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hemos querido analizar la asociaci&#243;n de MP con la supervivencia a corto plazo &#40;28 d&#237;as&#41; de los enfermos ingresados en una unidad de cuidados intensivos &#40;UCI&#41; por SARS-CoV-2&#46; Para ello&#44; utilizando los datos de nuestro registro de enfermos COVID desarrollado con la aceptaci&#243;n del Comit&#233; de &#201;tica de Investigaci&#243;n local y la concesi&#243;n del consentimiento de los pacientes&#47;representantes &#40;escrito y&#47;o telef&#243;nico&#41;&#44; realizamos un an&#225;lisis retrospectivo de todos los casos ingresados en nuestra UCI entre marzo de 2020 y julio de 2021&#44; y ventilados mec&#225;nicamente por SDRA debido a infecci&#243;n por SARS-CoV-2&#46; El muestreo fue consecutivo y la muestra se dividi&#243; en 2 cohortes atendiendo al valor de MP dentro de las primeras 24<span class="elsevierStyleHsp" style=""></span>h despu&#233;s de la intubaci&#243;n endotraqueal&#58; MP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min y MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min&#46; 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estado&#58; fallecimiento en UCI a los 28 d&#237;as&#59; se utilizan como covariables&#58; la edad&#44; la PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> previa a la intubaci&#243;n y el valor de la compliancia pulmonar&#41;&#46; Para todos los an&#225;lisis&#44; la significaci&#243;n estad&#237;stica se estableci&#243; en p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">De los 565 pacientes que ingresaron en la UCI-COVID en el periodo de estudio&#44; se analizaron finalmente aquellos con infecci&#243;n por SARS-CoV-2 probada&#44; que recibieron VM controlada y se les midieron las variables necesarias para el c&#225;lculo del MP en posici&#243;n supina&#44; despu&#233;s de sedaci&#243;n y par&#225;lisis muscular&#44; dentro de las 24<span class="elsevierStyleHsp" style=""></span>h de iniciada la VM&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las principales diferencias entre los 79 pacientes analizados&#44; categorizados seg&#250;n su MP&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Las medianas de los tiempos de supervivencia de ambas cohortes fueron de 16 d&#237;as &#40;p25-75&#58; 3-27&#41; para la cohorte de enfermos con MP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min&#44; frente a 11 d&#237;as &#40;p25-75&#58; 2-18&#41; en la cohorte de enfermos con MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46; El grupo de pacientes con un valor de MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min se asoci&#243; de manera significativa con una mayor probabilidad de fallecer a los 28 d&#237;as &#40;OR&#58; 2&#44;91&#59; IC95&#37; 1&#44;04-8&#44;09&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de regresi&#243;n de Cox&#44; valores<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min de MP en las primeras 24<span class="elsevierStyleHsp" style=""></span>h de inicio de la VM se asociaron de manera independiente con la mortalidad &#40;HR&#58; 2&#44;70&#59; IC95&#37; 1&#44;31-6&#44;47&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nuestros resultados est&#225;n en consonancia con estudios recientes que demostraron el efecto adverso de la exposici&#243;n a valores de MP m&#225;s elevados en pacientes cr&#237;ticos que recibieron VM por insuficiencia respiratoria por infecci&#243;n por SARS-CoV-2 o un motivo diferente<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Estos hallazgos pueden calificarse como esperables si entendemos que la MP es una variable que incluye todos los componentes que cl&#225;sicamente se han relacionado con la producci&#243;n de VILI&#58; presiones&#44; volumen&#44; flujo&#44; frecuencia respiratoria&#46; Adem&#225;s&#44; es importante recordar que la teor&#237;a reol&#243;gica prev&#233; que densidades de energ&#237;a superiores a la resiliencia de un material son las que ser&#237;an responsables de la producci&#243;n de VILI&#46; Esta densidad de energ&#237;a &#40;energ&#237;a por unidad de superficie&#41; nos invita&#44; en la pr&#225;ctica cl&#237;nica&#44; a valorar en todo momento la relaci&#243;n entre la MP y el &#225;rea alveolar expuesta a la energ&#237;a suministrada<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Por otro lado&#44; la aparici&#243;n de alteraciones en el pulm&#243;n <span class="elsevierStyleItalic">&#40;stress raisers&#41;</span> que podr&#237;an desencadenar finalmente VILI&#44; causadas por la aplicaci&#243;n de MP&#44; parece un fen&#243;meno con efecto umbral&#46; En animales de experimentaci&#243;n &#40;m&#243;dulo de Young o elastancia pulmonar espec&#237;fica<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> 5&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; se ha establecido en 12<span class="elsevierStyleHsp" style=""></span>J&#47;min este umbral de potencia energ&#233;tica<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#46; En humanos<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> &#40;m&#243;dulo de Young 13&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41;&#44; estudios cl&#237;nicos recientes parecen indicar que niveles de MP superiores a los 18-20<span class="elsevierStyleHsp" style=""></span>J&#47;min se asocian a un aumento del riesgo de muerte en pacientes sometidos a VM<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Reconocer que la MP puede reflejar una conjunci&#243;n de par&#225;metros que pueden predisponer a VILI es un paso importante hacia la optimizaci&#243;n de la VM en pacientes cr&#237;ticos&#46;</p></span>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">DE&#58; desviaci&#243;n est&#225;ndar&#59; DM&#58; diabetes mellitus&#59; HFNO&#58; ox&#237;geno nasal de alto flujo&#59; HTA&#58; hipertensi&#243;n arterial&#59; iNO&#58; &#243;xido n&#237;trico inhalado&#59; MP&#58; potencia mec&#225;nica&#59; SOFA&#58; <span class="elsevierStyleItalic">Sequential Organ Failure Assessment score&#59;</span> PEEP&#58; presi&#243;n positiva al final de la espiraci&#243;n&#59; TRR&#58; t&#233;cnicas de reemplazo renal&#59; UCI&#58; Unidad de Cuidados Intensivos&#59; VM&#58; ventilaci&#243;n mec&#225;nica&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pacientes con MP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;minn<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">63 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">32 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>HTA&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">20 &#40;49&#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
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                  \t\t\t\t">23 &#40;71&#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
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                  \t\t\t\t">0&#44;75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;10&#41;&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">10 &#40;26&#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">11 &#40;29&#41;&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</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&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">18 &#40;44&#41;&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">16 &#40;42&#41;&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">0&#44;23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fumador&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">16 &#40;39&#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">12 &#40;31&#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;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">SOFA score&#44; media &#40;DE&#41;</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">3 &#40;3&#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">4 &#40;3&#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;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;FiO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">ingreso en UCI&#44; media &#40;DE&#41;</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">127 &#40;40&#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">131 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">PaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;FiO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">previo VM&#44; media &#40;DE&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">PaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;FiO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">170 previo VM&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Datos de laboratorio&#44; media &#40;DE&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatina cinasa&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">181 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>D&#237;mero D &#40;ng&#47;mL&#41;&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;052 &#40;400&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento empleado durante estancia en UCI&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tratamiento combinado inmunomodulador tocilizumab-corticoide&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dec&#250;bito prono&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Empleo de HFNO al ingreso en UCI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necesidad de vasopresores&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Empleo de terapia con iNO&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necesidad de TRR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;5&#41;&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"><span class="elsevierStyleItalic">Terapias antivirales&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Plasma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;82&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Remdesivir&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Principales par&#225;metros ventilatorios &#40;primer d&#237;a de VM&#41;&#44; media &#40;DE&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Volumen tidal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">465 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">480 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia respiratoria inicial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PEEP &#40;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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CARTA CIENTÍFICA
Poder mecánico mayor de 17 julios/min en pacientes con insuficiencia respiratoria secundaria a infección por SARS-CoV-2
Mechanical power greater than 17 joules/min in patients with respiratory failure secondary to SARS-CoV-2 infection
A. González-Castro
Autor para correspondencia
e409@humv.es

Autor para correspondencia.
, E. Cuenca Fito, A. Fernandez-Rodriguez, P. Escudero Acha, J.C. Rodríguez Borregán, Y. Peñasco
Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
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hemos querido analizar la asociaci&#243;n de MP con la supervivencia a corto plazo &#40;28 d&#237;as&#41; de los enfermos ingresados en una unidad de cuidados intensivos &#40;UCI&#41; por SARS-CoV-2&#46; Para ello&#44; utilizando los datos de nuestro registro de enfermos COVID desarrollado con la aceptaci&#243;n del Comit&#233; de &#201;tica de Investigaci&#243;n local y la concesi&#243;n del consentimiento de los pacientes&#47;representantes &#40;escrito y&#47;o telef&#243;nico&#41;&#44; realizamos un an&#225;lisis retrospectivo de todos los casos ingresados en nuestra UCI entre marzo de 2020 y julio de 2021&#44; y ventilados mec&#225;nicamente por SDRA debido a infecci&#243;n por SARS-CoV-2&#46; El muestreo fue consecutivo y la muestra se dividi&#243; en 2 cohortes atendiendo al valor de MP dentro de las primeras 24<span class="elsevierStyleHsp" style=""></span>h despu&#233;s de la intubaci&#243;n endotraqueal&#58; MP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min y MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min&#46; 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estado&#58; fallecimiento en UCI a los 28 d&#237;as&#59; se utilizan como covariables&#58; la edad&#44; la PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> previa a la intubaci&#243;n y el valor de la compliancia pulmonar&#41;&#46; Para todos los an&#225;lisis&#44; la significaci&#243;n estad&#237;stica se estableci&#243; en p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">De los 565 pacientes que ingresaron en la UCI-COVID en el periodo de estudio&#44; se analizaron finalmente aquellos con infecci&#243;n por SARS-CoV-2 probada&#44; que recibieron VM controlada y se les midieron las variables necesarias para el c&#225;lculo del MP en posici&#243;n supina&#44; despu&#233;s de sedaci&#243;n y par&#225;lisis muscular&#44; dentro de las 24<span class="elsevierStyleHsp" style=""></span>h de iniciada la VM&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las principales diferencias entre los 79 pacientes analizados&#44; categorizados seg&#250;n su MP&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Las medianas de los tiempos de supervivencia de ambas cohortes fueron de 16 d&#237;as &#40;p25-75&#58; 3-27&#41; para la cohorte de enfermos con MP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min&#44; frente a 11 d&#237;as &#40;p25-75&#58; 2-18&#41; en la cohorte de enfermos con MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46; El grupo de pacientes con un valor de MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min se asoci&#243; de manera significativa con una mayor probabilidad de fallecer a los 28 d&#237;as &#40;OR&#58; 2&#44;91&#59; IC95&#37; 1&#44;04-8&#44;09&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de regresi&#243;n de Cox&#44; valores<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min de MP en las primeras 24<span class="elsevierStyleHsp" style=""></span>h de inicio de la VM se asociaron de manera independiente con la mortalidad &#40;HR&#58; 2&#44;70&#59; IC95&#37; 1&#44;31-6&#44;47&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nuestros resultados est&#225;n en consonancia con estudios recientes que demostraron el efecto adverso de la exposici&#243;n a valores de MP m&#225;s elevados en pacientes cr&#237;ticos que recibieron VM por insuficiencia respiratoria por infecci&#243;n por SARS-CoV-2 o un motivo diferente<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Estos hallazgos pueden calificarse como esperables si entendemos que la MP es una variable que incluye todos los componentes que cl&#225;sicamente se han relacionado con la producci&#243;n de VILI&#58; presiones&#44; volumen&#44; flujo&#44; frecuencia respiratoria&#46; Adem&#225;s&#44; es importante recordar que la teor&#237;a reol&#243;gica prev&#233; que densidades de energ&#237;a superiores a la resiliencia de un material son las que ser&#237;an responsables de la producci&#243;n de VILI&#46; Esta densidad de energ&#237;a &#40;energ&#237;a por unidad de superficie&#41; nos invita&#44; en la pr&#225;ctica cl&#237;nica&#44; a valorar en todo momento la relaci&#243;n entre la MP y el &#225;rea alveolar expuesta a la energ&#237;a suministrada<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Por otro lado&#44; la aparici&#243;n de alteraciones en el pulm&#243;n <span class="elsevierStyleItalic">&#40;stress raisers&#41;</span> que podr&#237;an desencadenar finalmente VILI&#44; causadas por la aplicaci&#243;n de MP&#44; parece un fen&#243;meno con efecto umbral&#46; En animales de experimentaci&#243;n &#40;m&#243;dulo de Young o elastancia pulmonar espec&#237;fica<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> 5&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;2<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; se ha establecido en 12<span class="elsevierStyleHsp" style=""></span>J&#47;min este umbral de potencia energ&#233;tica<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#46; En humanos<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> &#40;m&#243;dulo de Young 13&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;1<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41;&#44; estudios cl&#237;nicos recientes parecen indicar que niveles de MP superiores a los 18-20<span class="elsevierStyleHsp" style=""></span>J&#47;min se asocian a un aumento del riesgo de muerte en pacientes sometidos a VM<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Reconocer que la MP puede reflejar una conjunci&#243;n de par&#225;metros que pueden predisponer a VILI es un paso importante hacia la optimizaci&#243;n de la VM en pacientes cr&#237;ticos&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fumador&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  " align="left" valign="\n
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                  \t\t\t\t">12 &#40;31&#41;&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">0&#44;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">SOFA score&#44; media &#40;DE&#41;</span>&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">3 &#40;3&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;3&#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;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;FiO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">ingreso en UCI&#44; media &#40;DE&#41;</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">127 &#40;40&#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">131 &#40;39&#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;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;FiO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">previo VM&#44; media &#40;DE&#41;</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">99 &#40;39&#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">105 &#40;39&#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;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PaO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;FiO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">170 previo VM&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Datos de laboratorio&#44; media &#40;DE&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatina cinasa&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>D&#237;mero D &#40;ng&#47;mL&#41;&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;052 &#40;400&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento empleado durante estancia en UCI&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tratamiento combinado inmunomodulador tocilizumab-corticoide&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dec&#250;bito prono&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Empleo de HFNO al ingreso en UCI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necesidad de vasopresores&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Empleo de terapia con iNO&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necesidad de TRR&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"><span class="elsevierStyleItalic">Terapias antivirales&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Plasma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Remdesivir&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Principales par&#225;metros ventilatorios &#40;primer d&#237;a de VM&#41;&#44; media &#40;DE&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Volumen tidal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">465 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">480 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia respiratoria inicial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PEEP &#40;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ppico &#40;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">32 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Compliancia &#40;mL&#47;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">42 &#40;13&#41;&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">40 &#40;18&#41;&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">0&#44;22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia en UCI &#40;d&#237;as&#41;&#44;</span> media &#40;DE&#41;&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">11 &#40;9&#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">16 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
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        "descripcion" => array:1 [
          "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de las principales diferencias de las variables entre los enfermos que recibieron un MP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min y los que recibieron un MP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>J&#47;min</p>"
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ISSN: 02105691
Idioma original: Español
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