Original Article
Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation
Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración
José Domingo López Castilla
, Norma Sánchez Fernández, María Teresa Charlo Molina, Antonio Vázquez Florido, Maria Angeles Murillo Pozo, Inmaculada Sánchez Ganfornina, Manuel Fernández Elías, Elía Sánchez Valderrábanos
Corresponding author
Unidad de Gestión Clínica de Cuidados Intensivos Pediátricos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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ventilation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "115" "paginaFinal" => "121" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Domingo López Castilla, Norma Sánchez Fernández, María Teresa Charlo Molina, Antonio Vázquez Florido, Maria Angeles Murillo Pozo, Inmaculada Sánchez Ganfornina, Manuel Fernández Elías, Elía Sánchez Valderrábanos" "autores" => array:8 [ 0 => array:4 [ "nombre" => "José Domingo" "apellidos" => "López Castilla" "email" => array:1 [ 0 => "pepedomi1953@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Norma" "apellidos" => "Sánchez Fernández" ] 2 => array:2 [ "nombre" => "María Teresa" "apellidos" => "Charlo Molina" ] 3 => array:2 [ "nombre" => "Antonio" "apellidos" => "Vázquez Florido" ] 4 => array:2 [ "nombre" => "Maria Angeles" "apellidos" => "Murillo Pozo" ] 5 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Sánchez Ganfornina" ] 6 => array:2 [ "nombre" => "Manuel" "apellidos" => "Fernández Elías" ] 7 => array:2 [ "nombre" => "Elía" "apellidos" => "Sánchez Valderrábanos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Cuidados Intensivos Pediátricos, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1201 "Ancho" => 1508 "Tamanyo" => 50190 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Time elapsed from discontinuation of sedation/analgesia to awakening. Group A: propofol-remifentanil (11.8 ± 10.6 min); Group B: midazolam-fentanyl (137 ± 45 min).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">One of the important goals of paediatric intensive care units (PICUs) is the adequate management of postoperative pain, especially in patients under mechanical ventilation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sedation and analgesia are key elements in the management of critically ill children<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and necessary during endotracheal intubation and mechanical ventilation. Children that need mechanical ventilation in the immediate postoperative period usually require analgesia to alleviate pain and sedation to maintain comfort, safety and adequate adaptation to the ventilator. The most frequently used analgesic in our region is fentanyl, and benzodiazepines, especially midazolam, are the most frequently used sedatives. Some of the other drugs commonly used are morphine hydrochloride, clonidine and ketamine.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, classic analgesics and sedatives like fentanyl and midazolam have a cumulative effect when administered as continuous infusion, which increases their half-life and results in prolonged sedation and an unpredictable extubation time after discontinuation of infusion. Children frequently wake slowly, do not adapt to the ventilator and have breathing impulses and airway reflexes that are insufficient for extubation, hindering weaning and increasing the risk of accidental extubation during this stage.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Weaning is defined as the transition from ventilatory support to full spontaneous breathing, during which the patient is responsible for gas exchange while ventilatory support is removed, and ending with the extubation process.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore, an optimal sedation and analgesia regimen should provide adequate sedation and analgesia while the child is receiving mechanical ventilation and facilitate rapid recovery and weaning after the medication is discontinued.</p><p id="par0020" class="elsevierStylePara elsevierViewall">For this reason, we compared 2 sedation/analgesia regimens, one with frequently used drugs (midazolam/fentanyl) and one with drugs with a shorter half-life (propofol/remifentanil), with the hypothesis that the time to awakening and to extubation after discontinuation of treatment would be shorter in patients treated with propofol-remifentanil.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The primary objective of our study was to analyse the time elapsed from discontinuation of sedation/analgesia to awakening and to extubation in the 2 groups.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The secondary objective was to analyse and compare the incidence of adverse events, including the development of hyperlacticaemia, in the 2 groups of patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted an observational study in the PICU of a tertiary care hospital in patients that required mechanical ventilation for a maximum of 72 h after undergoing elective surgery.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We compared 2 separate groups of patients:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0045" class="elsevierStylePara elsevierViewall">Group A: patients enrolled prospectively that received sedation/analgesia with propofol-remifentanil between November 2014 and June 2016.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0050" class="elsevierStylePara elsevierViewall">Group B: patients included retrospectively through the review of health records and the PICU database that received midazolam-fentanyl between June 2012 and October 2014.</p></li></ul></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Inclusion criteria</span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0060" class="elsevierStylePara elsevierViewall">Haemodynamically stable.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">Age 1–18 years.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0070" class="elsevierStylePara elsevierViewall">Mechanical ventilation required for less than 72 h in the postoperative period.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0075" class="elsevierStylePara elsevierViewall">Signed informed consent of parents or legal guardians.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Exclusion criteria</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0085" class="elsevierStylePara elsevierViewall">Known intolerance or allergy to any of the drugs.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients that underwent cardiovascular surgery.</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Sedation/analgesia protocol used in the study</span><p id="par0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0100" class="elsevierStylePara elsevierViewall">Propofol: intravenous infusion starting at a rate of 1 mg/kg/h, with progressive increases of 0.5 mg/kg/h if the Ramsay sedation scale score was less than 4 until a score of 5 was achieved.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0105" class="elsevierStylePara elsevierViewall">Remifentanil: intravenous infusion starting at a rate of 10 μg/kg/h, with progressive increases of 5 μg/kg/h if the pain scale score was greater than 2 until adequate analgesia was achieved (pain scale score ≤ 2).</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">–</span><p id="par0110" class="elsevierStylePara elsevierViewall">Midazolam: intravenous infusion starting at a rate of 0.2 mg/kg/h, with progressive increases of 0.5 mg/kg/h if the Ramsay sedation scale score was less than 4 until the optimal score of 5 was achieved.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0115" class="elsevierStylePara elsevierViewall">Fentanyl: intravenous infusion starting at a rate of 2 μg/kg/h, with progressive increases of 0.5 μg/kg/h if the pain score was greater than 2.</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">If the patient experienced severe pain (pain scale score > 6) or agitation (Ramsay scale score of 2–3), rescue boluses of the drug applicable to the study group were delivered intravenously: remifentanil at 1 μg/kg or midazolam at 0.1 mg/kg in group A, and fentanyl at 1 μg/kg or propofol at 1 mg/kg in group B.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Assessment of analgesia</span><p id="par0125" class="elsevierStylePara elsevierViewall">We used the Multidimensional Assessment Pain Scale (MAPS) in patients under deep sedation, applied by a paediatrician or nurse in the unit. If the patients were awake, we used the MAPS scale in children aged 0–3 years, the Wong-Baker FACES scale in children aged 3–7 years and the Visual Analog Scale in children aged more than 7 years. Pain was assessed on a 0–10 scale (0 no pain, 1–2 mild pain, 3–6 moderate pain, 7–8 intense pain, 9–10 unbearable pain). The target of analgesia was a score of 2 or less.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Assessment of sedation</span><p id="par0130" class="elsevierStylePara elsevierViewall">We used the Ramsay sedation scale, which has been recently validated for monitoring sedation during invasive procedures involving deep sedation and analgesia in the paediatric population.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The scale establishes 6 levels of sedation. Level 1: awake, anxious, agitated or restless; level 2: awake, cooperative, oriented and tranquil; level 3: appears asleep, responding to commands only; level 4: appears asleep, with brief responses to light and sound; level 5: asleep, responsive only to painful stimuli; level 6: deeply asleep and unresponsive to stimuli. The objective was to maintain the level of sedation at 5.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Assessment of time of awakening</span><p id="par0135" class="elsevierStylePara elsevierViewall">We defined the time of awakening as the time patients reached a Ramsay scale score of less than 3 after discontinuation of medication.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Patient monitoring</span><p id="par0140" class="elsevierStylePara elsevierViewall">All patients underwent continuous monitoring of systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, respiratory rate and transcutaneous oxygen saturation.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Study variables</span><p id="par0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">–</span><p id="par0150" class="elsevierStylePara elsevierViewall">Age.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">–</span><p id="par0155" class="elsevierStylePara elsevierViewall">Weight.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">–</span><p id="par0160" class="elsevierStylePara elsevierViewall">Sex.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">–</span><p id="par0165" class="elsevierStylePara elsevierViewall">Type of surgery.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">–</span><p id="par0170" class="elsevierStylePara elsevierViewall">Assessment of pain and sedation.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">–</span><p id="par0175" class="elsevierStylePara elsevierViewall">Time elapsed from discontinuation of sedation/analgesia to awakening.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">–</span><p id="par0180" class="elsevierStylePara elsevierViewall">Time elapsed from discontinuation of sedation/analgesia to extubation.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">–</span><p id="par0185" class="elsevierStylePara elsevierViewall">Need of reintubation.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">–</span><p id="par0190" class="elsevierStylePara elsevierViewall">Doses of all drugs used.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">–</span><p id="par0195" class="elsevierStylePara elsevierViewall">Need of rescue doses of sedatives or analgesics.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">–</span><p id="par0200" class="elsevierStylePara elsevierViewall">Adverse events (accidental extubation, reintubation, respiratory depression, need of reversal, other).</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">–</span><p id="par0205" class="elsevierStylePara elsevierViewall">Lactate level in peripheral blood at admission and at 24 h (mmol/L, normal range: 0.6−2 mmol/L).</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical analysis</span><p id="par0210" class="elsevierStylePara elsevierViewall">We performed a basic descriptive analysis of the study variables. We calculated absolute and relative frequencies for qualitative variables. Depending on whether the data were normally distributed or not, which we determined using the Kolmogorov–Smirnov or the Shapiro–Wilk (<span class="elsevierStyleItalic">n</span> < 50) test, we summarised quantitative variables as mean ± standard deviation (SD) and range (minimum–maximum) or median and interquartile range (IQR), respectively. We compared qualitative data in the study groups by means of the χ<span class="elsevierStyleSup">2</span> or Fisher exact test, and quantitative data with the Student <span class="elsevierStyleItalic">t</span> test for independent samples or the Mann–Whitney <span class="elsevierStyleItalic">U</span> test depending on whether the data followed a normal distribution. We defined statistical significance as a <span class="elsevierStyleItalic">p-</span>value of less than 0.05. The statistical analysis was performed with the software PASW Statistics version 18.0 (IBM® SPSS Statistics v18.0).</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical considerations</span><p id="par0215" class="elsevierStylePara elsevierViewall">Patients were assigned a numerical code, and only the researchers that conducted the study had access to personally identifiable data, maintaining the confidentiality of participants in adherence with Organic Law 15/1999.</p><p id="par0220" class="elsevierStylePara elsevierViewall">The study was approved by the Ethics Committee of the Autonomous Community of Andalusia.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0225" class="elsevierStylePara elsevierViewall">The study included a total of 82 patients, 43 in group A and 39 in group B.</p><p id="par0230" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the general characteristics of the patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">The time to awakening after discontinuation of sedation/analgesia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) was significantly shorter in group A compared to group B (11.8 ± 10.6 min vs 137.3 ± 45 min; <span class="elsevierStyleItalic">P</span> < .001. On the other hand, the time to extubation after discontinuation of the medication (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) was 24.2 ± 21 min in group A compared to 230 ± 102 min in group B, a difference that was also statistically significant (<span class="elsevierStyleItalic">P</span> < .001).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">In group A, 10.5% of the patients experienced adverse events (4 patients accidental extubation, 3 patients agitation, 2 apnoea and 1 low blood pressure), none requiring reintubation. In group B, 13% of the patients experienced adverse events. Five of them developed respiratory depression after extubation, of who 2 required reintubation and 3 reversion of depressor effects with naloxone and flumazenil. In addition, 3 patients in this group experienced accidental extubation. We did not find significant differences between groups (<span class="elsevierStyleItalic">P</span> = .572).</p><p id="par0245" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the dosage of the drugs administered to the patients, expressed as the total dose (mean, range) of each drug, including rescue doses, required to achieve the established analgesia and sedition targets (pain scale score < 3, Ramsay sedation level 5).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">The serum lactate levels measured at admission and at 24 h were in the normal range in every patient in the total sample, without significant differences between groups (<span class="elsevierStyleItalic">P</span> = .93) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0255" class="elsevierStylePara elsevierViewall">When we analysed the outcomes under study, we found that the times to awakening and to extubation after discontinuation of sedation/analgesia were significantly shorter in the propofol-remifentanil group compared to the midazolam-fentanyl group, with results similar to those reported by Welzing et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0260" class="elsevierStylePara elsevierViewall">The most widely used combination of drugs is fentanyl or morphine for analgesia and midazolam for sedation,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which achieve adequate levels of sedation and analgesia in paediatric patients that require mechanical ventilation after surgery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, these drugs have a longer half-life, which may complicate extubation after their discontinuation and result in the need to reintubate or administer specific antidotes for reversion, as was the case in some of our patients. This is the reason that clinicians sometimes choose to give analgesics and sedatives with shorter half-lives, such as remifentanil and propofol, which can shorten the time to awakening and extubation after the medication is discontinued.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Based on the study conducted by Welzing et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> neonates and infants aged less than 60 days metabolise commonly used opiates like fentanyl and morphine slower, which, added to the accumulation of these drugs due to the immaturity of the liver, carries a risk of respiratory depression upon discontinuation of the opiate. Remifentanil could be very useful in these patients, as it does not accumulate when administered as continuous infusion and is metabolised by nonspecific esterases that exhibit a high metabolic activity even in preterm infants,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> which explain the shorter time to awakening and extubation,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> including in adults.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However, remifentanil has not proven superior to fentanyl in achieving and maintaining adequate analgesia.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In agreement with the study by Welzing et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> we found few adverse events, with a similar incidence in both groups (10.5% in group A and 13% in group B). Still, we ought to mention that adverse events were more severe in the fentanyl-midazolam group, as several patients experienced respiratory depression post extubation, requiring reversion with naloxone and flumazenil, and even reintubation in 2 cases.</p><p id="par0275" class="elsevierStylePara elsevierViewall">Another sedation and analgesia strategy that needs to be considered is the one employed in the study by Welzing et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> who switched from fentanyl-midazolam to remifentanil-propofol at the end of the weaning phase, thereby achieving a rapid transition from hypnosis to an appropriate level of alertness and regular spontaneous breathing.</p><p id="par0280" class="elsevierStylePara elsevierViewall">Propofol and remifentanil are widely used both in children and adults for anaesthesia induction and maintenance and for sedation in short operations or procedures.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–17</span></a> In association with dexmedetomidine, they can be used to reduce the dose of opioids and benzodiazepines.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Combining ketamine with remifentanil or propofol is also effective and safe, achieving adequate sedation and analgesia in procedures such as colonoscopy, although the scores were significantly better in the remifentanil-ketamine group compared to the propofol-ketamine group.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In mechanically ventilated children, the combination of remifentanil and midazolam achieves rapid sedation and analgesia, improves the effect of mechanical ventilation and allows a reduction in the dose of sedatives compared to midazolam as monotherapy, in addition to being well tolerated.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Despite the effectiveness of propofol, its use in continuous infusion, especially in children, has been limited due to the risk of the so-called propofol infusion syndrome, on account of which patients need to be closely monitored in order to suspend administration of propofol if abnormalities such as metabolic acidosis or hyperlactatemia of unknown aetiology develop.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">20</span></a> This is the reason that lactate levels were monitored in our patients, although hyperlactataemia was not detected in any in either group. This was consistent with the findings of previous studies, including some in which propofol was used for long periods of time without evidence of development of tolerance or adverse events. The risk is highest when continuous infusion lasts longer than 48 h and the dose is greater than 4 or 5 mg/kg/h, although the syndrome has been described in patients receiving lower doses or even a single dose.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Although the dosage of propofol, fentanyl and midazolam is well established, this is not the case of remifentanil, for which very different doses ranging from 6 to 120 μg/kg/h have been recommended,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> although they do not usually exceed 30 μg/kg/h.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,22</span></a> In our study, the total doses required to achieve adequate sedation/analgesia were as follows: remifentanil 28 ± 20 μg/kg/h, propofol 3 ± 2 mg/kg/h, fentanyl 3 ± 0.9 μg/kg/h and midazolam 0.5 ± 1.3 mg/kg/h.</p><p id="par0295" class="elsevierStylePara elsevierViewall">The chief limitations of this study are the retrospective inclusion of some of the patients and the relatively small sample size, due to which it is difficult to prove the superior effectiveness of one or the other sedation/analgesia regimens. Although few patients received neuromuscular blocking agents, we were not able to determine who these patients were, specifically.</p><p id="par0300" class="elsevierStylePara elsevierViewall">The main strength of the study is that the data corroborated our hypothesis, leading to the conclusion that the time elapsed to awakening, extubation and withdrawal of mechanical ventilation after discontinuation of medication was better in patients treated with propofol-remifentanil compared to those given midazolam-fentanyl.</p><p id="par0305" class="elsevierStylePara elsevierViewall">The frequency of adverse events was low and similar in both groups, although clinically significant respiratory depression was more frequent in the group treated with midazolam-fentanyl, in which some patients required specific antidotes for reversion of drug effects and even reintubation.</p><p id="par0310" class="elsevierStylePara elsevierViewall">While both propofol-remifentanil and midazolam-fentanyl seem to be effective combinations for sedation and analgesia in patients requiring short-term postoperative mechanical ventilation, randomised studies in larger samples are required to confirm this conclusion.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Data availability</span><p id="par0315" class="elsevierStylePara elsevierViewall">Our open-access data is available via Zenodo (<a href="https://doi.org/10.5281/zenodo.5794358">https://doi.org/10.5281/zenodo.5794358</a>) but we were unable to link this data set.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0320" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1710136" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1512685" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1710135" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1512684" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Exclusion criteria" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Sedation/analgesia protocol used in the study" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Assessment of analgesia" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Assessment of sedation" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Assessment of time of awakening" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Patient monitoring" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Study variables" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Statistical analysis" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Ethical considerations" ] ] ] 6 => array:2 [ "identificador" => "sec0065" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Data availability" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-22" "fechaAceptado" => "2020-11-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1512685" "palabras" => array:5 [ 0 => "Sedoanalgesia" 1 => "Midazolam" 2 => "Fentanyl" 3 => "Remifentanil" 4 => "Propofol" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1512684" "palabras" => array:5 [ 0 => "Sedoanalgesia" 1 => "Midazolam" 2 => "Fentanilo" 3 => "Remifentanilo" 4 => "Propofol" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 h. We compared two independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean ± standard deviation of patients were 49 ± 65 months, weight 17 ± 16 kg. Mechanical ventilation medium time was 22 h (3–72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8 ± 10,6 min group A and 137,3 ± 45 min group B (<span class="elsevierStyleItalic">P</span> < 0.001), extubation time after removing sedoanalgesia was of 24 ± 21 min group A and 230 ± 102 min group B (<span class="elsevierStyleItalic">P</span> < 0.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation) <span class="elsevierStyleItalic">P</span> = 0,572.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparar, entre 2 regímenes de sedoanalgesia, el tiempo trascurrido desde la retirada de la medicación hasta el despertar y hasta la extubación del paciente.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Metodología</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional, en pacientes pediátricos que, tras cirugía electiva, precisaron sedoanalgesia y ventilación mecánica durante un periodo máximo de 72 h. Comparamos dos grupos independientes de pacientes: grupo A, pacientes que recibieron sedoanalgesia con propofol-remifentanilo recogidos de forma prospectiva; y grupo B, pacientes que recibieron midazolam-fentanilo recogidos retrospectivamente mediante la revisión de las historias clínicas y base de datos de la unidad.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las variables estudiadas fueron: edad, peso, sexo, tipo de intervención, escalas de valoración de la sedoanalgesia, dosis totales empleadas, tiempo transcurrido desde la retirada de medicación hasta despertar y extubación, y efectos adversos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se recogieron 82 pacientes, 43 en el grupo A y 39 en el grupo B. La edad (media ± desviación estándar) de los pacientes fue de 49 ± 65 meses y 17,3 ± 16 kg de peso, con un tiempo de ventilación mecánica promedio de 22 horas (3–72). Tras retirar la medicación, el tiempo de despertar fue de 11,8 ± 10,6 min en el grupo A y de 137,3 ± 45 min en el grupo B (p < 0,001) y el tiempo de extubación de 24 ± 21 min en el grupo A y 230 ± 102 min en el B (p < 0,001). El 10,5% de los pacientes del grupo A presentó algún efecto adverso (7,9% agitación y 2,6% bradicardia) y, del grupo B, un 13% (depresión respiratoria tras extubación), con una p = 0,572.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los pacientes tratados con propofol-remifentanilo tienen un tiempo promedio significativamente menor de despertar, extubación y retirada de ventilación mecánica tras suspender la medicación. En el grupo de midazolam-fentanilo, fue más frecuente la existencia de depresión respiratoria, aunque el porcentaje de efectos adversos es similar en ambos grupos. Tanto la combinación de propofol-remifentanilo como midazolam-fentanilo parecen ser efectivas como pauta sedoanalgésica de pacientes sometidos a ventilación mecánica tras intervención quirúrgica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López Castilla JD, Sánchez Fernández N, Charlo Molina MT, Vázquez Florido A, Murillo Pozo MA, Sánchez Ganfornina I, et al. Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración. An Pediatr (Barc). 2022;96:115–121.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1201 "Ancho" => 1508 "Tamanyo" => 50190 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Time elapsed from discontinuation of sedation/analgesia to awakening. Group A: propofol-remifentanil (11.8 ± 10.6 min); Group B: midazolam-fentanyl (137 ± 45 min).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1203 "Ancho" => 1508 "Tamanyo" => 53559 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Time elapsed from discontinuation of sedation/analgesia to extubation. Group A: propofol-remifentanil (24.2 ± 21 min). Group B: midazolam-fentanyl (230 ± 102 min).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ramsay scale levels: 1–6; pain scale levels:0–10.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 ± 65 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.3 ± 16 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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56% female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44% 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"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maxillofacial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 patients (86.5%) \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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trauma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 patients (9.5%) \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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurosurgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 patients (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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time to awakening after discontinuation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.8 ± 10.6 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"><span class="elsevierStyleItalic">P</span> < .001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">137.3 ± 45 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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time to extubation after discontinuation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.2 ± 21 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"><span class="elsevierStyleItalic">P</span> .001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">230 ± 102 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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adverse events \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.5% of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span> > .05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13% of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lactate levels \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Admission, 1.22 ± 0.3 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span> > .05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 h, 0.89 ± 0.3 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Admission, 1.75 ± 0.3 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 h, 0.76 ± 0.3 mmol/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need of rescue doses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53% (23 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span> > .05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51% (20 patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scale sores before rescue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ramsay scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−3 (2.2 ± 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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7−9 (7.5 ± 0.6) \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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scale scores after rescue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ramsay scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5−6 (5.2 ± 04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0−2 (1.5 ± 0.9) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients that did not require rescue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ramsay scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−5 (4.5 ± 0.5) \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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0−3 (1.7 ± 1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2904490.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">General characteristics of the patients. Group A: sedoanalgesia con propofol-remifentanil; group B: sedoanalgesia con midazolam-fentanyl.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">h, hour; Max, maximum; Min, minimum; SD, standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dose \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Remifentanil μg/kg/h \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Propofol mg/kg/h \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fentanyl μg/kg/h \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Midazolam mg/kg/h \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Max \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2904489.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Total dose of sedation/analgesia drugs.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous propofol perfusión in critically ill children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.C. Agudelo" 1 => "S. Mencía" 2 => "A. Faro" 3 => "V. Escudero" 4 => "E. Sanavia" 5 => "J. López-Herce" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2011.11.018" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "410" "paginaFinal" => "415" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22244214" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population pharmacokinetics and metabolism of midazolam in pediatric intensive care patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.N. De Wilds" 1 => "M. de Hoog" 2 => "A.A. 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| Year/Month | Html | Total | |
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