Scientific Letter
Shock following subcutaneous injections of polymethylmethacrylate
Shock después de inyecciones subcutáneas de polimetilmetacrilato
M. Boattini
, A.R. Francisco, R. Cavaco, J. Rodrigues, L. Bento
Autor para correspondencia
Unidade de Urgência Médica, Hospital São José, Centro Hospitalar Lisboa Central, Portugal
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Rodríguez-Serrano, A. Leal-Micharet, O. Rajas, M. Chicot-Llano, J.A. García-Romero de Tejada" "autores" => array:5 [ 0 => array:2 [ "nombre" => "D.A." "apellidos" => "Rodríguez-Serrano" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Leal-Micharet" ] 2 => array:2 [ "nombre" => "O." "apellidos" => "Rajas" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Chicot-Llano" ] 4 => array:2 [ "nombre" => "J.A." "apellidos" => "García-Romero de Tejada" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114001739?idApp=WMIE" "url" => "/02105691/0000003900000004/v2_201504190201/S0210569114001739/v2_201504190201/es/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Shock following subcutaneous injections of polymethylmethacrylate" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "256" "paginaFinal" => "257" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Boattini, A.R. Francisco, R. Cavaco, J. Rodrigues, L. Bento" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Boattini" "email" => array:1 [ 0 => "matteoboattini@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A.R." "apellidos" => "Francisco" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Cavaco" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Rodrigues" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Bento" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidade de Urgência Médica, Hospital São José, Centro Hospitalar Lisboa Central, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Shock después de inyecciones subcutáneas de polimetilmetacrilato" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1541 "Ancho" => 995 "Tamanyo" => 162111 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">1A. Chest X-ray showing bilateral lung infiltrates. 1B-E. Chest CT angiographyshowing bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 35-year-old transsexual (male to female) went to emergency with 24<span class="elsevierStyleHsp" style=""></span>h of mild fever, cough and dyspnoea. Four days before he had been submitted to multiple gluteus subcutaneous injections of polymethylmethacrylate (PMMA) microspheres. Patient had a past medical history of uncontrolled hypertension.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On admission patient had Glasgow Coma Scale Score of 15, tachypnea and tachycardia, with central cyanosis and was sweating. No fever. Blood pressure was 100/70<span class="elsevierStyleHsp" style=""></span>mmHg and respiratory rate 40/min. Arterial blood gas analysis under 15<span class="elsevierStyleHsp" style=""></span>l/min oxygen therapy by a non-rebreathing mask with reservoir showed global respiratory insufficiency and sever acidemia (pH 7.22, pO<span class="elsevierStyleInf">2</span> 31<span class="elsevierStyleHsp" style=""></span>mmHg, pCO<span class="elsevierStyleInf">2</span> 49<span class="elsevierStyleHsp" style=""></span>mmHg, HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">−</span> 17.6<span class="elsevierStyleHsp" style=""></span>mEq/L, SatO<span class="elsevierStyleInf">2</span> 55%, lactate 6.17<span class="elsevierStyleHsp" style=""></span>mmol/L). Heart auscultation revealed audible S1 and S2 and chest auscultation revealed bilateral rales. The remaining physical examination just was unremarkable with exception of mild redness, warmth and swelling of the gluteus. No fluctuation was detected and no indication for surgical approach was considered. Chest X-ray showed bilateral lung infiltrates (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). At this time was intubated and mechanically ventilated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On intensive care unit (ICU) admission presented with hypotension, tachycardia, oligoanuric renal failure, mixed acidemia and pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio of 40. Biochemistry showed: normocytic normochromic anaemia, high white blood cells count, coagulation times prolonged, acute renal lesion with hyperkalemia, hyperbilirubinemia 1.49<span class="elsevierStyleHsp" style=""></span>mg/dL [0.3–1.2], conjugated bilirubin 0.79 [0–0.2], hepatic cytolysis high lactate dehydrogenase and C-reactive protein. Patient was started on empirical antibiotic therapy with meropenem due to the inflammatory signs in gluteus.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Electrocardiogram showed sinus tachycardia with S1Q3T3 pattern. Computed tomography angiography ruled out pulmonary embolism and disclosed bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B–E). Transthoracic echocardiogram revealed normal left ventricular systolic function with no contractility alterations, valve dysfunctions or pericardial effusion.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pulse contour cardiac output (PiCCO) catheter was placed and haemodynamic monitoring showed low cardiac index (CI), low intrathoracic blood volume index (ITBVI), low central venous oxygen saturation (cvSatO<span class="elsevierStyleInf">2</span>), high venous-to-arterial CO<span class="elsevierStyleInf">2</span> gap (pCO<span class="elsevierStyleInf">2</span> gap), high extravascular lung water index (EVLWI) and normal systemic vascular resistance (SVR) on norepinephrine 0.55<span class="elsevierStyleHsp" style=""></span>μg/kg/min. Distributive shock (DS) with vasoplegia, functional hypovolemia and pulmonary oedema complicated with multiple organ dysfunction syndrome (MODS) was diagnosed (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Patient was started on vasopressors and continuous renal replacement technique. He developed severe (pO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>100)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> acute respiratory distress syndrome (ARDS) with need of prone position and curarization.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Serologies for HIV, HBV, HCV, EBV, CMV, <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> and respiratory virus were negative. Tracheobronchial aspirate, uroculture and pneumococcal and <span class="elsevierStyleItalic">Legionella</span> urinary antigen tests were negative. Three sets of blood culture specimens exhibited no growth. Meropenem stopped on the 5th day of therapy.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patient remained apyretic, inflammatory markers decreased and gluteus inflammatory signs improved rapidly. Patient remained under continuous renal replacement technique for 5 days with gradual recovery of renal function and vasopressor support was stopped on 2nd day. He was mechanically ventilated for 15 days and was extubated on 16th day.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest CT with significant reduction of pulmonary infiltrates. Laboratory tests evidenced recovery of hepatic function with correction of the coagulation disorder.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patient was transferred to intermediate care on 17th day and then to the general ward, requiring only physical rehabilitation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Shock is a high mortality acute syndrome characterized by cellular dysoxia, and can lead if not quickly and appropriately managed to organ failure and death. It is classically rated has hypovolemic, cardiogenic, obstructive or distributive. The first three are associated with low CI while distributive shock is associated with normal or supranormal levels of CI,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> impaired distribution of microvascular blood flow and metabolic distress. DS occurs mainly during systemic inflammatory response syndrome (SIRS) which can be due to infectious or non-infectious causes. The most common aetiology of DS is septic shock. Non-infectious causes include burns, pancreatitis, toxic shock syndrome, anaphylaxis and drugs or toxins. PMMA is a no biodegradable injectable filling used for a variety of conditions such as percutaneous vertebroplasty and cosmetic soft tissue filling. PMMA subcutaneous injections local complications are nodules, filler migration and granulomas. Mostly described following percutaneous vertebroplasty systemic complications include pulmonary embolism,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> pulmonary embolism with ARDS,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> ventricular perforation,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> intracardiac embolism,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> aortic embolism,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> renal embolism<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and deep vein thrombosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Our patient never had fever. Inflammatory markers decreased rapidly and did not relapse after meropenem has been stopped. No pathogenic organisms were isolated. We assisted to a favourable evolution even in absence of antibiotherapy. These facts make infectious aetiology less probable. Most probable hypothesis due to patient's history of PMMA gluteus subcutaneous injections four days before, absence of positive culture results and favourable evolution just with organ support therapy is SIRS triggered by chemical insult induced by PMMA. To the best of our knowledge, this is the first case reported in literature of shock and MODS secondary to subcutaneous injection of PMMA.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">All the authors have reported no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1541 "Ancho" => 995 "Tamanyo" => 162111 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">1A. Chest X-ray showing bilateral lung infiltrates. 1B-E. Chest CT angiographyshowing bilateral consolidations with air-bronchograms and ground-glass-appearing opacities suggestive of alveolar damage.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BP, blood pressure; HR, heart rate; CVP, central venous pressure; CI, cardiac index; SVR, systemic vascular resistance; EVLWI, extravascular lung water index; ITBVI, intrathoracic blood volume index; paO<span class="elsevierStyleInf">2</span>, arterial oxygen partial pressure; aSatO<span class="elsevierStyleInf">2</span>, arterial oxygen saturation; pvO<span class="elsevierStyleInf">2</span>, venous oxygen partial pressure; cvSatO<span class="elsevierStyleInf">2</span>, central venous oxygen saturation; pCO<span class="elsevierStyleInf">2</span> gap, venous-to-arterial CO<span class="elsevierStyleInf">2</span> gap; FiO<span class="elsevierStyleInf">2</span>, fraction of inspired oxygen; PEEP, positive end-expiratory pressure; Hb, haemoglobin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">On admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 36<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 72<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After 96<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Norepinephrine, μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">151/66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">139/66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">145/80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">148/89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90/54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">179/103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">121/70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">HR, bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">CVP, cm H<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">CI (2.8–3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SVR (770–1500) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1169 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">731 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1034 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1115 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">630 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1720 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">725 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">EVLWI (3–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ITBVI (850–1000) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">486 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">594 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">619 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">676 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">714 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">766 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1043 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">paO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">122 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">116 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">162.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">111 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">aSatO<span class="elsevierStyleInf">2</span>% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">99.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pvO<span class="elsevierStyleInf">2</span>, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">cvSatO<span class="elsevierStyleInf">2</span>% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pCO<span class="elsevierStyleInf">2</span> gap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FiO<span class="elsevierStyleInf">2</span> (21–100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PEEP, cm H<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lactate, mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hb, g/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab755943.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PiCCO haemodynamic monitoring.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ 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Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jvs.2012.02.039" "Revista" => array:6 [ "tituloSerie" => "J Vasc Surg" "fecha" => "2012" "volumen" => "56" "paginaInicial" => "1119" "paginaFinal" => "1123" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22572011" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000003900000004/v2_201504190201/S0210569114001740/v2_201504190201/en/main.assets" "Apartado" => array:4 [ "identificador" => "53" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000003900000004/v2_201504190201/S0210569114001740/v2_201504190201/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114001740?idApp=WMIE" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 10 | 17 |
| 2024 Octubre | 55 | 60 | 115 |
| 2024 Septiembre | 55 | 43 | 98 |
| 2024 Agosto | 66 | 61 | 127 |
| 2024 Julio | 58 | 40 | 98 |
| 2024 Junio | 58 | 44 | 102 |
| 2024 Mayo | 43 | 29 | 72 |
| 2024 Abril | 62 | 43 | 105 |
| 2024 Marzo | 64 | 38 | 102 |
| 2024 Febrero | 38 | 44 | 82 |
| 2024 Enero | 46 | 28 | 74 |
| 2023 Diciembre | 36 | 39 | 75 |
| 2023 Noviembre | 46 | 35 | 81 |
| 2023 Octubre | 56 | 36 | 92 |
| 2023 Septiembre | 54 | 42 | 96 |
| 2023 Agosto | 37 | 26 | 63 |
| 2023 Julio | 43 | 32 | 75 |
| 2023 Junio | 48 | 22 | 70 |
| 2023 Mayo | 53 | 37 | 90 |
| 2023 Abril | 40 | 25 | 65 |
| 2023 Marzo | 50 | 35 | 85 |
| 2023 Febrero | 56 | 32 | 88 |
| 2023 Enero | 39 | 21 | 60 |
| 2022 Diciembre | 64 | 31 | 95 |
| 2022 Noviembre | 60 | 30 | 90 |
| 2022 Octubre | 53 | 25 | 78 |
| 2022 Septiembre | 68 | 36 | 104 |
| 2022 Agosto | 82 | 52 | 134 |
| 2022 Julio | 54 | 21 | 75 |
| 2022 Junio | 91 | 38 | 129 |
| 2022 Mayo | 49 | 41 | 90 |
| 2022 Abril | 47 | 29 | 76 |
| 2022 Marzo | 39 | 44 | 83 |
| 2022 Febrero | 38 | 29 | 67 |
| 2022 Enero | 41 | 36 | 77 |
| 2021 Diciembre | 36 | 54 | 90 |
| 2021 Noviembre | 46 | 44 | 90 |
| 2021 Octubre | 44 | 69 | 113 |
| 2021 Septiembre | 22 | 39 | 61 |
| 2021 Agosto | 23 | 46 | 69 |
| 2021 Julio | 26 | 42 | 68 |
| 2021 Junio | 20 | 29 | 49 |
| 2021 Mayo | 45 | 50 | 95 |
| 2021 Abril | 103 | 97 | 200 |
| 2021 Marzo | 66 | 25 | 91 |
| 2021 Febrero | 66 | 30 | 96 |
| 2021 Enero | 57 | 36 | 93 |
| 2020 Diciembre | 31 | 14 | 45 |
| 2020 Noviembre | 35 | 27 | 62 |
| 2020 Octubre | 49 | 31 | 80 |
| 2020 Septiembre | 39 | 18 | 57 |
| 2020 Agosto | 27 | 21 | 48 |
| 2020 Julio | 32 | 23 | 55 |
| 2020 Junio | 26 | 13 | 39 |
| 2020 Mayo | 35 | 13 | 48 |
| 2020 Abril | 31 | 10 | 41 |
| 2020 Marzo | 20 | 12 | 32 |
| 2020 Febrero | 39 | 61 | 100 |
| 2020 Enero | 35 | 26 | 61 |
| 2019 Diciembre | 41 | 21 | 62 |
| 2019 Noviembre | 36 | 39 | 75 |
| 2019 Octubre | 27 | 13 | 40 |
| 2019 Septiembre | 27 | 22 | 49 |
| 2019 Agosto | 40 | 22 | 62 |
| 2019 Julio | 38 | 26 | 64 |
| 2019 Junio | 26 | 13 | 39 |
| 2019 Mayo | 46 | 34 | 80 |
| 2019 Abril | 26 | 24 | 50 |
| 2019 Marzo | 13 | 26 | 39 |
| 2019 Febrero | 26 | 25 | 51 |
| 2019 Enero | 30 | 32 | 62 |
| 2018 Diciembre | 33 | 35 | 68 |
| 2018 Noviembre | 82 | 100 | 182 |
| 2018 Octubre | 43 | 25 | 68 |
| 2018 Septiembre | 33 | 14 | 47 |
| 2018 Agosto | 27 | 18 | 45 |
| 2018 Julio | 22 | 14 | 36 |
| 2018 Junio | 41 | 13 | 54 |
| 2018 Mayo | 18 | 8 | 26 |
| 2018 Abril | 34 | 9 | 43 |
| 2018 Marzo | 22 | 10 | 32 |
| 2018 Febrero | 18 | 14 | 32 |
| 2018 Enero | 59 | 21 | 80 |
| 2017 Diciembre | 36 | 10 | 46 |
| 2017 Noviembre | 33 | 9 | 42 |
| 2017 Octubre | 24 | 7 | 31 |
| 2017 Septiembre | 31 | 7 | 38 |
| 2017 Agosto | 22 | 7 | 29 |
| 2017 Julio | 27 | 11 | 38 |
| 2017 Junio | 32 | 15 | 47 |
| 2017 Mayo | 25 | 9 | 34 |
| 2017 Abril | 29 | 13 | 42 |
| 2017 Marzo | 24 | 7 | 31 |
| 2017 Febrero | 19 | 8 | 27 |
| 2017 Enero | 16 | 7 | 23 |
| 2016 Diciembre | 34 | 12 | 46 |
| 2016 Noviembre | 47 | 16 | 63 |
| 2016 Octubre | 41 | 16 | 57 |
| 2016 Septiembre | 34 | 6 | 40 |
| 2016 Agosto | 22 | 1 | 23 |
| 2016 Julio | 13 | 9 | 22 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Septiembre | 1 | 13 | 14 |
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