243;n de la positiva intrat&#243;racica secundaria a la ventilaci&#243;n mec&#225;nica en la precarga y&#44; por consiguiente&#44; en el GC&#46; La presi&#243;n positiva reduce la precarga en el VD&#59; si esto se transmite a la precarga del VI y&#44; por ende&#44; disminuye el volumen sist&#243;lico del VI de forma c&#237;clica con la presi&#243;n positiva&#44; indicar&#237;a que ambos ventr&#237;culos son dependientes <span class="elsevierStyleInf">de</span><span class="elsevierStyleInf">la</span> precarga<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;9&#44;16&#44;20&#44;21</span></a><span class="elsevierStyleInf">&#46;</span></p><p id="par0120" class="elsevierStylePara elsevierViewall">No obstante&#44; el VVS y el VPP presentan limitaciones importantes&#46; Requieren de ventilaci&#243;n mec&#225;nica y son poco fiables en caso de respiraci&#243;n espont&#225;nea&#46; Su fiabilidad tambi&#233;n disminuye en caso de arritmia cardiaca&#44; bajos vol&#250;menes tidales &#40;Vt&#41; o baja distensibilidad pulmonar &#40;p&#46; ej&#46;&#44; en el s&#237;ndrome de distr&#233;s respiratorio agudo &#91;SDRA&#93;&#41;&#44; esternotom&#237;a&#44; aumento de la presi&#243;n intraabdominal&#44; frecuencias respiratorias altas o insuficiencia card&#237;aca derecha<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0055">Colapsabilidad o distensibilidad de la vena cava</span><p id="par0125" class="elsevierStylePara elsevierViewall">Los cambios de la presi&#243;n intrator&#225;cica inducidos por la ventilaci&#243;n mec&#225;nica generan variaciones en las venas cavas cuando la precarga es baja&#44; lo que permite estimar la respuesta a la administraci&#243;n de volumen&#44; tanto la variaci&#243;n del di&#225;metro de la vena cava inferior&#44; por ecograf&#237;a transtor&#225;cica&#44; como la colapsabilidad de la vena cava superior por ecograf&#237;a transesof&#225;gica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;23</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Su fiabilidad para predecir la respuesta ha sido cuestionada por sus limitaciones<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Al igual que en el caso de la VVS y la VPP&#44; la precisi&#243;n de dichas mediciones disminuye considerablemente en pacientes en respiraci&#243;n espont&#225;nea &#8212;en cuyo caso parece que solo las variaciones de gran amplitud predicen buena respuesta a los l&#237;quidos<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;24</span></a>&#8212; y los casos de Vt bajos o baja distensibilidad pulmonar<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;24</span></a>&#46; Adem&#225;s&#44; requiere pericia con la ecograf&#237;a transtor&#225;cica o transesof&#225;gica &#40;en el caso de la vena cava superior&#41;&#46; A diferencia de la VPP y la VVS&#44; los &#237;ndices de colapsabilidad y distensibilidad de la vena cava s&#237; son fiables en pacientes con arritmias cardiacas<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;20&#44;24&#8211;26</span></a><span class="elsevierStyleInf">&#46;</span></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0060">Fluid challenge</span><p id="par0135" class="elsevierStylePara elsevierViewall">Cl&#225;sicamente esta prueba se basa en la administraci&#243;n de un volumen de 250&#8211;500<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido en 30<span class="elsevierStyleHsp" style=""></span>min&#44; y si produce un aumento del GC &#8805; 15&#37;&#44; se considera dependiente de precarga y&#44; por lo tanto&#44; respuesta a la administraci&#243;n de flui<span class="elsevierStyleSup">dos</span><span class="elsevierStyleSup">2</span><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">0&#44;6&#8211;9</span></a><span class="elsevierStyleInf">&#46;</span></p><p id="par0140" class="elsevierStylePara elsevierViewall">No obstante&#44; tiene principalmente dos limitaciones&#46; Por un lado&#44; requiere la medici&#243;n continua del GC&#59; por otro&#44; la administraci&#243;n deliberada de fluidos para predecir la respuesta es en s&#237; misma un tratamiento que contribuye a la sobrecarga de l&#237;quidos y la hemodiluci&#243;n&#46; Esto &#250;ltimo ha dado lugar al desarrollo de una provocaci&#243;n con minifluidos&#44; en la que se administran solo 100<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido en corto tiempo&#44; con una fiabilidad de predicci&#243;n de respuesta a fluidos incluso mejor que la VPP&#46; No obstante&#44; como ya se ha comentado&#44; requiere una medici&#243;n precisa del GC<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;27&#44;28</span></a>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0065">Elevaci&#243;n pasiva de las piernas</span><p id="par0145" class="elsevierStylePara elsevierViewall">Se trata de un <span class="elsevierStyleItalic">fluid challenge</span> &#8220;interno&#8221;&#44; reversible&#44; reproducible y de aproximadamente 300<span class="elsevierStyleHsp" style=""></span>ml de sangre&#44; suficiente para inducir un aumento significativo del GC que predice de manera fiable la respuesta a la administraci&#243;n ex&#243;gena de l&#237;quidos&#46; Se trata de una prueba fiable en pacientes en respiraci&#243;n espont&#225;nea&#44; con bajos vol&#250;menes o baja distensibilidad pulmonar&#44; as&#237; como en caso de hipertensi&#243;n intraabdominal&#46; Pese a que puede producir un aumento de la PAM en situaciones de dependencia de precarga y&#44; por consiguiente&#44; respuesta a los l&#237;quidos&#44; los cambios de la presi&#243;n arterial no permiten determinar con fiabilidad si los pacientes responden a los l&#237;quidos&#46; Por ello se requiere la medici&#243;n continua del GC con t&#233;cnicas invasivas o no invasivas<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9&#44;29&#44;30</span></a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0070">Prueba de oclusi&#243;n al final de espiraci&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Consiste en realizar una pausa espiratoria durante al menos 15 s&#46; Si el GC aumenta m&#225;s del 5&#37;&#44; indica que ambos ventr&#237;culos son dependientes de la precarga&#46; Requiere medici&#243;n continua del GC &#40;tanto invasiva como no invasiva&#41; y es fiable en caso de Vt bajo y baja distensibilidad pulmonar&#59; por lo tanto&#44; en el SDRA&#46; Una posible limitaci&#243;n es la ventilaci&#243;n en dec&#250;bito prono y no se puede realizar con pacientes que no se encuentren intubados o no toleren pausas espiratorias &#8805; 15 s<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;9&#44;21&#44;22</span></a>&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6</span><span class="elsevierStyleSectionTitle" id="sect0075">Otros &#237;ndices de respuesta a volumen</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0080">Aclaramiento de lactato s&#233;rico</span><p id="par0155" class="elsevierStylePara elsevierViewall">Se ha propuesto normalizar su concentraci&#243;n como objetivo de la reanimaci&#243;n inicial en el SS&#46; Sin embargo&#44; las cifras de lactato s&#233;rico han de interpretarse en el contexto cl&#237;nico y tras descartar otras causas de incremento&#46; En cualquier caso&#44; en una estrategia guiada por el lactato se ha de tener cautela y solo para las primeras horas del SS&#44; en las que la hiperlactacidemia es secundaria a disfunci&#243;n tisular por hipoperfusi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;6</span></a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0085">Normalizaci&#243;n del tiempo de llenado capilar</span><p id="par0160" class="elsevierStylePara elsevierViewall">Medida alternativa y no invasiva cuando no se dispone de monitorizaci&#243;n hemodin&#225;mica&#46; Permite evaluar con seguridad y eficacia la administraci&#243;n de fluidos seg&#250;n la perfusi&#243;n tisular&#46; Se ha demostrado una eficacia similar a la del tratamiento guiado por el aclaramiento de lactato<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Los &#237;ndices y par&#225;metros hemodin&#225;micos nunca deben considerarse de manera aislada y con valores predeterminados&#44; sino como un dato m&#225;s que apoya una sospecha fundada en una correcta y completa valoraci&#243;n del enfermo&#44; y siempre se debe individualizar cada caso<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;9</span></a>&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">7</span><span class="elsevierStyleSectionTitle" id="sect0090">Caracter&#237;sticas de los distintos tipos de fluidos</span><p id="par0170" class="elsevierStylePara elsevierViewall">Los fluidos se clasifican seg&#250;n su comportamiento frente a la membrana capilar y hay de 2 tipos&#58; cristaloides y coloides &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabla 3</a> y <a class="elsevierStyleCrossRef" href="#tbl0020">Tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8</span><span class="elsevierStyleSectionTitle" id="sect0095">Cristaloides</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los cristaloides generalmente est&#225;n constituidos por agua y sales minerales&#44; que se diluyen y difunden junto con el disolvente&#46; La mayor&#237;a de las soluciones cristaloides se distribuyen bien en el l&#237;quido intracelular y extracelular&#44; con un alto &#237;ndice de eliminaci&#243;n&#58; a los 60<span class="elsevierStyleHsp" style=""></span>min de la infusi&#243;n&#44; solamente permanece el 20&#37; del volumen infundido en el espacio intravascular<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11</span></a>&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0100">Soluciones no balanceadas</span><p id="par0180" class="elsevierStylePara elsevierViewall">Las soluciones no balanceadas son todas las que tienen osmolaridad&#44; tonicidad y contenido electrol&#237;tico distinto del plasma&#46; La m&#225;s utilizada es la soluci&#243;n salina al 0&#44;9&#37;&#44; &#40;SS0&#44;9&#37;&#41; mal denominada &#8220;fisiol&#243;gica&#8221;&#44; pues es hipert&#243;nica y &#225;cida respecto al plasma y contiene una cantidad supranormal de sodio y cloro&#46; Su capacidad de expandir la volemia depende de la concentraci&#243;n de sodio&#58; cuanto mayor concentraci&#243;n&#44; m&#225;s incremento de la volemia<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; No existe evidencia para administrar suero hipert&#243;nico para la resucitaci&#243;n en la sepsis<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#8211;8</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Las soluciones glucosadas tambi&#233;n tienen una osmolaridad diferente&#44; y cuanto mayor concentraci&#243;n de glucosa&#44; mayor osmolaridad&#46; Sin embargo&#44; las soluciones glucosadas no contienen electrolitos y tienen un coeficiente de Staverman extremo bajo&#44; de ah&#237; que se conozcan como agua libre&#46; Su permanencia en el espacio intravascular es muy corta<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a>&#46; Las soluciones no balanceadas tienen en com&#250;n varios efectos adversos&#46; Todas hacen un efecto de diluci&#243;n&#44; mientras que las de alto contenido en NaCl generan hipercloremia y eventualmente acidosis<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0105">Soluciones balanceadas</span><p id="par0190" class="elsevierStylePara elsevierViewall">Las soluciones balanceadas son las m&#225;s parecidas al plasma y tienen un amortiguador como lactato&#44; acetato o malato&#44; y cloro &#8804; 110 mEq&#47;l&#59; tambi&#233;n se las llama bajas en cloro&#44; en lugar de balanceadas&#46; Por ejemplo&#44; la soluci&#243;n de Hartmann tiene como variante el Ringer lactato como amortiguador&#46; La soluci&#243;n Plasmalyte&#174; tiene una osmolaridad cercana a la del plasma&#59; adem&#225;s contiene acetato y malato como amortiguador&#44; lo cual genera menor desequilibrio acidob&#225;sico<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a>&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">9</span><span class="elsevierStyleSectionTitle" id="sect0110">Coloides</span><p id="par0195" class="elsevierStylePara elsevierViewall">Los coloides son suspensiones de part&#237;culas s&#243;lidas muy finas&#44; de 10<span class="elsevierStyleSup">&#8722;9</span> a 10<span class="elsevierStyleSup">&#8722;5</span><span class="elsevierStyleHsp" style=""></span>m&#44; que no se difunden con su disolvente cuando este tiene que atravesar una membrana porosa&#46; Las macromol&#233;culas pueden estar elaboradas a partir de prote&#237;nas o carbohidratos&#44; por lo que todos los coloides en el mercado son sint&#233;ticos &#40;dextranos&#44; hidroxi-etil-almid&#243;n &#91;HEA&#93; y gelatinas&#41; con excepci&#243;n de la alb&#250;mina&#46; El HEA y las gelatinas tienen similar capacidad de expansi&#243;n plasm&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7&#44;11</span></a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Aunque los coloides tienen tendencia a permanecer m&#225;s tiempo en el espacio intravascular&#44; depende en gran parte de la integridad del glucoc&#225;liz&#59; en la sepsis&#44; como otros s&#237;ndromes&#44; hay una p&#233;rdida&#44; lo que aumenta el paso de los coloides a trav&#233;s de la membrana capilar&#44; o sea&#44; fuga capilar al intersticio<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">El gran peso molecular&#44; te&#243;ricamente&#44; confiere un alto coeficiente de reflexi&#243;n de Staverman&#59; sin embargo&#44; en la pr&#225;ctica cl&#237;nica el l&#237;quido en el que estas macromol&#233;culas est&#225;n suspendidas puede difundir pasivamente al intersticio o por medio de gradientes de presi&#243;n onc&#243;tica<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9</span></a>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">La alb&#250;mina es la prote&#237;na m&#225;s abundante en el plasma humano &#40;50&#8211;60&#37;&#41; y aporta el 80&#37; de la presi&#243;n onc&#243;tica del plasma&#46; Regula la presi&#243;n coloidonc&#243;tica&#44; trasporta f&#225;rmacos&#44; es antioxidante y modula el &#243;xido n&#237;trico<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9&#44;11</span></a>&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10</span><span class="elsevierStyleSectionTitle" id="sect0115">Evidencias en fluidoterapia en la resucitaci&#243;n de la sepsis</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0120">Cristaloides</span><p id="par0215" class="elsevierStylePara elsevierViewall">Los cristaloides siguen siendo los fluidos m&#225;s indicados parael tratamiento inicial de la sepsis y el SS<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;13</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">En 2014&#44; un estudio retrospectivo observ&#243; menor mortalidad dependiente de la dosis en pacientes con SS reanimados en las primeras 48<span class="elsevierStyleHsp" style=""></span>h con una combinaci&#243;n de cristaloides cl&#225;sicos y balanceados&#44; comparados con los que hab&#237;an recibido solo SS0&#44;9&#37;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Otro estudio con <span class="elsevierStyleItalic">propensity score</span> compar&#243; el SS0&#44;9&#37; con 2 soluciones balanceadas &#40;Plasmalyte&#174; y Normosol&#174;&#41; en m&#225;s de 3&#46;000 pacientes con criterios de SRIS que hab&#237;an recibido m&#225;s de 500<span class="elsevierStyleHsp" style=""></span>ml en las primeras 48<span class="elsevierStyleHsp" style=""></span>h&#46; Se observ&#243; que el SS0&#44;9&#37; incrementaba la mortalidad&#44; las complicaciones cardiacas&#44; respiratorias y hem&#225;ticas&#44; la necesidad de reemplazo de electrolitos e infecciones&#44; pero no en los ri&#241;ones<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; El ensayo aleatorizado SMART&#44; con m&#225;s de 15&#46;000 pacientes cr&#237;ticos&#44; compar&#243; la SS0&#44;9&#37; con cristaloides balanceados &#40;Ringer lactato o Plasmalyte&#174;&#41;&#46; El objetivo combinado era&#58; mortalidad a los 30 d&#237;as y&#47;o aparici&#243;n de insuficiencia renal aguda con necesidad de TRR&#46; Hubo un mayor beneficio en el grupo de cristaloides balanceados&#44; pero al analizar el subgrupo con 1&#46;600 pacientes s&#233;pticos&#44; estos resultados eran m&#225;s marcados&#46; Incluso hab&#237;a una disminuci&#243;n significativa de la mortalidad a los 30 d&#237;as<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Sin embargo&#44; en un reciente estudio aleatorizado con 10&#46;520 pacientes cr&#237;ticos que compar&#243; la SS0&#44;9&#37; con soluci&#243;n balanceada&#44; no hubo diferencia significativa en la mortalidad a los 90 d&#237;as &#40;el 27&#44;2 frente al 26&#44;4&#37; respectivamente&#41;&#46; Hay que destacar que el 48&#44;4&#37; eran pacientes de cirug&#237;a programada&#44; aunque el 60&#37; ten&#237;a hipotensi&#243;n o tomaba vasopresores&#44; pero solamente alrededor del 18&#37; estaban s&#233;pticos<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Otro reciente estudio aleatorizado&#44; controlado y a doble ciego en 53 unidades de cuidados intensivos &#40;UCI&#41; de Australia y Nueva Zelanda compar&#243; una soluci&#243;n balanceada &#40;Plasmalyte&#174; 148&#41; con la SS0&#44;9&#37; en 5&#46;037 pacientes&#46; Los autores no observaron diferencias significativas entre los 2 grupos en la mortalidad a los 90 d&#237;as&#44; la aparici&#243;n de insuficiencia renal aguda o el n&#250;mero de otros efectos secundarios<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0125">Coloides sint&#233;ticos</span><p id="par0240" class="elsevierStylePara elsevierViewall">El uso de coloides tipo almidones &#40;HEA&#41; se han asociado a distintos efectos secundarios&#44; tales como anafilaxia&#44; coagulopat&#237;a o insuficiencia renal&#46; El HEA tiene mayor poder onc&#243;tico cuanto mayor peso molecular &#40;PM&#41; tenga y un efecto m&#225;s duradero cuanto mayor sea su &#237;ndice de sustituci&#243;n &#40;IS&#41;&#46; Hace varios a&#241;os&#44; el ensayo VISEP asoci&#243; la dosis de HEA &#40;PM&#44; 200&#59; IS&#44; 0&#44;5&#41; con insuficiencia renal aguda&#44; necesidad de TRR y mayor mortalidad<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&#46; Posteriormente&#44; el 6<span class="elsevierStyleHsp" style=""></span>S tambi&#233;n describi&#243; una mayor mortalidad dependiente de la necesidad de TRR a los 90 d&#237;as en los pacientes s&#233;pticos reanimados con HEA 130&#47;04 comparados con el Ringer acetato<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>&#46; En 2013&#44; un metan&#225;lisis incluy&#243; a 3&#46;456 pacientes s&#233;pticos para comparar HES 130&#47;0&#44;38-0&#44;45 frente a cristaloides o albumina&#46; Los autores no encontraron diferencias en mortalidad&#44; pero en el grupo de HEA se increment&#243; significativamente el riesgo de TRR y administraci&#243;n de hemoderivados<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46; Estos resultados se confirmaron en 2 metan&#225;lisis posteriores<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a>&#46; Uno de ellos incluy&#243; 38 ensayos con m&#225;s de 10&#46;800 pacientes diagnosticados de sepsis&#44; traumatismos o hipovolemias en Urgencias o UCI entre 1982 y 2012&#46; Se compar&#243; HEA con cristaloides&#44; gelatinas y alb&#250;mina&#46; No hubo diferencias en la mortalidad y la estancia en UCI u hospitalaria entre los grupos&#46; Sin embargo&#44; en el an&#225;lisis de subgrupos los pacientes tratados con HES presentaban un significativo aumento de la insuficiencia renal aguda y necesidad de TRR<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Un estudio con 7&#46;000 pacientes de 34 UCI compar&#243; la SS0&#44;9&#37; con coloides frente a HEA&#46; La dosis m&#225;xima de HEA fue 50<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;d&#237;a&#46; No hubo diferencias de mortalidad a los 90 d&#237;as&#44; pero s&#237; un incremento estad&#237;sticamente significativo de la necesidad de TRR en el grupo de HEA&#44; con un incremento relativo del 21&#37;&#46; Este grupo tambi&#233;n presentaba m&#225;s insuficiencia renal aguda&#44; eritema y prurito&#44; insuficiencia hep&#225;tica y necesidad de trasfusiones&#44; aunque en el grupo de HEA mejor&#243; la insuficiencia cardiaca y disminuy&#243; la necesidad y el tiempo de vasopresores<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46; Por todo ello&#44; desde 2013 las autoridades sanitarias espa&#241;olas han restringido el uso de coloides tipo HEA por los potenciales efectos secundarios graves en pacientes s&#233;pticos<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11</span></a>&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Sobre las gelatinas hay menos estudios&#44; aunque la mayor&#237;a no aporta beneficios comparadas con los cristaloides&#44; y varios de ellos describen mayor riesgo de anafilaxia&#44; hemorragias&#44; insuficiencia renal o mortalidad hospitalaria<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;45&#44;46</span></a>&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Una revisi&#243;n sistematizada de la literatura y metan&#225;lisis de 40 estudios prospectivos y ensayos cl&#237;nicos con 3&#46;275 pacientes evalu&#243; la seguridad de las gelatinas comparadas con un grupo de control que inclu&#237;a a pacientes tratados con SS0&#44;9&#37;&#44; Ringer lactato&#44; plasma y alb&#250;mina&#46; La dosis media de las gelatinas fue 17<span class="elsevierStyleHsp" style=""></span>ml&#47;kg en las primeras 24<span class="elsevierStyleHsp" style=""></span>h&#44; una media de 1 l&#46; Los autores concluyen que eran heterog&#233;neos los grupos de pacientes y los estudios&#46; No observaron aumento de trasfusiones&#44; insuficiencia renal o mortalidad entre gelatinas y el grupo de control con una dosis de 17<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#46; Sin embargo&#44; cuando la dosis de gelatinas era<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#44; aumentaba el riesgo de mortalidad y de trasfusiones<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">11</span><span class="elsevierStyleSectionTitle" id="sect0130">Alb&#250;mina</span><p id="par0260" class="elsevierStylePara elsevierViewall">El coloide natural que genera mucho debate es la alb&#250;mina&#46; El ensayo SAFE incluy&#243; a casi 7&#46;000 pacientes cr&#237;ticos y compar&#243; los tratamientos con SS0&#44;9&#37; y con alb&#250;mina al 4&#37; en la reanimaci&#243;n inicial&#46; La principal conclusi&#243;n fue que no se observaron diferencias en la mortalidad<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#44; pero al analizar el subgrupo de pacientes s&#233;pticos de la serie&#44; los tratados con alb&#250;mina al 4&#37; presentaban una mortalidad significativamente menor &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;71&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; Otro in teresante estudio&#44; EARSS&#44; administr&#243; aleatoriamente 10<span class="elsevierStyleHsp" style=""></span>ml de alb&#250;mina al 20&#37; o 100<span class="elsevierStyleHsp" style=""></span>ml de SS0&#44;9&#37; cada 8<span class="elsevierStyleHsp" style=""></span>h durante 3 d&#237;as a 798 pacientes cr&#237;ticos&#46; No encontraron diferencias en estancia en UCI u hospitalaria o en mortalidad&#44; pero los tratados con alb&#250;mina al 20&#37; ten&#237;an significativamente menos d&#237;as con vasopresores<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; Un estudio que ha sido importante para los defensores de la alb&#250;mina en la sepsis es el ensayo cl&#237;nico ALBIOS&#46; Este aleatoriz&#243; a 2 grupos de pacientes con sepsis graves&#58; cristaloides frente a alb&#250;mina al 20&#37;&#44; para alcanzar un objetivo de alb&#250;mina plasm&#225;tica<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>g&#47;l&#46; No hubo diferencias en mortalidad a los 28 y a los 90 d&#237;as&#44; pero los pacientes con SS que recibieron alb&#250;mina al 20&#37; presentaban una mortalidad a los 90 d&#237;as significativamente menor &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a>&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Infecci&#243;n y potencial inicio de los fen&#243;menos fisiopatog&#233;nicos de la sepsis&#58; tiempo muy variable&#44; desde horas hasta d&#237;as despu&#233;s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Ya empiezan los signos&#47;s&#237;ntomas de alteraciones cl&#237;nicas&#47;anal&#237;ticas&#47;radiol&#243;gicas compatibles con inflamaci&#243;n y DO de sepsis&#46; Estos son muy variables y dependen de la interacci&#243;n entre pat&#243;geno y hu&#233;sped&#46; Por ejemplo&#44; la variabilidad fenot&#237;pica de presentaci&#243;n de una sepsis depende de varios factores&#58; gen&#243;micos del paciente&#44; del tipo de pat&#243;geno &#40;virus o bacteria&#41;&#44; ambientales&#44; administraci&#243;n de otros f&#225;rmacos &#40;p&#46; ej&#46;&#44; quimioterapia&#41;&#44; etc&#46; En este momento de detecci&#243;n hay que proceder al <span class="elsevierStyleItalic">bundle</span> inicial&#58; toma de hemocultivos&#44; iniciar ATB&#44; lactato plasm&#225;tico&#44; e iniciar tratamiento hemodin&#225;mico con fluidoterapia y considerar VP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Una tercera fase precoz &#40;primeras 3<span class="elsevierStyleHsp" style=""></span>h&#41; del proceso s&#233;ptico&#44; en que se valora espec&#237;ficamente la HD&#44; est&#225; solapada a la previa&#44; que es la monitorizaci&#243;n utilizando criterios cl&#237;nicos &#40;PAM&#44; FC&#41;&#44; de laboratorio &#40;lactato&#44; SatVO2&#41;&#44; par&#225;metros est&#225;ticos &#40;PVC&#41; y&#44; por supuesto&#44; tambi&#233;n din&#225;micos&#46; La nueva SSC de 2021 no incluye la SatVO2 para monitorizaci&#243;n&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">La cuarta fase de la evoluci&#243;n de la sepsis&#44; que puede desarrollarse desde las primeras horas hasta d&#237;as&#44; la monitorizaci&#243;n HD utilizando par&#225;metros din&#225;micos es crucial para evaluar la respuesta cl&#237;nica y los potenciales ajustes del tratamiento HD&#46; Se ha demostrado que las maniobras como elevar pasivamente las piernas o minifluidos&#44; ecocardiograf&#237;a o los par&#225;metros VVS y VVP aportan m&#225;s y mejores datos para el tratamiento HD&#46; Y el lactato&#44; principalmente en las primeras 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#44; considerando sus limitaciones&#44; tambi&#233;n aporta una r&#225;pida informaci&#243;n de la respuesta HD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Hay que destacar que actualmente&#44; seg&#250;n la mayor&#237;a de consensos&#44; la indicaci&#243;n es iniciar el tratamiento HD con fluidos tipo cristaloides a dosis de 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#44; pero hay muchas controversias en este punto&#46; Uno&#44; la dosis&#58; la tendencia actual es ajustar&#47;personalizar esta dosis&#46; Dos&#44; la posibilidad de sustituir por cristaloides balanceados que podr&#237;an tener m&#225;s eficacia y menos efectos secundarios &#40;p&#46; ej&#46;&#44; hipercloremia&#41;&#46; Tres&#44; la posibilidad de tratamiento con fluidos combinado &#40;p&#46; ej&#46;&#44; con alb&#250;mina&#41; con varios estudios muy favorables&#44; incluso con menor mortalidad asociada en enfermos s&#233;pticos&#46; Cuatro&#44; hay que considerar el inicio precoz de los VP &#161;siempre&#33;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Esta fase&#44; que tambi&#233;n es muy variable&#44; pero ser&#225;n d&#237;as&#44; hasta semanas&#44; es cuando puede haber soluci&#243;n cl&#237;nica del proceso s&#233;ptico&#44; pero tambi&#233;n se puede observar los efectos delet&#233;reos de los distintos tratamientos&#44; como ATB&#44; VP o fluidos&#46; En este caso&#44; uno de vital importancia es la sobrecarga h&#237;drica con aumento de DO &#40;que puede ocurrir desde las fases iniciales en las primeras horas de la resucitaci&#243;n HD&#41;&#46; Se trata de un factor asociado con la mayor morbimortalidad del paciente s&#233;ptico&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Por ello&#44; para evitar la sobrecarga h&#237;drica&#44; se debe ser proactivos en el ajuste&#47;desescalada de fluidos y el balance h&#237;drico negativo evaluando de manera continua&#44; principalmente con una monitorizaci&#243;n HD basada en par&#225;metros din&#225;micos&#46; Por ello&#44; la atenci&#243;n continuada es crucial para una resucitaci&#243;n HD eficaz y con m&#237;nimos efectos secundarios para el paciente&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Todo el proceso s&#233;ptico&#44; espec&#237;ficamente el tratamiento HD&#44; siempre se debe considerar individualizadamente&#44; tanto el tipo como la dosis&#44; las cantidades y la desescalada de fluidos&#44; as&#237; como su monitorizaci&#243;n de respuesta cl&#237;nica HD&#46; La medicina personalizada es un reto en la atenci&#243;n de la sepsis&#44; y el tratamiento HD es un reto complejo que necesita experiencia y flexibilidad durante las diferentes fases de la sepsis&#46;</p></li></ul></p><p id="par0305" class="elsevierStylePara elsevierViewall">ATB&#58; antibi&#243;ticos&#59; DO&#58; difunci&#243;n org&#225;nica&#59; EF&#58; exploraci&#243;n f&#237;sica&#59; HD&#58; hemodin&#225;mica&#59; SS&#58; <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#59; VP&#58; vasopresores&#59; VPP&#58; variaci&#243;n de la presi&#243;n de pulso&#59; VVS&#58; variaci&#243;n de volumen sist&#243;lico&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">El ensayo multic&#233;ntrico internacional CRISTAL compar&#243; la reanimaci&#243;n con cristaloides frente a coloides en 2&#46;857 pacientes en <span class="elsevierStyleItalic">shock</span> hipovol&#233;mico&#44; includos s&#233;pticos&#46; El grupo de control con cristaloides bajo SS0&#44;9&#37; y Ringer lactato frente a coloides hipoonc&#243;ticos &#40;gelatinas&#44; albumina al 4&#37;&#41; e hiperonc&#243;ticos &#40;dextranos&#44; alb&#250;mina al 20&#37; y HEA en dosis &#60; 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41;&#46; La media de volumen de cristaloides administrado fue 3&#46;000<span class="elsevierStyleHsp" style=""></span>ml y depend&#237;a del facultativo&#46; El volumen medio de coloides administrado fue 2&#46;000<span class="elsevierStyleHsp" style=""></span>ml&#46; El tiempo promedio de administraci&#243;n fue menos de 2 d&#237;as&#46; No hubo diferencias de mortalidad entre uno y otro grupo a los 28 d&#237;as&#44; pero s&#237; a los 90 d&#237;as&#44; cuando fue significativamente mayor en el grupo de cristaloides&#44; motivo por el que se suspendi&#243; el estudio&#46; Tampoco hubo diferencias en los d&#237;as de estancia en UCI u hospitalaria&#44; SOFA a los 28 d&#237;as o necesidad de TRR a los 7 y 28 d&#237;as&#46; Los pacientes con coloides ten&#237;an menos d&#237;as de ventilaci&#243;n mec&#225;nica y vasopresores<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a>&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Sobre el empleo de alb&#250;minas al 4-5&#37; frente al 20&#37;&#44; el estudio SWIPE las compar&#243; en la reanimaci&#243;n en pacientes cr&#237;ticos&#46; El grupo con alb&#250;mina al 20&#37; recibi&#243; una media de 600<span class="elsevierStyleHsp" style=""></span>ml &#40;65&#37;&#41; menos de fluidos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y un balance h&#237;drico acumulado a las 48<span class="elsevierStyleHsp" style=""></span>h significativamente menor&#44; alrededor de 576<span class="elsevierStyleHsp" style=""></span>ml &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Se observ&#243; menos sodio y potasio en el grupo de alb&#250;mina al 20&#37;&#46; Por &#250;ltimo&#44; no se han observado diferencias en anafilaxia&#44; aparici&#243;n de insuficiencia renal aguda o mortalidad en UCI u hospitalaria<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">12</span><span class="elsevierStyleSectionTitle" id="sect0135">Combinaci&#243;n de fluidos</span><p id="par0320" class="elsevierStylePara elsevierViewall">De la combinaci&#243;n de cristaloides y albumina hay nueva evidencia&#44; incluso la SSC de 2021 indica considerar esta posibilidad en pacientes que hayan recibido gran cantidad de volumen<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; En un reciente an&#225;lisis retrospectivo de reanimaci&#243;n con fluidos en pacientes s&#233;pticos de la base MIMIC-IV&#44; 6&#46;597 pacientes recibieron solo cristaloides frente a 920 con una combinaci&#243;n precoz de cristaloides m&#225;s albumina&#46; Se objetiv&#243; que los pacientes con la combinaci&#243;n administrada en las primeras 24<span class="elsevierStyleHsp" style=""></span>h ten&#237;an una mortalidad a los 28 d&#237;as significativamente menor &#40;el 12&#44;5 frente al 16&#44;4&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#44; aunque ten&#237;an una estancia en UCI significativamente m&#225;s larga &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">13</span><span class="elsevierStyleSectionTitle" id="sect0140">Comentarios finales</span><p id="par0325" class="elsevierStylePara elsevierViewall">Aunque sigue habiendo controversias en la reanimaci&#243;n con fluidos en la sepsis y el SS&#44; hay algunos puntos de la pr&#225;ctica cl&#237;nica basada en la &#8220;poca&#8221; evidencia que se siguen en la actualidad<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;53</span></a>&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">La fluidoterapia es&#44; por lo tanto&#44; un elemento clave en el tratamiento de la sepsis&#44; y su inicio inmediato en la resucitaci&#243;n precoz es imprescindible con el objetivo de restaurar el volumen intravascular para mejorar el GC y&#44; por ende&#44; la perfusi&#243;n tisular&#46; En la <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> se resume el papel de la fluidoterapia y c&#243;mo plantearla en las diferentes fases de la resucitaci&#243;n en la sepsis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0335" class="elsevierStylePara elsevierViewall">En principio&#44; para los pacientes s&#233;pticos se debe iniciar la reanimaci&#243;n con cristaloides<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a>&#44; pero hay que valorar la posibilidad de reanimar con los cristaloides balanceados en determinados casos &#40;p&#46; ej&#46;&#44; que ya hayan recibido SS0&#44;9&#37; o tengan cifras elevadas de cloro plasm&#225;tico&#41; por sus potenciales ventajas&#44; como menor incidencia de acidosis metab&#243;lica hiperclor&#233;mica o insuficiencia renal<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;9</span></a>&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">La tendencia actual es considerar la posibilidad de reanimaci&#243;n con fluidos mixta con cristaloides &#40;considerando la posibilidad de los balanceados&#41;&#44; con alb&#250;mina &#40;m&#225;s al 20&#37; que al 4&#37;&#41;&#44; para los pacientes que necesiten altas cantidades de los primeros o ya est&#233;n en tratamiento con dosis elevadas de vasopresores y tengan la alb&#250;mina plasm&#225;tica<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>g&#47;l<span class="elsevierStyleSup">4</span><a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">0&#44;7&#8211;9</span></a>&#46; Otro factor determinante es alcanzar una reanimaci&#243;n con fluidos eficaz&#44; pero restrictiva para evitar la sobrecarga h&#237;drica&#46; Para ello&#44; la monitorizaci&#243;n din&#225;mica &#40;m&#225;s que la est&#225;tica&#41;&#44; principalmente en las fases de optimizaci&#243;n y estabilizaci&#243;n&#44; son cruciales para disminuir la potencial morbimortalidad de balances h&#237;dricos positivos acumulados&#46; Ensayos cl&#237;nicos como de Douglas et al&#46; han demostrado que las medidas din&#225;micas &#40;como el aumento de la precarga durante la movilizaci&#243;n de las extremidades inferiores&#41; pueden orientar una resucitaci&#243;n con fluidos y vasopresores m&#225;s eficaz&#44; segura y restrictiva en cuanto a evitar la sobrecarga h&#237;drica<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a>&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Por todo ello&#44; actualmente se recomienda individualizar la terapia con fluidos y una monitorizaci&#243;n hemodin&#225;mica adecuada de cada paciente<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#8211;9</span></a>&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">14</span><span class="elsevierStyleSectionTitle" id="sect0145">Conflicto de intereses</span><p id="par0350" class="elsevierStylePara elsevierViewall">Marcio Borges Sa&#44; ha sido ponente de simposos de MSD&#44; Pfizer y Biomerieux&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Los dem&#225;s autores declaran no tener conflictos de intereses&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">15</span><span class="elsevierStyleSectionTitle" id="sect0150">Nota al suplemento</span><p id="par0360" class="elsevierStylePara elsevierViewall">Este art&#237;culo forma parte del suplemento &#171;Resucitaci&#243;n del paciente con sepsis y <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#187;&#44; que cuenta con el patrocinio de AOP HEALTH IBERIA&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La reanimaci&#243;n con fluidos es una parte crucial en el tratamiento de la hipotensi&#243;n y el <span class="elsevierStyleItalic">shock</span> de cualquier etiolog&#237;a y&#44; particularmente en el <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#44; un elemento esencial del <span class="elsevierStyleItalic">bundle</span> de atenci&#243;n inicial&#46; Como todos los tratamientos en sepsis&#44; tambi&#233;n est&#225; expuesto a m&#250;ltiples controversias&#58; qu&#233; tipo de fluido&#44; qu&#233; cantidad&#44; en cu&#225;nto tiempo se administra&#44; cu&#225;les son los potenciales riesgos y la toxicidad&#46; La principal gu&#237;a&#44; la <span class="elsevierStyleItalic">Surviving Sepsis Campaign&#44;</span> sigue indicando los cristaloides como principal fluido en la reanimaci&#243;n&#46; Pero la posibilidad de cristaloides balanceados sobre el suero salino al 0&#44;9&#37; o el uso combinado con alb&#250;mina en la reanimaci&#243;n del paciente s&#233;ptico siguen en debate&#46; Probablemente estemos delante de otro punto en que deber&#237;amos considerar siempre individualizar tanto el tipo como la cantidad de fluidos que se administran en las fases inicial y de mantenimiento en el tratamiento de la sepsis y el <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fluid resuscitation is a crucial part of the treatment of hypotension and shock of any etiology&#46; Particularly in septic shock&#44; it is an essential element of the initial care bundle&#46; Like all treatments in sepsis&#44; it is also subject to multiple controversies&#58; what type of fluid&#44; how much&#44; how long to administer it&#44; potential risks&#44; toxicity&#63; The main guideline&#44; the Surviving Sepsis Campaign&#44; continues to indicate crystalloids as the main fluid in resuscitation&#46; But the possibility of crystalloids balanced on 0&#46;9&#37; saline or combined use with albumin in the resuscitation of the septic patient is still under debate&#46; This is probably another point where we should always consider individualizing both the type and amount of fluids to be administered in both the initial and maintenance phases of the management of sepsis and septic shock&#46;</p></span>"
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          "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Resumen del papel de la fluidoterapia en las diferentes fases de la resucitaci&#243;n en la sepsis&#46;</p>"
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      1 => array:8 [
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        "etiqueta" => "Tabla 1"
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        "tabla" => array:1 [
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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">Variables&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">Fase 1&#58; reanimaci&#243;n&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">Fase 2&#58; optimizaci&#243;n&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">Fase 3&#58; estabilizaci&#243;n&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">Fase 4&#58; desescaladaevacuaci&#243;n&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">Tiempo de presentaci&#243;n&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">Minutos&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">Horas&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">Horas-d&#237;as&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">D&#237;as-semanas&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">Forma de presentaci&#243;n&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">Sepsis o <span class="elsevierStyleItalic">shock</span> s&#233;ptico&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">Inestabilidad hemodin&#225;mica o <span class="elsevierStyleItalic">shock</span>&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">Ausencia de <span class="elsevierStyleItalic">shock</span>&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">Recuperaci&#243;n del <span class="elsevierStyleItalic">shock</span> o persistencia de permeabilidad capilar aumentada&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">Mecanismode inestabilidad&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">Primera se&#241;al&#58; inflamaci&#243;n&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">Segunda se&#241;al&#58; isquemia-reperfusi&#243;n&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">Segunda se&#241;al&#58;isquemia-reperfusi&#243;n&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">Tercera se&#241;al&#58; permeabilidad capilar aumentada&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">C&#243;mo se aplica la terapiacon fluidos&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">Bolo de 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#46; Monitorizaci&#243;n de respuesta a la fluidoterapia basada en par&#225;metros dependientesde la precarga&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">Bolo basado en par&#225;metros dependientes de la precarga&#44; preferentemente din&#225;micos&#44; de respuesta a los fluidos&#46; Tb con lactato y SatvO2&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">Solamente para mantenimientoy&#47;o como reposici&#243;n de otras p&#233;rdidas&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">Reversi&#243;n del balance h&#237;drico positivo&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">Resultado&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">Supervivencia inmediata del paciente&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">Rescate o asistencia de &#243;rganos&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">Rescate o asistencia de &#243;rganos&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">Recuperaci&#243;n de la disfunci&#243;n org&#225;nica&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">Riesgos&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">Reanimaci&#243;n insuficiente&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">Reanimaci&#243;n insuficienteo sobrecarga h&#237;drica &#40;edema pulmonar&#44; s&#237;ndrome compartimental celular&#44; hipertensi&#243;n abdominal&#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">Sobrecarga h&#237;drica &#40;edema pulmonar&#44; s&#237;ndrome compartimental celular&#44; hipertensi&#243;n abdominal&#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">Eliminaci&#243;n excesiva de l&#237;quidosy posibilidad de hipotensi&#243;ny&#47;o hipoperfusi&#243;ntisular&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">Balance h&#237;drico&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">Positivo&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">Neutral&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">Neutral o negativo&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">Negativo&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">Objetivo principalModificada de las r&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">Administraci&#243;n de fluidosguiada por objetivoseferencias 1&#44; 4&#44; 6&#44; 7 y 8&#46;&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">Basada en asistencia de &#243;rganos y mantenimiento de la perfusi&#243;n tisular&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">Tratamiento de fluidos conservador y tard&#237;o&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">Eliminaci&#243;n tard&#237;a de l&#237;quidos basada en objetivos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AV&#58; auriculoventricular&#59; CP450&#58; citpcromo 450&#59; FE&#58; fracci&#243;n de eyecci&#243;n&#59; GC&#58; gasto cardiaco&#59; GI&#58; gastrointestinal&#59; NAVM&#58; neu- mon&#237;a asociada con VM&#59; POAP&#58; presi&#243;n de oclusi&#243;n de la arteria pulmonar&#59; PVC&#58; presi&#243;n venosa central&#59; VI&#58; ventr&#237;culo izquierdo&#59; VM&#58; ventilaci&#243;n mec&#225;nica&#59; F&#58; aumento&#59; f&#58; reducci&#243;n&#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">Cardiovascular&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">Pulmonar&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">Abdominal&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">Renal&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">SNC&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">Piel-muslo&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">Edema pulmonar&#44;&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">Edema pulmonar&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">Edema GI&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">Edema renal&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">Edema cerebral&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">Edema tisular&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">disfunci&#243;n del VI&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">Hipoxemia&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">Ascitis&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">f Filtrado&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">Alteraci&#243;n&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">f Perfusi&#243;n&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">f Retorno venoso&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">Derrame pleural&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">Hipertensi&#243;n abdominal&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">glomerular&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">de la conciencia&#44;&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">perif&#233;rica&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">f FE&#44; GC&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">Alteraci&#243;n de la&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">F Presi&#243;n&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">F Presi&#243;n venosa&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">confusi&#243;n&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">F &#218;lceras&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">F PVC&#44; POAP&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">distensibilidad&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">intraabdominal&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">renal&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">Delirio&#44; coma&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">de presi&#243;n&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">Depresi&#243;n&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">pulmonar&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">F Permeabilidad&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">F Presi&#243;n intersticial&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">f Presi&#243;n de&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">f Masa&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">mioc&#225;rdica&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">f Volumen&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">intestinal&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">Insuficiencia renal&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">perfusi&#243;n cerebral&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">muscular&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">Dilataci&#243;n del VI&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">pulmonar&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">F Traslocaci&#243;n&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">agudo&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">F Presi&#243;n&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">f Movilidad&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">Disfunci&#243;n&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">f Gradiente&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">bacteriana&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">F Creatinina&#44; uremia&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">intracraneal&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">Peor&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">diast&#243;lica&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">alveoloarterial&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">S&#237;ndrome&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">F Resistencia&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">Hipertensi&#243;n&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">evoluci&#243;n&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">Edema miorc&#225;rdico&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">F Trabajo&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">compartimental&#58;&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">vascular renal&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">intracraneal&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">de las heridas&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">Derrame&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">respiratorio&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">GI&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">Retenci&#243;n de agua&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">S&#237;ndrome&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">F Infecci&#243;n&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">peric&#225;rdico&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">Dificultad&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">Hep&#225;tico&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">y solutos&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">compartimental&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">de heridas&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">Alteraci&#243;n de&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">destete VM&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">Pared abdominal&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">S&#237;ndrome&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">intracraneal&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="" 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">la conducci&#243;n AV&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">F NAVM&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">f Perfusi&#243;n espl&#225;cnica&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">compartimental&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">F Presi&#243;n intraocular&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="" 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">Arritmias&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="" 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">f pH intrag&#225;strico&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">renal&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">S&#237;ndrome&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" 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">Colestasis&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="" 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">compartimental&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" 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">f Actividad de CP450&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="" 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">ocular&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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" 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">Intolerancia digestiva&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="" 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="" 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="" 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>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3456032.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diferentes complicaciones de la sobrecarga h&#237;drica</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de soluciones</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Soluciones balanceadas</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Soluciones no balanceadas</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">Ringer&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">Ringer&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">Plasmalyte&#174; &#40;Baxter&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">Isolyte S&#174; &#40;B&#46; Braun&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">NaCl&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">NaCl 0&#44;18&#37;&#47;&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">NaCl 0&#44;45&#37;&#47;&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">Glucosa&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">NaHCO3&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">NaHCO3&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">NaHCO3&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">Par&#225;metro&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">Plasma&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">lactato&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">acetato&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">International&#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">Medical Inc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;9&#37;&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">glucosa 4&#37;&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">glucosa 4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37;&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">Hartmann&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&#44;26&#37;&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&#44;4&#37;&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">8&#44;4&#37;&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">Na<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#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
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                  \t\t\t\t">23<span class="elsevierStyleHsp" style=""></span>mmol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Glucosa &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PH&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">295&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Gelofusine&#174;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Geloplasma&#174;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Hetastarch&#174; 6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">P&#225;rametro&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Plasma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Alb&#250;mina 5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Alb&#250;mina 20&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Haemacel&#174;&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">&#40;B&#46; Braun Medical Inc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#40;Fresenius Kabi&#41;&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">Dextran&#174; 40&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">Dextran&#174; 70 en NaCl&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">HES130&#47;0&#46;4 &#40;B&#46; Braun Medical Inc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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">Donante&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">Donante&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">Gelatina&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">Gelatina&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">Gelatina&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><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">Fuente&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">humano&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">humano&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">bovina&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">bovina&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">bovina&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">Sucrosa&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">Sucrosa&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">Almid&#243;n de ma&#237;z&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">Na<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#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">135-145&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">148&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">130&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">145&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">154&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">150&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">154&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">154&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">154&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">K<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5-4&#44;5&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="" 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="" 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">5&#44;1&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="" 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">5&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="" 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="" 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="" 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">Cl<span class="elsevierStyleSup">&#8211;</span>&#40;mmol&#47;l&#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">95-105&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">128&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">77&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">120&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">120&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">100&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">154&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">154&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">154&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">Ca2<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#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">2&#44;2-2&#44;6&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="" 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="" 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">6&#44;25&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="" 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="" valign="\n
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                  \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="" 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="" 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="" 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">Mg2<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;8-1&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">1&#44;5&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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">HCO3<span class="elsevierStyleSup">&#8211;</span>&#40;mmol&#47;l&#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">24-32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;como&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">lactato&#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="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">Lactato &#40;mmol&#47;l&#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">1&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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">Glucosa &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5-6&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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">252&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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">Acetato&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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">Malato&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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="" valign="\n
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                  \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="" valign="\n
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                  \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">Octanotato&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="" valign="\n
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                  \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">8&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">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \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">PH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;35-7&#44;45&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">6&#44;4-7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#44;7-7&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;0-7&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#44;5-7&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;0-5&#44;5&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">PM &#40;kD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                0 => array:1 [
                  "referenciaCompleta" => "Borges M&#44; Candel FJ&#44; Ferrer R&#44; et al&#46;&#44; Documento de Consenso Nacional&#58; C&#243;digo Sepsis&#46; IMC&#59; 2015&#46; Disponible en&#58; www&#46;&#44; seguridaddelpaciente&#46;es&#46;"
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            1 => array:3 [
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                          "etal" => true
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Article information
ISSN: 21735727
Original language: Spanish
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