Pre-anaesthetic medication with intranasal dexmedetomidine and oral midazolam as an anxiolytic. A clinical trial

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En el grupo de dexmedetomidina se registraron cambios estadísticamente significativos en la FC, la PAM y la SatO2, sin repercusión clínica. FC: frecuencia cardiaca; PAM: presión arterial media; SatO2: saturación de oxígeno." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Linares Segovia, M.A. García Cuevas, I.L. Ramírez Casillas, J.F. Guerrero Romero, I. Botello Buenrostro, R. Monroy Torres, X.S. Ramírez Gómez" "autores" => array:7 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Linares Segovia" ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "García Cuevas" ] 2 => array:2 [ "nombre" => "I.L." "apellidos" => "Ramírez Casillas" ] 3 => array:2 [ "nombre" => "J.F." "apellidos" => "Guerrero Romero" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Botello Buenrostro" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Monroy Torres" ] 6 => array:2 [ "nombre" => "X.S." 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A clinical trial" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "226" "paginaFinal" => "231" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B. Linares Segovia, M.A. García Cuevas, I.L. Ramírez Casillas, J.F. Guerrero Romero, I. Botello Buenrostro, R. Monroy Torres, X.S. Ramírez Gómez" "autores" => array:7 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Linares Segovia" "email" => array:2 [ 0 => "blinares70@ugto.mx" 1 => "blinares70@yahoo.com.mx" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.A." "apellidos" => "García Cuevas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "I.L." 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"apellidos" => "Ramírez Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Medicina y Nutrición, División de Ciencias de la Salud, Campus León, Universidad de Guanajuato, León, Guanajuato, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Enseñanza e Investigación, Hospital Regional Salamanca de Petróleos Mexicanos, Salamanca, Guanajuato, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Medicación preanestésica con dexmedetomidina intranasal y midazolam oral como ansiolítico. Un ensayo clínico" ] ] "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" => 3788 "Ancho" => 1680 "Tamanyo" => 275861 ] ] "descripcion" => array:1 [ "en" => "Changes in haemodynamic variables following treatment. We found statistically significant differences in HR, MAP, and SpO2 in the dexmedetomidine group that had no clinical relevance. HR, heart rate; MAP, mean arterial pressure; SpO2, oxygen saturation." ] ] ] "textoCompleto" => "IntroductionIn a surgical procedure, the high anxiety levels that children experience during the preoperative period may be associated to negative medical, psychological, and social consequences. To reduce the distress of children and to facilitate the induction of anaesthesia, the child is given a sedative before going into the operating room.The main goals of premedication in children are to facilitate a smooth separation from the parents and ease the induction of anaesthesia. Other effects that can be achieved with the pharmacological preparation of the patient are: amnesia, anxiolysis, prevention of psychological stress, and a reduction in the total anaesthetic requirements. The groups of patients that benefit most from premedication are toddlers and preschoolers, in whom separation anxiety is paramount; and also adolescents, who are sensitive about their body image and loss of control, patients with previous unpleasant hospital experiences, and patients who are unable to communicate or cooperate.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Midazolam is the premedication most frequently used in children.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> It has been demonstrated that midazolam administered orally at 0.5mg/kg is efficacious in reducing anxiety and improving the conditions for induction of anaesthesia, but it has been associated with adverse effects such as agitation, paradoxical reaction, and negative postoperative behaviour changes.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> For this reason, other drugs and delivery routes are being explored. One of those drugs is dexmedetomidine.Dexmedetomidine is a highly specific α2-adrenergic receptor agonist with sedative, anxiolytic, and analgesic properties, and a considerable sympatholytic effect. Its bioavailability when administered via the buccal route is 81.8%.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In 1999 dexmedetomidine was approved in the United States by the Food and Drug Administration to be used in human patients as a short-term (<24h) sedative and analgesic in intensive care units.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In healthy volunteers, intravenous dexmedetomidine has an action onset of 15min; it can also have systemic effects when administered by the transdermal, buccal, or intramuscular routes, with the latter two routes having showed bioavailabilities of 82% and 104%, respectively.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>It has been shown that in adult patients, intranasal administration of 1–1.5μg/kg of dexmedetomidine produces sedation within 45–60min, and has its peak effect at 90–105min. This is accompanied by mild to moderate changes in heart rate and arterial blood pressure.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Recent studies in paediatric patients have shown that intranasal dexmedetomidine produces more sedation than oral midazolam.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> It has been used successfully in diagnostic radiology procedures, such as magnetic resonance imaging and computed tomography scans, and in invasive procedures, such as placement of venous lines in infants, bronchoscopy, laryngoscopy, cardiac catheterisation, and others.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> It has been used alone or in combination with other drugs to sedate paediatric patients that underwent different kinds of surgery.<a class="elsevierStyleCrossRefs" href="#bib0055">11–13</a> These studies did not report the effect of dexmedetomidine on anxiety, so the purpose of our study was to compare the efficacy of intranasal dexmedetomidine to oral midazolam in reducing preoperative anxiety in paediatric patients.Materials and methodsWe conducted a double-blind controlled clinical trial. We included children 2–12 years of age of both sexes. Using the Power and Sample Size software, we calculated that a sample of 75 patients per group (n=150 patients) was needed to detect a difference of at least 15% in the prevalence of anxiety among groups, with an alpha of 0.05, a beta of 0.20, and a power of 0.80.Patients were included by consecutive sampling of cases scheduled for elective surgery, ASA grade I, at the Hospital Regional Salamanca de Petróleos Mexicanos in Salamanca, Guanajuato, Mexico, between March 2009 and December 2011. We excluded patients with a history of allergy or hypersensibility to midazolam or dexmedetomidine, congenital heart disease or heart arrhythmias, mental retardation, or currently being treated with psychoactive medications.The parents or guardian of the minors were informed of the purpose of the study and its procedures, and were asked to sign a consent form for participation.The patients for whom we obtained consent to participate were assigned to one of 2 groups by means of a random number table with a secret sequence. Patients in the control group (midazolam) received oral midazolam, 0.5mg/kg, as preanaesthetic medication along with an intranasal placebo (0.9N isotonic saline solution). The study group (dexmedetomidine) received intranasal dexmedetomidine, 1μg/kg, as preanaesthetic medication, and an oral placebo (5% glucose solution). The drugs were administered 60min prior to induction of anaesthesia. Intranasal dexmedetomidine was prepared from the parenteral preparation (100μg/mL) and administered undiluted. The preparation and administration of medications were performed by a resident doctor in anaesthesiology that did not participate in clinical assessment, and the participating anaesthesiologists were blinded to the treatment. During surgery, all participants were monitored with class II (noninvasive) devices with electrocardiography, pulse oxymetry for monitoring oxygen saturation, and monitoring of blood pressure until they were discharged from the postanaesthetic care unit.We assessed anxiety using the modified Yale scale,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> which determines the anxiety of the child based on a total of 22 items divided into 5 categories, each of which can contribute up to 4 or 6 points to the final score: activity (4), vocalizations (6), emotional expressivity (4), state of arousal (4), and use of parent (4). The scale was applied at 4 times: a baseline assessment prior to medication; 60min before induction; at time of induction of anaesthesia, and during post-emergence recovery. Patients were considered to have no anxiety for scores of 23.4–30, and to have anxiety for scores greater than 30.We compared the groups by means of the chi-squared or the Student's t-tests as appropriate for the type of variable. We compared the prevalence of anxiety between groups with the chi-squared test with Yates’ correction or Fisher's test depending on the distribution of the data. We performed risk-reduction and intention-to-treat analyses.During the preanaesthetic interview a week before the surgery, the parents or guardian of the minor were informed in detail of the characteristics of the study, its risks (respiratory depression with midazolam and haemodynamic alterations with dexmedetomidine) and possible benefits, and were asked to sign the informed consent form. The study protocol was submitted for approval to the Local Research Committee of the Hospital Regional Salamanca de PEMEX, and to the Research Committee of the Department of Medicine and Nutrition, and was accepted under the Registry N. 362-10. The medications used in the project were supplied by the hospital's pharmacy.ResultsWe studied 108 patients aged 2–12 years (4 years, 95% CI: 3–5); the dexmedetomidine group included 52 participants (48.1%) and the midazolam group 56 participants (51.9%). The study included all patients undergoing elective surgery at the Hospital Regional Salamanca de Petróleos Mexicanos during the established period. We did not observe significant differences in age, anthropometric variables, or the baseline haemodynamic variables (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The types of surgery performed are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The most frequent procedure in the dexmedetomidine group was inguinal hernia repair (53.5%), followed by amygdalectomy (15.3%) and umbilical hernia repair (11.5%); while in the midazolam group the most frequent procedure was circumcision (28.5%), followed by inguinal hernia repair (25.0%), and umbilical hernia repair in 10.7% of patients (χ2=22.7, P=.006).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Previous to treatment administration, anxiety levels were similar in both groups (χ2=1.5, P=.26); however, as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, anxiety was lower in the dexmedetomidine group at 60min (P=.001), at induction (P=.04), and during recovery (P=.0001). Risk analysis showed that 60min after administration, dexmedetomidine had reduced the risk of anxiety by 28%, and 4 patients needed to be treated with intranasal dexmedetomidine to prevent 1 case of anxiety (number needed to treat=4; 95% CI: 3–9).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Data for the noninvasive monitoring carried out during surgical procedures are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Children in the dexmedetomidine group showed a statistically significant reduction in heart rate (F=7.6, P=.001), mean arterial pressure (F=12.4, P=.001), and oxygen saturation (F=7.3, P=.001). Analysis of variance (ANOVA) with Tukey's post hoc test showed that on average heart rate had decreased by an average of 8 beats per minute (95% CI: 2–13) 45min after administration of the drug (P=.001), while arterial blood pressure had decreased by an average of 5mm Hg (95% CI: 1–8) by 30min post-treatment (P=.005), and oxygen saturation had decreased an average of 1.5% (95% CI: 1.1–1.9) at 30min post-treatment (P=.001). There were no cases of bradycardia, hypotension, or oxygen desaturation.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The midazolam group did not show significant changes in heart rate (P=.47) or mean arterial pressure (P=.78), while showing a significant change in oxygen saturation (P=.001) that had dropped by 1.2% on average (95% CI: 0.8–1.5) 15min after administration. There were no cases of bradycardia, hypotension, or oxygen desaturation in this group.DiscussionVarious drugs have been used for premedication in paediatric patients to achieve hypnosis and anxiolysis, which are important factors in facilitating non-distressful separation from parents and a safe and non-traumatic induction of anaesthesia. Midazolam and clonidine have been used for oral delivery.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Midazolam has been associated with adverse effects including agitation, paradoxical reaction, and negative postoperative behavioural changes, making it less safe for use in children, and clonidine is not available in Mexico. Respiratory depression can be a complication resulting from sedation or preanaesthetic medication with these drugs, and it has been observed in 5.5% of children.Dexmedetomidine is an alpha-2-agonist drug that has been proven useful as an sedative, analgesic, anxiolytic, and anaesthetic coadjuvant both in adults and children.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Recent studies have assessed the efficacy of intranasal dexmedetomidine as a sedative in children with promising results,<a class="elsevierStyleCrossRefs" href="#bib0040">8,12,13</a> although they have not assessed the anxiolytic effects of this drug.An intranasal preparation of dexmedetomidine is not available yet. In this study, we used the parenteral preparation directly, without diluting it, which was done in other studies.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> These variations could lead to significant errors when comparing study results. By not diluting the drug, it was administered in small volumes that were better accepted by patients. We did not observe any adverse haemodynamic or ventilatory effects.During the study design we calculated that we needed a sample size of 75 patients per group (n=150), and during the period of the study we only managed to enrol 108 participants. This does not mean that the favourable results should be disregarded, as the sample in the study achieved an alpha of 0.05, a beta of 0.20, and a power of 0.89.In our series, intranasal administration of dexmedetomidine produced a statistically significant reduction in heart rate, mean arterial blood pressure, and oxygen saturation, effects that have been described for the pharmacokinetics of α-2-agonists<a class="elsevierStyleCrossRef" href="#bib0025">5</a>; but the average changes of these variables did not have relevant clinical consequences. This study shows that intranasal dexmedetomidine can be a useful pharmacological option for preanaesthetic medication in paediatric patients with no haemodynamic or ventilatory adverse effects.ConclusionsIntranasal dexmedetomidine is a more efficacious premedication oral midazolam to reduce preoperative anxiety in paediatric patients.RecommendationsUse of intranasal dexmedetomidine is recommended for preanesthetic medication in paediatric patients; the drug is easily administered, is a flavourless solution, and is given in small volumes.Conflicts of interestThe medications used in the study were provided by the pharmacy of the Hospital Regional Salamanca de Petróleos Mexicanos.The authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres375161" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec354302" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres375160" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec354303" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Recommendations" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-05" "fechaAceptado" => "2013-12-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec354302" "palabras" => array:4 [ 0 => "Anxiety" 1 => "Sedative" 2 => "Midazolam" 3 => "Dexmedetomidine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec354303" "palabras" => array:4 [ 0 => "Ansiedad" 1 => "Sedantes" 2 => "Midazolam" 3 => "Dexmedetomidina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionDexmedetomidine is a pharmacological option for sedation in children. In this study, the efficacy of intranasal dexmedetomidine to reduce preoperative anxiety in paediatric patients is compared with that of oral midazolam. Materials and methodsA prospective, randomized, double-blind, controlled trial was conducted on children 2–12 years of age, randomly assigned to one of the following two groups: group A received premedication with oral midazolam and intranasal placebo, group B received intranasal dexmedetomidine and oral placebo. Anxiety was assessed with the modified Yale scale, and a risk analysis and number needed to treat was performed. ResultsA total of 108 patients were included, 52 (48.1%) treated with dexmedetomidine, and 56 (51.9%) with midazolam. Anxiety was less frequent in the dexmedetomidine group at 60min (P=.001), induction (P=.04), and recovery (P=.0001). Risk analysis showed that dexmedetomidine reduced the risk of anxiety by 28% (RAR=0.28, 95% CI: 0.12–0.43) and to prevent one case of anxiety, four patients need to be treated with intranasal dexmedetomidine (NNT=4, 95% CI: 3–9). Changes in heart rate, mean arterial pressure, and oxygen saturation were statistically significant in the dexmedetomidine group, with no clinical consequences. There were no cases of bradycardia, hypotension or oxygen desaturation. ConclusionsIntranasal dexmedetomidine premedication is more effective than oral midazolam to reduce preoperative anxiety in paediatric patients." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa dexmedetomidina es una opción farmacológica en la sedación del paciente pediátrico. En este estudio, se compara la eficacia de la dexmedetomidina intranasal versus midazolam por vía oral para disminuir la ansiedad preoperatoria en pacientes pediátricos. Material y métodosSe realizó un ensayo clínico, doble ciego, en niños de 2 a 12 años de edad, asignados aleatoriamente a uno de los siguientes dos grupos: a) recibió medicación preanestésica con midazolam por vía oral y placebo intranasal; b) recibió dexmedetomidina intranasal y placebo por vía oral. Se evaluó la ansiedad con la escala de Yale modificada y realizamos el análisis de reducción de riesgo y un número necesario a tratar. ResultadosSe estudió a 108 pacientes, 52 (48,1%) tratados con dexmedetomidina y 56 (51,9%) con midazolam. La ansiedad fue menos frecuente en el grupo de dexmedetomidina a los 60min (p=0,001), en la inducción (p=0,04) y en la recuperación (p=0,0001). El análisis de riesgo mostró que la dexmedetomidina redujo el riesgo de ansiedad en un 28% (RAR=0,28, IC del 95%, 0,12 a 0,43) y que para prevenir un caso de ansiedad es necesario tratar con dexmedetomidina intranasal a 4 pacientes (NNT=4, IC del 95%, 3 a 9). En el grupo de dexmedetomidina se registraron cambios estadísticamente significativos en la frecuencia cardiaca, la presión arterial media y la saturación de oxígeno, sin repercusión clínica; no se registraron casos de bradicardia, hipotensión ni desaturación de oxígeno. ConclusionesLa premedicación con dexmedetomidina intranasal es más eficaz que el midazolam por vía oral para disminuir la ansiedad preoperatoria en pacientes pediátricos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Linares Segovia B, García Cuevas MA, Ramírez Casillas IL, Guerrero Romero JF, Botello Buenrostro I, Monroy Torres R, et al. Medicación preanestésica con dexmedetomidina intranasal y midazolam oral como ansiolítico. Un ensayo clínico. Anales de Pediatría. 2014;81:226–231." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3788 "Ancho" => 1680 "Tamanyo" => 275861 ] ] "descripcion" => array:1 [ "en" => "Changes in haemodynamic variables following treatment. We found statistically significant differences in HR, MAP, and SpO2 in the dexmedetomidine group that had no clinical relevance. HR, heart rate; MAP, mean arterial pressure; SpO2, oxygen saturation." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: HR, heart rate; MAP, mean arterial pressure; SpO2, oxygen saturation.The values are expressed as mean±SD." "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"><td 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" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Dexmedetomidine, n=52 \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Midazolam, n=56 \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 (3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.61 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex (female/male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28/24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.0±5.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.4±7.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.43 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Height (m) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72.4±40.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71.9±41.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.96 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HR (beats/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104.8±11.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">102.2±11.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.41 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MAP (mm Hg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.8±7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.9±8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.95 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SpO2 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">98.9±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">98.6±0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab569274.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the population under study." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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"><td 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">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Group</td><td 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">Total \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-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Dexmedetomidine N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Midazolam N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amygdalectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (15.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (10.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (12.9) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Circumcision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (28.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (18.5) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypospadias repair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.8) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Endoscopy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.8) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Synovial cyst excision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.9) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inguinal hernia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (53.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 (38.8) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Umbilical hernia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (10.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (11.1) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orchidopexy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (2.7) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polyp resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.8) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (5.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab569273.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Types of surgery performed in the two groups of the study." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: CI, confidence interval; NNT, number needed to treat; RR, risk reduction; RRR, relative risk reduction." "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"><td 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" style="border-bottom: 2px solid black">Surgical time \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">DexmedetomidineWith/without anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">MidazolamWith/without anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">RR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">RRR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">RAR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">NNT (95% CI) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.08 (0.16–7.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22/34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.29 (0.13–0.67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.71 (0.33–0.87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.28 (0.12–0.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (3–9) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Induction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18/38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.48 (0.23–1.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.52 (0.01–0.77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.17 (0.01–0.32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (4–93) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recovery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30/26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.07 (0.02–0.29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.93 (0.71–0.98) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.50 (0.36–0.64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (2–3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab569275.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Changes in anxiety following treatment." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manual de anestesia pediátrica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Bell" 1 => "C. Hughes" 2 => "Z.N. Kain" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "2nd ed." "fecha" => "1998" "editorial" => "Editorial Mosby" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995–2002: results of a follow-up national survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Z.N. Kain" 1 => "A.A. Caldwell-Andrews" 2 => "D.M. Krivutza" 3 => "M.E. Weinberg" 4 => "S.-M. Wang" 5 => "D. 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Original Article

Pre-anaesthetic medication with intranasal dexmedetomidine and oral midazolam as an anxiolytic. A clinical trial

Medicación preanestésica con dexmedetomidina intranasal y midazolam oral como ansiolítico. Un ensayo clínico

B. Linares Segoviaa,b,

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blinares70@ugto.mx
blinares70@yahoo.com.mx

Corresponding author.

, M.A. García Cuevasb, I.L. Ramírez Casillasb, J.F. Guerrero Romerob, I. Botello Buenrostrob, R. Monroy Torresa, X.S. Ramírez Gómeza

a Departamento de Medicina y Nutrición, División de Ciencias de la Salud, Campus León, Universidad de Guanajuato, León, Guanajuato, Mexico

b Servicio de Enseñanza e Investigación, Hospital Regional Salamanca de Petróleos Mexicanos, Salamanca, Guanajuato, Mexico

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In a surgical procedure&#44; the high anxiety levels that children experience during the preoperative period may be associated to negative medical&#44; psychological&#44; and social consequences&#46; To reduce the distress of children and to facilitate the induction of anaesthesia&#44; the child is given a sedative before going into the operating room&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main goals of premedication in children are to facilitate a smooth separation from the parents and ease the induction of anaesthesia&#46; Other effects that can be achieved with the pharmacological preparation of the patient are&#58; amnesia&#44; anxiolysis&#44; prevention of psychological stress&#44; and a reduction in the total anaesthetic requirements&#46; The groups of patients that benefit most from premedication are toddlers and preschoolers&#44; in whom separation anxiety is paramount&#59; and also adolescents&#44; who are sensitive about their body image and loss of control&#44; patients with previous unpleasant hospital experiences&#44; and patients who are unable to communicate or cooperate&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Midazolam is the premedication most frequently used in children&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has been demonstrated that midazolam administered orally at 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg is efficacious in reducing anxiety and improving the conditions for induction of anaesthesia&#44; but it has been associated with adverse effects such as agitation&#44; paradoxical reaction&#44; and negative postoperative behaviour changes&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For this reason&#44; other drugs and delivery routes are being explored&#46; One of those drugs is dexmedetomidine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Dexmedetomidine is a highly specific &#945;2-adrenergic receptor agonist with sedative&#44; anxiolytic&#44; and analgesic properties&#44; and a considerable sympatholytic effect&#46; Its bioavailability when administered via the buccal route is 81&#46;8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In 1999 dexmedetomidine was approved in the United States by the Food and Drug Administration to be used in human patients as a short-term &#40;&#60;24<span class="elsevierStyleHsp" style=""></span>h&#41; sedative and analgesic in intensive care units&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In healthy volunteers&#44; intravenous dexmedetomidine has an action onset of 15<span class="elsevierStyleHsp" style=""></span>min&#59; it can also have systemic effects when administered by the transdermal&#44; buccal&#44; or intramuscular routes&#44; with the latter two routes having showed bioavailabilities of 82&#37; and 104&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It has been shown that in adult patients&#44; intranasal administration of 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg of dexmedetomidine produces sedation within 45&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; and has its peak effect at 90&#8211;105<span class="elsevierStyleHsp" style=""></span>min&#46; This is accompanied by mild to moderate changes in heart rate and arterial blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Recent studies in paediatric patients have shown that intranasal dexmedetomidine produces more sedation than oral midazolam&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It has been used successfully in diagnostic radiology procedures&#44; such as magnetic resonance imaging and computed tomography scans&#44; and in invasive procedures&#44; such as placement of venous lines in infants&#44; bronchoscopy&#44; laryngoscopy&#44; cardiac catheterisation&#44; and others&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> It has been used alone or in combination with other drugs to sedate paediatric patients that underwent different kinds of surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a> These studies did not report the effect of dexmedetomidine on anxiety&#44; so the purpose of our study was to compare the efficacy of intranasal dexmedetomidine to oral midazolam in reducing preoperative anxiety in paediatric patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a double-blind controlled clinical trial&#46; We included children 2&#8211;12 years of age of both sexes&#46; Using the Power and Sample Size software&#44; we calculated that a sample of 75 patients per group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>150 patients&#41; was needed to detect a difference of at least 15&#37; in the prevalence of anxiety among groups&#44; with an alpha of 0&#46;05&#44; a beta of 0&#46;20&#44; and a power of 0&#46;80&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were included by consecutive sampling of cases scheduled for elective surgery&#44; ASA grade I&#44; at the Hospital Regional Salamanca de Petr&#243;leos Mexicanos in Salamanca&#44; Guanajuato&#44; Mexico&#44; between March 2009 and December 2011&#46; We excluded patients with a history of allergy or hypersensibility to midazolam or dexmedetomidine&#44; congenital heart disease or heart arrhythmias&#44; mental retardation&#44; or currently being treated with psychoactive medications&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The parents or guardian of the minors were informed of the purpose of the study and its procedures&#44; and were asked to sign a consent form for participation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patients for whom we obtained consent to participate were assigned to one of 2 groups by means of a random number table with a secret sequence&#46; Patients in the control group &#40;midazolam&#41; received oral midazolam&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; as preanaesthetic medication along with an intranasal placebo &#40;0&#46;9<span class="elsevierStyleHsp" style=""></span>N isotonic saline solution&#41;&#46; The study group &#40;dexmedetomidine&#41; received intranasal dexmedetomidine&#44; 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#44; as preanaesthetic medication&#44; and an oral placebo &#40;5&#37; glucose solution&#41;&#46; The drugs were administered 60<span class="elsevierStyleHsp" style=""></span>min prior to induction of anaesthesia&#46; Intranasal dexmedetomidine was prepared from the parenteral preparation &#40;100<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL&#41; and administered undiluted&#46; The preparation and administration of medications were performed by a resident doctor in anaesthesiology that did not participate in clinical assessment&#44; and the participating anaesthesiologists were blinded to the treatment&#46; During surgery&#44; all participants were monitored with class II &#40;noninvasive&#41; devices with electrocardiography&#44; pulse oxymetry for monitoring oxygen saturation&#44; and monitoring of blood pressure until they were discharged from the postanaesthetic care unit&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We assessed anxiety using the modified Yale scale&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which determines the anxiety of the child based on a total of 22 items divided into 5 categories&#44; each of which can contribute up to 4 or 6 points to the final score&#58; activity &#40;4&#41;&#44; vocalizations &#40;6&#41;&#44; emotional expressivity &#40;4&#41;&#44; state of arousal &#40;4&#41;&#44; and use of parent &#40;4&#41;&#46; The scale was applied at 4 times&#58; a baseline assessment prior to medication&#59; 60<span class="elsevierStyleHsp" style=""></span>min before induction&#59; at time of induction of anaesthesia&#44; and during post-emergence recovery&#46; Patients were considered to have no anxiety for scores of 23&#46;4&#8211;30&#44; and to have anxiety for scores greater than 30&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We compared the groups by means of the chi-squared or the Student&#39;s <span class="elsevierStyleItalic">t</span>-tests as appropriate for the type of variable&#46; We compared the prevalence of anxiety between groups with the chi-squared test with Yates&#8217; correction or Fisher&#39;s test depending on the distribution of the data&#46; We performed risk-reduction and intention-to-treat analyses&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">During the preanaesthetic interview a week before the surgery&#44; the parents or guardian of the minor were informed in detail of the characteristics of the study&#44; its risks &#40;respiratory depression with midazolam and haemodynamic alterations with dexmedetomidine&#41; and possible benefits&#44; and were asked to sign the informed consent form&#46; The study protocol was submitted for approval to the Local Research Committee of the Hospital Regional Salamanca de PEMEX&#44; and to the Research Committee of the Department of Medicine and Nutrition&#44; and was accepted under the Registry N&#46; 362-10&#46; The medications used in the project were supplied by the hospital&#39;s pharmacy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">We studied 108 patients aged 2&#8211;12 years &#40;4 years&#44; 95&#37; CI&#58; 3&#8211;5&#41;&#59; the dexmedetomidine group included 52 participants &#40;48&#46;1&#37;&#41; and the midazolam group 56 participants &#40;51&#46;9&#37;&#41;&#46; The study included all patients undergoing elective surgery at the Hospital Regional Salamanca de Petr&#243;leos Mexicanos during the established period&#46; We did not observe significant differences in age&#44; anthropometric variables&#44; or the baseline haemodynamic variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The types of surgery performed are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The most frequent procedure in the dexmedetomidine group was inguinal hernia repair &#40;53&#46;5&#37;&#41;&#44; followed by amygdalectomy &#40;15&#46;3&#37;&#41; and umbilical hernia repair &#40;11&#46;5&#37;&#41;&#59; while in the midazolam group the most frequent procedure was circumcision &#40;28&#46;5&#37;&#41;&#44; followed by inguinal hernia repair &#40;25&#46;0&#37;&#41;&#44; and umbilical hernia repair in 10&#46;7&#37; of patients &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#46;7&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Previous to treatment administration&#44; anxiety levels were similar in both groups &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;26&#41;&#59; however&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; anxiety was lower in the dexmedetomidine group at 60<span class="elsevierStyleHsp" style=""></span>min &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; at induction &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#44; and during recovery &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Risk analysis showed that 60<span class="elsevierStyleHsp" style=""></span>min after administration&#44; dexmedetomidine had reduced the risk of anxiety by 28&#37;&#44; and 4 patients needed to be treated with intranasal dexmedetomidine to prevent 1 case of anxiety &#40;number needed to treat<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#59; 95&#37; CI&#58; 3&#8211;9&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Data for the noninvasive monitoring carried out during surgical procedures are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Children in the dexmedetomidine group showed a statistically significant reduction in heart rate &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;6&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; mean arterial pressure &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;4&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; and oxygen saturation &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;3&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Analysis of variance &#40;ANOVA&#41; with Tukey&#39;s post hoc test showed that on average heart rate had decreased by an average of 8 beats per minute &#40;95&#37; CI&#58; 2&#8211;13&#41; 45<span class="elsevierStyleHsp" style=""></span>min after administration of the drug &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; while arterial blood pressure had decreased by an average of 5<span class="elsevierStyleHsp" style=""></span>mm Hg &#40;95&#37; CI&#58; 1&#8211;8&#41; by 30<span class="elsevierStyleHsp" style=""></span>min post-treatment &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41;&#44; and oxygen saturation had decreased an average of 1&#46;5&#37; &#40;95&#37; CI&#58; 1&#46;1&#8211;1&#46;9&#41; at 30<span class="elsevierStyleHsp" style=""></span>min post-treatment &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; There were no cases of bradycardia&#44; hypotension&#44; or oxygen desaturation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The midazolam group did not show significant changes in heart rate &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;47&#41; or mean arterial pressure &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;78&#41;&#44; while showing a significant change in oxygen saturation &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; that had dropped by 1&#46;2&#37; on average &#40;95&#37; CI&#58; 0&#46;8&#8211;1&#46;5&#41; 15<span class="elsevierStyleHsp" style=""></span>min after administration&#46; There were no cases of bradycardia&#44; hypotension&#44; or oxygen desaturation in this group&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Various drugs have been used for premedication in paediatric patients to achieve hypnosis and anxiolysis&#44; which are important factors in facilitating non-distressful separation from parents and a safe and non-traumatic induction of anaesthesia&#46; Midazolam and clonidine have been used for oral delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Midazolam has been associated with adverse effects including agitation&#44; paradoxical reaction&#44; and negative postoperative behavioural changes&#44; making it less safe for use in children&#44; and clonidine is not available in Mexico&#46; Respiratory depression can be a complication resulting from sedation or preanaesthetic medication with these drugs&#44; and it has been observed in 5&#46;5&#37; of children&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Dexmedetomidine is an alpha-2-agonist drug that has been proven useful as an sedative&#44; analgesic&#44; anxiolytic&#44; and anaesthetic coadjuvant both in adults and children&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Recent studies have assessed the efficacy of intranasal dexmedetomidine as a sedative in children with promising results&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;12&#44;13</span></a> although they have not assessed the anxiolytic effects of this drug&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">An intranasal preparation of dexmedetomidine is not available yet&#46; In this study&#44; we used the parenteral preparation directly&#44; without diluting it&#44; which was done in other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> These variations could lead to significant errors when comparing study results&#46; By not diluting the drug&#44; it was administered in small volumes that were better accepted by patients&#46; We did not observe any adverse haemodynamic or ventilatory effects&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">During the study design we calculated that we needed a sample size of 75 patients per group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>150&#41;&#44; and during the period of the study we only managed to enrol 108 participants&#46; This does not mean that the favourable results should be disregarded&#44; as the sample in the study achieved an alpha of 0&#46;05&#44; a beta of 0&#46;20&#44; and a power of 0&#46;89&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In our series&#44; intranasal administration of dexmedetomidine produced a statistically significant reduction in heart rate&#44; mean arterial blood pressure&#44; and oxygen saturation&#44; effects that have been described for the pharmacokinetics of &#945;-2-agonists<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; but the average changes of these variables did not have relevant clinical consequences&#46; This study shows that intranasal dexmedetomidine can be a useful pharmacological option for preanaesthetic medication in paediatric patients with no haemodynamic or ventilatory adverse effects&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Intranasal dexmedetomidine is a more efficacious premedication oral midazolam to reduce preoperative anxiety in paediatric patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recommendations</span><p id="par0125" class="elsevierStylePara elsevierViewall">Use of intranasal dexmedetomidine is recommended for preanesthetic medication in paediatric patients&#59; the drug is easily administered&#44; is a flavourless solution&#44; and is given in small volumes&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The medications used in the study were provided by the pharmacy of the Hospital Regional Salamanca de Petr&#243;leos Mexicanos&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres375161"
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            0 => "Abstract"
            1 => "Introduction"
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          "titulo" => "Keywords"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Introducci&#243;n"
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            3 => "Resultados"
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          "titulo" => "Palabras clave"
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          "titulo" => "Materials and methods"
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          "titulo" => "Conclusions"
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          "titulo" => "Recommendations"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-09-05"
    "fechaAceptado" => "2013-12-16"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec354302"
          "palabras" => array:4 [
            0 => "Anxiety"
            1 => "Sedative"
            2 => "Midazolam"
            3 => "Dexmedetomidine"
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      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Ansiedad"
            1 => "Sedantes"
            2 => "Midazolam"
            3 => "Dexmedetomidina"
          ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dexmedetomidine is a pharmacological option for sedation in children&#46; In this study&#44; the efficacy of intranasal dexmedetomidine to reduce preoperative anxiety in paediatric patients is compared with that of oral midazolam&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; randomized&#44; double-blind&#44; controlled trial was conducted on children 2&#8211;12 years of age&#44; randomly assigned to one of the following two groups&#58; group A received premedication with oral midazolam and intranasal placebo&#44; group B received intranasal dexmedetomidine and oral placebo&#46; Anxiety was assessed with the modified Yale scale&#44; and a risk analysis and number needed to treat was performed&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 108 patients were included&#44; 52 &#40;48&#46;1&#37;&#41; treated with dexmedetomidine&#44; and 56 &#40;51&#46;9&#37;&#41; with midazolam&#46; Anxiety was less frequent in the dexmedetomidine group at 60<span class="elsevierStyleHsp" style=""></span>min &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; induction &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#44; and recovery &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Risk analysis showed that dexmedetomidine reduced the risk of anxiety by 28&#37; &#40;RAR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#44; 95&#37; <span class="elsevierStyleSmallCaps">CI</span>&#58; 0&#46;12&#8211;0&#46;43&#41; and to prevent one case of anxiety&#44; four patients need to be treated with intranasal dexmedetomidine &#40;NNT<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44; 95&#37; CI&#58; 3&#8211;9&#41;&#46; Changes in heart rate&#44; mean arterial pressure&#44; and oxygen saturation were statistically significant in the dexmedetomidine group&#44; with no clinical consequences&#46; There were no cases of bradycardia&#44; hypotension or oxygen desaturation&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Intranasal dexmedetomidine premedication is more effective than oral midazolam to reduce preoperative anxiety in paediatric patients&#46;</p>"
      ]
      "es" => array:2 [
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La dexmedetomidina es una opci&#243;n farmacol&#243;gica en la sedaci&#243;n del paciente pedi&#225;trico&#46; En este estudio&#44; se compara la eficacia de la dexmedetomidina intranasal versus midazolam por v&#237;a oral para disminuir la ansiedad preoperatoria en pacientes pedi&#225;tricos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un ensayo cl&#237;nico&#44; doble ciego&#44; en ni&#241;os de 2 a 12 a&#241;os de edad&#44; asignados aleatoriamente a uno de los siguientes dos grupos&#58; <span class="elsevierStyleItalic">a&#41;</span> recibi&#243; medicaci&#243;n preanest&#233;sica con midazolam por v&#237;a oral y placebo intranasal&#59; <span class="elsevierStyleItalic">b&#41;</span> recibi&#243; dexmedetomidina intranasal y placebo por v&#237;a oral&#46; Se evalu&#243; la ansiedad con la escala de Yale modificada y realizamos el an&#225;lisis de reducci&#243;n de riesgo y un n&#250;mero necesario a tratar&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a 108 pacientes&#44; 52 &#40;48&#44;1&#37;&#41; tratados con dexmedetomidina y 56 &#40;51&#44;9&#37;&#41; con midazolam&#46; La ansiedad fue menos frecuente en el grupo de dexmedetomidina a los 60<span class="elsevierStyleHsp" style=""></span>min &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; en la inducci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; y en la recuperaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; El an&#225;lisis de riesgo mostr&#243; que la dexmedetomidina redujo el riesgo de ansiedad en un 28&#37; &#40;RAR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;28&#44; IC del 95&#37;&#44; 0&#44;12 a 0&#44;43&#41; y que para prevenir un caso de ansiedad es necesario tratar con dexmedetomidina intranasal a 4 pacientes &#40;NNT<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44; IC del 95&#37;&#44; 3 a 9&#41;&#46; En el grupo de dexmedetomidina se registraron cambios estad&#237;sticamente significativos en la frecuencia cardiaca&#44; la presi&#243;n arterial media y la saturaci&#243;n de ox&#237;geno&#44; sin repercusi&#243;n cl&#237;nica&#59; no se registraron casos de bradicardia&#44; hipotensi&#243;n ni desaturaci&#243;n de ox&#237;geno&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La premedicaci&#243;n con dexmedetomidina intranasal es m&#225;s eficaz que el midazolam por v&#237;a oral para disminuir la ansiedad preoperatoria en pacientes pedi&#225;tricos&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Linares Segovia B&#44; Garc&#237;a Cuevas MA&#44; Ram&#237;rez Casillas IL&#44; Guerrero Romero JF&#44; Botello Buenrostro I&#44; Monroy Torres R&#44; et al&#46; Medicaci&#243;n preanest&#233;sica con dexmedetomidina intranasal y midazolam oral como ansiol&#237;tico&#46; Un ensayo cl&#237;nico&#46; Anales de Pediatr&#237;a&#46; 2014&#59;81&#58;226&#8211;231&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Changes in haemodynamic variables following treatment&#46; We found statistically significant differences in HR&#44; MAP&#44; and SpO<span class="elsevierStyleInf">2</span> in the dexmedetomidine group that had no clinical relevance&#46; HR&#44; heart rate&#59; MAP&#44; mean arterial pressure&#59; SpO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; HR&#44; heart rate&#59; MAP&#44; mean arterial pressure&#59; SpO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The values are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Dexmedetomidine&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&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" style="border-bottom: 2px solid black">Midazolam&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Age &#40;years&#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">4 &#40;3&#8211;5&#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">4 &#40;3&#8211;5&#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="char" valign="\n
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                  \t\t\t\t">0&#46;61&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex &#40;female&#47;male&#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">28&#47;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#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">16&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;43&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Height &#40;m&#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">72&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;96&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HR &#40;beats&#47;min&#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">104&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;41&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAP &#40;mm Hg&#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">67&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;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">67&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;95&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SpO<span class="elsevierStyleInf">2</span> &#40;&#37;&#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">98&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab569274.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of the population under study&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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"><td 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">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Group</td><td 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">Total&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-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Dexmedetomidine <span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Midazolam <span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Amygdalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;15&#46;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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;10&#46;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;12&#46;9&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Circumcision&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;7&#46;6&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;28&#46;5&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;18&#46;5&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypospadias repair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;9&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;8&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;4&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;8&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Synovial cyst excision&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;9&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inguinal hernia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;53&#46;8&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;25&#46;0&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;38&#46;8&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Umbilical hernia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;11&#46;5&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;10&#46;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;11&#46;1&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Orchidopexy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;8&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#46;7&#41;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polyp resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;1&#46;8&#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">Other&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3 &#40;5&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\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="char" valign="\n
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                  \t\t\t\t">4 &#40;3&#8211;9&#41;&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="left" valign="\n
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                  \t\t\t\t">Induction&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">8&#47;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
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                  \t\t\t\t">18&#47;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;48 &#40;0&#46;23&#8211;1&#46;01&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;52 &#40;0&#46;01&#8211;0&#46;77&#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="char" valign="\n
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                  \t\t\t\t">0&#46;17 &#40;0&#46;01&#8211;0&#46;32&#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="char" valign="\n
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                  \t\t\t\t">6 &#40;4&#8211;93&#41;&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="left" valign="\n
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                  \t\t\t\t">Recovery&nbsp;\t\t\t\t\t\t\n
                  \t\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">2&#47;50&nbsp;\t\t\t\t\t\t\n
                  \t\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">30&#47;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;07 &#40;0&#46;02&#8211;0&#46;29&#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">0&#46;93 &#40;0&#46;71&#8211;0&#46;98&#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="char" valign="\n
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                  \t\t\t\t">0&#46;50 &#40;0&#46;36&#8211;0&#46;64&#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">3 &#40;2&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        0 => array:2 [
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            0 => array:3 [
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                    0 => array:2 [
                      "titulo" => "Manual de anestesia pedi&#225;trica"
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                          "autores" => array:3 [
                            0 => "C&#46; Bell"
                            1 => "C&#46; Hughes"
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                  "contribucion" => array:1 [
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                      "titulo" => "Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States&#44; 1995&#8211;2002&#58; results of a follow-up national survey"
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                            2 => "D&#46;M&#46; Krivutza"
                            3 => "M&#46;E&#46; Weinberg"
                            4 => "S&#46;-M&#46; Wang"
                            5 => "D&#46; Gaal"
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                      "Revista" => array:6 [
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                      "doi" => "10.1016/S0034-7094(12)70110-1"
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                        "fecha" => "2009"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2013.12.003

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Year/Month	Html	Pdf	Total

2024 November	7	11	18
2024 October	51	54	105
2024 September	61	37	98
2024 August	98	78	176
2024 July	81	42	123
2024 June	50	28	78
2024 May	52	53	105
2024 April	60	29	89
2024 March	48	32	80
2024 February	53	27	80
2024 January	47	32	79
2023 December	39	27	66
2023 November	59	31	90
2023 October	48	40	88
2023 September	39	34	73
2023 August	37	20	57
2023 July	64	40	104
2023 June	50	30	80
2023 May	50	29	79
2023 April	32	14	46
2023 March	72	28	100
2023 February	57	22	79
2023 January	39	27	66
2022 December	78	45	123
2022 November	67	38	105
2022 October	57	47	104
2022 September	44	39	83
2022 August	63	55	118
2022 July	50	32	82
2022 June	79	50	129
2022 May	89	49	138
2022 April	140	40	180
2022 March	169	56	225
2022 February	175	30	205
2022 January	149	55	204
2021 December	98	35	133
2021 November	110	48	158
2021 October	77	79	156
2021 September	43	37	80
2021 August	50	39	89
2021 July	42	30	72
2021 June	48	29	77
2021 May	41	31	72
2021 April	79	82	161
2021 March	60	30	90
2021 February	57	26	83
2021 January	54	18	72
2020 December	53	22	75
2020 November	33	19	52
2020 October	30	11	41
2020 September	25	7	32
2020 August	26	14	40
2020 July	26	18	44
2020 June	36	12	48
2020 May	40	23	63
2020 April	41	17	58
2020 March	46	25	71
2020 February	29	13	42
2020 January	31	18	49
2019 December	46	21	67
2019 November	21	17	38
2019 October	29	20	49
2019 September	74	18	92
2019 August	42	31	73
2019 July	44	18	62
2019 June	35	32	67
2019 May	77	32	109
2019 April	83	28	111
2019 March	46	31	77
2019 February	54	23	77
2019 January	48	24	72
2018 December	51	31	82
2018 November	94	42	136
2018 October	130	54	184
2018 September	61	26	87
2018 August	2	0	2
2018 June	3	0	3
2018 May	10	0	10
2018 April	31	0	31
2018 March	20	0	20
2018 February	16	0	16
2018 January	19	0	19
2017 December	16	0	16
2017 November	23	0	23
2017 October	21	0	21
2017 September	17	0	17
2017 August	20	0	20
2017 July	16	0	16
2017 June	31	10	41
2017 May	32	10	42
2017 April	22	8	30
2017 March	24	10	34
2017 February	14	6	20
2017 January	24	4	28
2016 December	42	27	69
2016 November	71	6	77
2016 October	55	22	77
2016 September	40	22	62
2016 August	43	3	46
2016 July	14	2	16
2016 May	1	0	1
2016 March	1	0	1
2016 February	1	0	1
2015 December	4	0	4
2015 November	2	29	31
2015 October	8	38	46
2015 August	3	67	70
2015 July	1	0	1
2015 June	2	0	2
2015 May	2	21	23
2015 April	6	24	30
2015 March	3	0	3
2015 February	7	0	7
2015 January	1	0	1
2014 December	2	1	3
2014 November	4	1	5

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