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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Desde la publicaci&#243;n de Holliday y Segar &#40;H &#38; S&#41; en 1957&#44; la fluidoterapia intravenosa de mantenimiento &#40;FIM&#41; en pediatr&#237;a ha consistido en la administraci&#243;n de l&#237;quidos hipot&#243;nicos con un volumen total en funci&#243;n del gasto energ&#233;tico estimado&#44; situado entre el del metabolismo basal y el de la actividad f&#237;sica normal<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a>&#46; Desde entonces han sido comunicados casos de hiponatremias dilucionales secundarias a la utilizaci&#243;n de fluidos hipot&#243;nicos con un exceso de agua libre de electrolitos&#44; a vol&#250;menes diarios excesivos y al aumento de hormona antidiur&#233;tica &#40;ADH&#41; secundaria a algunos procesos<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; En 2003 Moritz et al&#46; plantearon por primera vez la utilizaci&#243;n de fluidos isot&#243;nicos como una alternativa m&#225;s segura a la pauta cl&#225;sica<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a>&#44; lo cual tuvo respuesta en sendos manuscritos por parte de Holliday et al<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Estos centraban sus argumentos en 2 cuestiones&#44; la normalizaci&#243;n del exceso de ADH mediante un bolo de fluido isot&#243;nico intravenoso&#44; a raz&#243;n de 20-40<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#44; administrado en 2-4<span class="elsevierStyleHsp" style=""></span>horas y que el planteamiento de Moritz et al&#46; no estaba respaldado por ning&#250;n ensayo cl&#237;nico en aquel momento&#46; No obstante&#44; diferentes sistemas nacionales de salud se hicieron eco de esta alarma&#44; suscribiendo unas recomendaciones muy claras al respecto<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46; En 2 metaan&#225;lisis publicados en el a&#241;o 2014<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">10&#44;11</span></a> se conclu&#237;a que la utilizaci&#243;n de fluidos isot&#243;nicos como FIM&#44; en comparaci&#243;n con hipot&#243;nicos&#44; disminu&#237;a el riesgo&#44; aunque no de forma completa&#44; tal y como se evidencia en el ensayo cl&#237;nico de McNab et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a>&#44; de aparici&#243;n de hiponatremia sin aumentar el riesgo de complicaciones como hipernatremia&#44; hipertensi&#243;n arterial y&#47;o edemas&#46; No obstante&#44; la mayor parte de los pacientes incluidos en los estudios referidos eran pacientes posquir&#250;rgicos o pacientes graves ingresados en unidades de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41;&#44; de tal forma que estas conclusiones podr&#237;an no ser aplicables a pacientes ingresados en una planta de hospitalizaci&#243;n general&#46; En el a&#241;o 2015 Friedman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> publicaron un ensayo cl&#237;nico en el que no se evidenciaban diferencias en la concentraci&#243;n de sodio en plasma a las 24 y 48<span class="elsevierStyleHsp" style=""></span>horas del inicio de la FIM&#44; independientemente de que esta estuviera compuesta por un fluido isot&#243;nico &#40;ClNa 0&#44;9&#37;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G 5&#37;&#41; o uno hipot&#243;nico &#40;ClNa 0&#44;45&#37;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G5&#37;&#41;&#46; Sin embargo las 2 hiponatremias acontecieron en 2 pacientes del grupo de fluidos hipot&#243;nicos&#44; obligando a excluirlos del estudio a las 24<span class="elsevierStyleHsp" style=""></span>horas del inicio de la infusi&#243;n&#46; Adem&#225;s&#44; en este mismo estudio se constataron&#44; en la rama de los tratados con fluidos isot&#243;nicos&#44; sendos casos de hipertensi&#243;n&#44; hipernatremia y edemas&#44; poniendo en duda la rotunda afirmaci&#243;n de los metaan&#225;lisis publicados un a&#241;o antes<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">10&#44;11</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A lo largo de la &#250;ltima d&#233;cada&#44; diversas investigaciones demuestran variaciones en la pr&#225;ctica a este respecto&#44; y que la FIM seg&#250;n H &#38; S sigue estando vigente en la cl&#237;nica habitual<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;19</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En este contexto actual el objetivo de nuestra investigaci&#243;n ha sido describir los conocimientos y las actitudes de los profesionales sanitarios de nuestro pa&#237;s respecto a la FIM en pediatr&#237;a&#44; su diversidad y los posibles factores asociados a la misma&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o y poblaci&#243;n</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudio observacional de corte transversal&#46; Hemos tomado como punto de partida las recomendaciones realizadas por la Sociedad Espa&#241;ola de Pediatr&#237;a Hospitalaria en su documento de consenso al respecto<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a>&#44; junto a otras 2 publicaciones<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">21&#44;22</span></a>&#44; para confeccionar mediante una herramienta del programa Google Drive una encuesta con 19 preguntas &#40;ve&#225;se la informaci&#243;n suplementaria en el <a class="elsevierStyleCrossRef" href="#sec0060">anexo 1</a>&#41;&#46; Habida cuenta de la ausencia de encuestas validadas para la realizaci&#243;n de un estudio de estas caracter&#237;sticas&#44; de acuerdo con los objetivos planteados y atendiendo a las pruebas cient&#237;ficas disponibles&#44; deb&#237;amos confeccionar una encuesta que recogiera&#44; a juicio del equipo investigador&#44; aspectos esenciales de la FIM&#58; volumen total a infundir en 24<span class="elsevierStyleHsp" style=""></span>horas&#44; tonicidad y composici&#243;n i&#243;nica&#46; Por otro lado&#44; deb&#237;an recogerse factores dependientes del profesional y de su &#225;mbito de trabajo que pudieran condicionar su prescripci&#243;n tal y como han sido ya comunicados en publicaciones previas<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; La encuesta elaborada finalmente se difundi&#243; v&#237;a <span class="elsevierStyleItalic">on-line</span> entre las distintas sociedades cient&#237;ficas m&#233;dicas y quir&#250;rgicas espa&#241;olas de &#225;mbito nacional y regional cuyo colectivo atiende a pacientes pedi&#225;tricos y pautan FIM&#44; solicit&#225;ndoles colaboraci&#243;n para su difusi&#243;n entre todos los asociados&#46; Tambi&#233;n se envi&#243; a la organizaci&#243;n m&#233;dica colegial de la provincia donde nace el estudio para que se difundiera al resto de organizaciones m&#233;dicas colegiales del territorio espa&#241;ol&#46; En el formulario enviado se invitaba a contestar &#250;nicamente a aquellos profesionales que pautaran FIM a pacientes pedi&#225;tricos en su pr&#225;ctica habitual&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Criterios de inclusi&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">Los destinatarios de nuestro formulario fueron todos aquellos profesionales que manejaran esta terapia en pacientes pedi&#225;tricos de un mes a 14 a&#241;os de edad&#44; en 4 contextos fundamentales&#58; pacientes atendidos en &#225;reas de urgencia&#44; pacientes ingresados en plantas hospitalarias por un proceso m&#233;dico agudo&#44; por un proceso quir&#250;rgico y los ingresados en unidades de cuidados intensivos pedi&#225;tricos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recogida de datos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Tras el env&#237;o del formulario v&#237;a <span class="elsevierStyleItalic">on-line</span> de forma protocolizada en 3 momentos diferentes&#58; primera difusi&#243;n&#44; diciembre de 2016&#59; segunda difusi&#243;n febrero-marzo de 2017&#59; tercera difusi&#243;n&#44; mayo de 2017 se recogieron encuestas hasta el 31 de diciembre de 2017&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico de los datos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Las variables estudiadas son todas cualitativas&#44; se muestran como recuentos absolutos y porcentajes con sus intervalos de confianza al 95&#37;&#44; y se analiz&#243; la asociaci&#243;n entre respuestas de estas variables de la encuesta mediante Chi cuadrado&#46; Posteriormente se realiz&#243; un an&#225;lisis multivariado mediante regresi&#243;n log&#237;stica binaria&#44; referido &#250;nicamente a la variable &#171;uso de fluidos hipot&#243;nicos como FIM habitual&#187;&#44; incluy&#233;ndose en el modelo aquellas variables que hab&#237;an resultado significativas en el an&#225;lisis bivariado&#44; las marginalmente significativas y otras que sin alcanzar significaci&#243;n estad&#237;stica se consideraron cl&#237;nicamente relevantes&#46; Se tom&#243; como nivel de significaci&#243;n p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 y de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;25 para el nivel de significaci&#243;n marginal&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se consider&#243; suficiente una muestra de 385 individuos para estimar&#44; con una confianza del 95&#37; y una precisi&#243;n de<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5 unidades porcentuales&#44; un porcentaje poblacional que previsiblemente fuera de alrededor del 50&#37;&#46; El an&#225;lisis estad&#237;stico se realiz&#243; mediante el programa SPSS para Windows versi&#243;n 21&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; Illinois&#44; Estados Unidos&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos &#233;ticos</span><p id="par0045" class="elsevierStylePara elsevierViewall">Se recibi&#243; la aprobaci&#243;n por parte del comit&#233; de &#233;tica e investigaci&#243;n del centro coordinador del estudio&#46; No se incluyen datos de pacientes y las encuestas han sido an&#243;nimas y voluntarias&#46; Los investigadores del estudio han sido los &#250;nicos que han tenido acceso a los datos de la encuesta&#44; recogidos &#250;nicamente con fines estad&#237;sticos&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se recibieron un total de 487 encuestas&#44; 456 de pediatras&#44; siendo de ellos m&#233;dicos residentes 67&#44; un 14&#44;69&#37;&#46; Bas&#225;ndonos en datos publicados por la Sociedad Espa&#241;ola de Pediatr&#237;a Hospitalaria<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a>&#44; la cifra total de pediatras que desempe&#241;an su labor asistencial en hospitales p&#250;blicos y privados de nuestro pa&#237;s&#44; en el a&#241;o 2011&#44; es de 4&#46;194 facultativos&#46; Esto supondr&#237;a una proporci&#243;n de respuesta a nuestra encuesta de aproximadamente el 10&#44;8&#37;&#46; Las 6 comunidades aut&#243;nomas desde las que se recibieron m&#225;s encuestas fueron Madrid&#44; 115&#44; un 25&#44;21&#37;&#59; Valencia&#44; 105&#44; un 23&#44;02&#37;&#59; Andaluc&#237;a&#44; 55&#44; un 12&#44;06&#37;&#59; Canarias&#44; 32&#44; un 7&#44;03&#37;&#59; Castilla La Mancha&#44; 31&#44; un 6&#44;81&#37;&#59; y Catalu&#241;a&#44; 28&#44; un 6&#44;14&#37;&#46; Las restantes agrupadas sumaron 90 encuestas&#44; un 19&#44;73&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se sintetiza la encuesta con sus opciones de respuesta&#46; De ella puede destacarse que un 7&#44;45&#37; &#40;IC 95&#37;&#58; 4&#44;22-10&#44;68&#41; de los profesionales no hace una distinci&#243;n conceptual correcta entre fluidos hipot&#243;nicos e isot&#243;nicos&#46; Los fluidos hipot&#243;nicos son utilizados de forma general por el 28&#44;95&#37; &#40;IC 95&#37;&#58; 24&#44;77-33&#44;13&#41; de los profesionales y &#250;nicamente el 14&#44;47&#37; &#40;IC 95&#37;&#58; 11&#44;23-17&#44;72&#41; utilizan vol&#250;menes inferiores a los propuestos por H &#38; S&#46; Adem&#225;s&#44; el 14&#44;91&#37; &#40;IC 95&#37;&#58; 11&#44;63-18&#44;19&#41; de los encuestados declara que en su grupo de trabajo no existe ning&#250;n tipo de consenso al respecto de este tema&#46; Por otro lado&#44; la <span class="elsevierStyleItalic">utilizaci&#243;n de fluidos hipot&#243;nicos</span> se asocia a caracter&#237;sticas del prescriptor y de su contexto de trabajo&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 2</a> puede observarse un an&#225;lisis bivariado y multivariado al respecto que muestra los factores que con una mayor fuerza se asocian a la prescripci&#243;n de fluidos hipot&#243;nicos&#46; La <span class="elsevierStyleItalic">utilizaci&#243;n de vol&#250;menes inferiores</span> a los recomendados tradicionalmente se asocia tambi&#233;n a un determinado perfil profesional&#44; destacando que los que trabajan en UCIP utilizan m&#225;s frecuentemente vol&#250;menes inferiores en comparaci&#243;n con los que no&#44; 28&#37; frente a un 11&#44;5&#37;&#46; &#218;nicamente 19 de los pediatras encuestados&#44; un 4&#44;3&#37;&#44; utilizan vol&#250;menes superiores a las recomendaciones de H &#38; S y de ellos 9&#44; un 2&#37; sobre el total&#44; prescriben adem&#225;s fluidos hipot&#243;nicos&#46; Otros aspectos relacionados con la prescripci&#243;n de la FIM y algunos factores que podr&#237;an encontrarse asociados a la misma pueden observarse en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0055" class="elsevierStylePara elsevierViewall">Existen importantes evidencias a favor del uso de fluidos isot&#243;nicos como FIM<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">10&#44;11&#44;24</span></a>&#46; Parece por tanto el momento de valorar la sustituci&#243;n de los fluidos hipot&#243;nicos &#40;ClNa<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;45&#37;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G5&#37;&#41; en favor de isot&#243;nicos &#40;ClNa 0&#44;9&#37;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G5&#37;&#41; en la mayor&#237;a de los pacientes ingresados que precisen FIM<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">25&#8211;27</span></a>&#46; No obstante&#44; estudios a nivel internacional demuestran que esto no es as&#237;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;19</span></a>&#44; siendo nuestra investigaci&#243;n ejemplo de ello&#44; pues un 28&#44;9&#37; de los encuestados declara utilizar hipot&#243;nicos de forma general en su pr&#225;ctica cl&#237;nica habitual&#46; Adem&#225;s&#44; un 7&#44;4&#37; de los profesionales de nuestro estudio no distingue correctamente los fluidos intravenosos atendiendo a su tonicidad&#46; Por otro lado&#44; existe una l&#243;gica fisiopatol&#243;gica en favor de que si tomamos como referencia los vol&#250;menes propuestos por H &#38; S&#44; basados en ni&#241;os sanos con actividad normal&#44; podr&#237;amos estar sobrestimando las necesidades de nuestros pacientes hospitalizados&#44; dada su inactividad inherente al ingreso y la retenci&#243;n de agua libre como consecuencia de un exceso de ADH asociada a varios est&#237;mulos no osm&#243;ticos presentes en estos pacientes&#46; Esto hace que algunos profesionales restrinjan el volumen total de la FIM&#44; tal y como se refleja en el estudio de Davies<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a>&#46; En nuestro caso particular es el 14&#44;4&#37; de los facultativos los que restringen de forma general el volumen de la FIM que aplican a sus pacientes&#44; y este porcentaje aumenta a un 28&#37; cuando se trata de facultativos de UCIP&#46; No obstante&#44; no podemos saber con exactitud c&#243;mo de potente es el est&#237;mulo no osm&#243;tico que cada paciente sufre durante su hospitalizaci&#243;n&#46; Probablemente los pacientes quir&#250;rgicos y los que padecen enfermedades del sistema nervioso central &#40;meningitis&#44; encefalitis y traumatismos craneoencef&#225;licos graves&#41; sean los que presenten un mayor exceso de ADH&#44; y por tanto tendr&#225;n mayor riesgo de hiponatremia dilucional si les administramos hipot&#243;nicos y con un volumen total acorde con H &#38; S&#46; No obstante&#44; tambi&#233;n hay otros pacientes hospitalizados con procesos leves&#44; no como los anteriores&#44; sin est&#237;mulos no osm&#243;ticos para la ADH&#44; en los cuales los vol&#250;menes seg&#250;n pauta de H &#38; S sean una opci&#243;n adecuada&#46; Probablemente la situaci&#243;n de mayor riesgo para que un paciente pedi&#225;trico hospitalizado presente una hiponatremia dilucional ser&#237;a la administraci&#243;n de unos fluidos intravenosos hipot&#243;nicos a vol&#250;menes por encima de H &#38; S&#44; aunque esto no lo podemos afirmar con rotundidad dadas las pruebas cient&#237;ficas de las que disponemos en la actualidad<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a>&#46; Debemos destacar que aun siendo esta pr&#225;ctica anecd&#243;tica en nuestra muestra&#44; tan solo un 2&#37; de los encuestados&#44; no podemos afirmar lo mismo a la vista de los resultados del estudio de Davies et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a>&#44; donde hasta un 38&#37; utilizaban vol&#250;menes superiores a H &#38; S&#44; que junto a unos fluidos hipot&#243;nicos lo convert&#237;an en aquel momento&#44; a&#241;o 2008&#44; en una pr&#225;ctica poco segura para el paciente&#46; As&#237;&#44; un metaan&#225;lisis reciente demuestra la asociaci&#243;n entre la sobrecarga de volumen de fluidos y el aumento de la morbimortalidad en pacientes pedi&#225;tricos cr&#237;ticamente enfermos<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">No hemos encontrado en la literatura estudios que describan la pr&#225;ctica cl&#237;nica a este respecto centrados en pediatras&#46; En la mayor&#237;a de ellos&#44; y a trav&#233;s de una encuesta&#44; se eval&#250;a mediante la propuesta de diferentes escenarios cl&#237;nicos los conocimientos de los profesionales a cerca del tipo de fluidos a infundir en cuanto a su tonicidad y volumen total&#46; En ellos&#44; el fluido utilizado var&#237;a ampliamente y&#44; en general&#44; se siguen utilizando los hipot&#243;nicos&#44; sin restringir su volumen&#46; Estas diferencias est&#225;n poco estudiadas&#44; y as&#237; Way et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> concluyen que a mayor entrenamiento espec&#237;fico y n&#250;mero de intervenciones con pacientes pedi&#225;tricos mayor probabilidad de utilizar fluidos isot&#243;nicos&#46; Keijzers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a>&#44; en una investigaci&#243;n desarrollada en un solo hospital y en un grupo heterog&#233;neo de m&#233;dicos&#44; evidenciaron que la elecci&#243;n correcta de fluidos en cuanto a su tonicidad y volumen a infundir en funci&#243;n de un determinado escenario cl&#237;nico se correlacionaba con el grado de experiencia en el manejo de pacientes pedi&#225;tricos&#44; con el hecho de ser pediatra y especialista de urgencias hospitalarias frente al resto de especialidades &#40;cirug&#237;a&#44; anestesia&#41; y con haber recibido formaci&#243;n espec&#237;fica en cuanto a la prescripci&#243;n de la FIM en pacientes pedi&#225;tricos&#46; En el resto de investigaciones &#250;nicamente evaluaron los conocimientos de los profesionales en comparaci&#243;n con las mejores pruebas disponibles en aquel momento&#44; concluyendo algunos de ellos que la tendencia a prescribir hipot&#243;nicos en lugar de isot&#243;nicos en un contexto cl&#237;nico que requer&#237;a de estos &#250;ltimos era mayor en caso de que el paciente fuera un lactante<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>12 meses en comparaci&#243;n con pacientes de mayor edad<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#8211;17&#44;19</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">En nuestro trabajo se observa c&#243;mo el desempe&#241;ar la asistencia en un centro p&#250;blico frente a privado&#44; en una UCIP frente al resto&#44; ser pediatra frente a residente de pediatr&#237;a y existir consenso en el grupo profesional son factores que podr&#237;an estar asociados a la no utilizaci&#243;n de fluidos hipot&#243;nicos&#44; utilizando isot&#243;nicos en su lugar al pautar FIM&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Hemos estudiado tambi&#233;n algunas pr&#225;cticas de prescripci&#243;n respecto a los iones potasio y calcio como componentes de la FIM&#46; No hemos encontrado literatura espec&#237;fica que clarifique determinados aspectos de este tema&#44; como el hecho de esperar a adicionar el potasio a la FIM tras corroborar diuresis en el paciente&#46; Algunos manuales recomiendan unas cantidades de ClK entre 20 y 40<span class="elsevierStyleHsp" style=""></span>mEq&#47;l<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">21&#44;22</span></a>&#44; sin que hayamos podido encontrar evidencias en la literatura de cu&#225;l es la dosis m&#225;s adecuada&#46; Llamativa es tambi&#233;n la diferencia de criterio en cuanto a la adici&#243;n de calcio&#44; siendo los intensivistas los que en mayor proporci&#243;n lo a&#241;aden&#46; La homeostasis del calcio es de gran importancia en el paciente cr&#237;tico&#44; especialmente en pacientes politraumatizados y en situaci&#243;n de shock<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a>&#46; Tal vez sea este el motivo por el cual los profesionales que trabajan en unidades cr&#237;ticas a&#241;aden este ion al gotero&#46; No obstante&#44; ser&#237;an necesarios estudios m&#225;s espec&#237;ficos para esclarecer estas motivaciones&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Nuestro trabajo presenta limitaciones&#59; la primera es que se trata de una encuesta elaborada espec&#237;ficamente por los propios autores para el desarrollo de la investigaci&#243;n y&#44; por tanto&#44; no est&#225; validada previamente&#46; Esta se autoadministr&#243; por correo electr&#243;nico&#44; teniendo cobertura y representatividad limitada&#46; Adem&#225;s&#44; presenta un sesgo de cobertura geogr&#225;fica en relaci&#243;n con la comunidad aut&#243;noma de procedencia de los diferentes autores&#44; predominando las respuestas desde la Comunidad Valenciana&#44; Madrid y Castilla La Mancha&#46; En segundo lugar presenta un sesgo de inter&#233;s dif&#237;cil de evitar en este tipo de investigaciones&#44; que hace que principalmente el profesional interesado&#44; y tal vez actualizado en este tema&#44; tienda a participar m&#225;s&#44; sobreestimando a este grupo&#44; alterando el resultado final no ajust&#225;ndose a la realidad&#46; La tercera es que lo que nos comunican los encuestados como pr&#225;ctica cl&#237;nica no tiene por qu&#233; corresponderse de forma fidedigna con su realidad&#44; ya que en ocasiones el profesional responde lo que sabe que se debe hacer&#44; y no lo que hace en realidad<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a>&#46; Adem&#225;s&#44; nuestra investigaci&#243;n se produce 14 a&#241;os despu&#233;s de que Moritz et al&#46; propusieran por primera vez la utilizaci&#243;n de isot&#243;nicos como fluidos de mantenimiento<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a>&#44; y 11 tras la primera publicaci&#243;n que analizaba la prescripci&#243;n de la FIM en pediatr&#237;a<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a>&#46; No obstante&#44; esto m&#225;s que restar valor a nuestra investigaci&#243;n nos deber&#237;a preocupar m&#225;s si cabe&#44; pues todav&#237;a a la vista de nuestros resultados quedan facultativos en nuestro pa&#237;s que podr&#237;an estar prescribiendo una FIM no ajustada a las necesidades de cada paciente en funci&#243;n de las mejores pruebas disponibles&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Querr&#237;amos destacar el hecho de ser una investigaci&#243;n realizada exclusivamente en pediatras&#44; al no haber encontrado en la literatura otro estudio sobre este tema centrado en esta especialidad m&#233;dica&#46; Por n&#250;mero de encuestas incluidas nuestro trabajo resulta ser el m&#225;s numeroso<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;19</span></a>&#46; Adem&#225;s hemos investigado otros aspectos de la FIM que no han sido analizados hasta la fecha&#44; como son la adici&#243;n de potasio y calcio a estos fluidos de mantenimiento&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">M&#225;s de una cuarta parte de los pediatras espa&#241;oles siguen pautando fluidos hipot&#243;nicos como FIM&#46; Se presentan posibles factores asociados al hecho de la diferente aplicaci&#243;n de la evidencia cient&#237;fica a la pr&#225;ctica que los pediatras realizan a este respecto&#46; Investigaciones como la nuestra son reflejo de la lentitud para trasladar la evidencia cient&#237;fica a la pr&#225;ctica m&#233;dica<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a>&#46; Ser capaces de elaborar gu&#237;as de pr&#225;ctica cl&#237;nica que nos permitan sintetizar el conocimiento para transmitirlo y diseminarlo posteriormente de forma efectiva es lo que transforma nuestras organizaciones sanitarias en empresas que prestan un servicio de calidad y seguro para el paciente<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">32&#44;33</span></a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0090" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => "Fluidoterapia"
            1 => "Infusiones intravenosas"
            2 => "Hiponatremia"
            3 => "Encuestas de atenci&#243;n de salud"
            4 => "Pediatras"
            5 => "Pautas de pr&#225;ctica en medicina"
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            0 => "Fluid therapy"
            1 => "Infusions intravenous"
            2 => "Hyponatraemia"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los fluidos isot&#243;nicos&#44; en la mayor&#237;a de los casos&#44; constituyen la forma m&#225;s segura de administraci&#243;n de l&#237;quidos por v&#237;a intravenosa&#46; Los objetivos de nuestro trabajo han sido describir las pr&#225;cticas de prescripci&#243;n de los fluidos intravenosos de mantenimiento y estudiar los posibles factores asociados&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal&#44; descriptivo&#44; multic&#233;ntrico de &#225;mbito nacional&#44; mediante encuesta <span class="elsevierStyleItalic">on-line</span>&#44; difundida a trav&#233;s de sociedades cient&#237;ficas m&#233;dicas y la Organizaci&#243;n M&#233;dica Colegial&#44; entre diciembre de 2016 y diciembre de 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Un total de 487 encuestas fueron recibidas&#44; 456 de pediatras&#46; El 28&#44;95&#37; &#40;IC 95&#37;&#58; 24&#44;77-33&#44;13&#41; de ellos prescrib&#237;an habitualmente fluidos hipot&#243;nicos y el 81&#44;14&#37; &#40;IC 95&#37;&#58; 77&#44;54-84&#44;74&#41; se basaba en la regla de Holliday y Segar para calcular el volumen total a infundir&#46; El perfil del pediatra en Espa&#241;a que utiliza fluidos hipot&#243;nicos intravenosos es el de m&#233;dico residente de pediatr&#237;a&#44; pediatra que trabaja en &#225;reas diferentes a las unidades de cuidados intensivos pedi&#225;tricos&#44; en hospitales privados&#44; y aquellos que reconocen que no existe un consenso al respecto en su grupo de trabajo&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">M&#225;s de una cuarta parte de los pediatras en nuestro pa&#237;s sigue utilizando los fluidos hipot&#243;nicos como fluidoterapia intravenosa de mantenimiento&#46; Diferentes factores podr&#237;an estar asociados a este hecho&#46; Estos estudios son prueba de las grandes dificultades existentes para trasladar el conocimiento a la pr&#225;ctica&#46;</p></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Isotonic fluids&#44; in most cases&#44; are the safest way to dispense fluids intravenously&#46; The aim of this study was to determine the prescription of maintenance intravenous fluids and to study possible associated factors&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A descriptive&#44; cross-sectional&#44; multi-centre study was performed&#46; A questionnaire was sent nationwide to several healthcare providers via an on-line survey&#44; sent by email through different Medical Scientific Societies&#44; and the Official Spanish Medical Association&#44; between December 2016 and December 2017&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A total of 487 questionnaires were received&#44; of which 456 were submitted by paediatricians&#46; More than one quarter &#40;28&#46;95&#37;&#41; &#40;95&#37; CI&#59; 24&#46;77-33&#46;13&#41; of the paediatricians usually dispense hypotonic fluids and 81&#46;14&#37; &#40;95&#37; CI&#59; 77&#46;54-84&#46;74&#41; prescribe infusion rates based on the Holliday and Segar protocol&#46; The general profile of paediatricians who prescribe hypotonic fluids intravenously in Spain are medical residents&#44; paediatricians working in paediatric non-intensive care units&#44; in private hospitals&#44; and those who recognise that no consensus exists among their direct work colleagues regarding this subject&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">More than twenty-five per cent of all paediatricians in our country continue to use hypotonic fluids as maintenance intravenous fluid therapy&#46; There might be several potential factors associated to this&#46; These kind of studies provide evidence of the great difficulties in transferring scientific knowledge to clinical practice&#46;</p></span>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">En la columna de la izquierda se presenta la pregunta planteada&#44; expres&#225;ndose el n&#250;mero absoluto de respuestas a cada una de ellas y su porcentaje respecto al total entre par&#233;ntesis&#46; En la columna de la derecha las diferentes opciones de respuesta&#44; expres&#225;ndose sus recuentos en n&#250;meros absolutos y sus porcentajes junto a su intervalo de confianza del 95&#37;&#44; entre par&#233;ntesis&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ClK&#58; cloruro pot&#225;sico&#59; FIM&#58; fluidoterapia intravenosa de mantenimiento&#59; H &#38; S&#58; Holliday and Segar&#59; IC&#58; intervalo de confianza&#59; 2<span class="elsevierStyleHsp" style=""></span>M&#58; 2 molar&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t">1&#46; Distingue correctamente los distintos tipos de fluidos intravenosos en funci&#243;n de su tonicidad&#44; 456 &#40;100&#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">Distingue correctamente&#44; 422 &#40;92&#44;54&#59; IC 90&#44;12-94&#44;96&#41;&#46;El isot&#243;nico es el lactato de ringer&#44; 9 &#40;1&#44;97&#59; IC 0&#44;69-3&#44;26&#41;&#46;Son isot&#243;nicos los fluidos 0&#44;20&#37; &#40;1&#47;5&#41; y 0&#44;33&#37; &#40;1&#47;3&#41;&#44; 25 &#40;5&#44;48&#59; IC 3&#44;39-7&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&#46; Tipo de FIM en su pr&#225;ctica habitual en un paciente en normonatremia&#44; 455 &#40;99&#44;8&#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">Predominantemente isot&#243;nicos&#44; 297 &#40;65&#44;13&#59; IC 60&#44;74-69&#44;52&#41;&#46;Indistintamente isot&#243;nicos e hipot&#243;nicos&#44; 27 &#40;5&#44;92&#59; IC 3&#44;75-8&#44;10&#41;&#46;Predominantemente hipot&#243;nicos&#44; 131 &#40;28&#44;95&#59; IC 24&#44;77-33&#44;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">3&#46; Volumen total de FIM en 24<span class="elsevierStyleHsp" style=""></span>horas&#44; 455 &#40;99&#44;8&#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">Siguen la regla de H &#38; S&#44; 370 &#40;81&#44;14&#59; IC 77&#44;54-84&#44;74&#41;&#46;Utilizan en general vol&#250;menes inferiores&#44; 80&#37; de esta regla&#44; 66 &#40;14&#44;47&#59; IC 11&#44;23-17&#44;72&#41;Utilizan vol&#250;menes superiores a la regla de H &#38; S&#44; 19 &#40;4&#44;39&#59; IC 2&#44;50-6&#44;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">4&#46; Momento de la adici&#243;n de ClK a la FIM&#44; 456 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Siempre FIM con cloruro pot&#225;sico desde el inicio de la infusi&#243;n&#44; 33 &#40;7&#44;24&#59; IC 4&#44;85-9&#44;62&#41;Se a&#241;ade el ClK tras corroborarse diuresis del paciente&#44; 100 &#40;21&#44;93&#59; IC 18&#44;12-25&#44;74&#41;Depende del estado cl&#237;nico y grado de deshidrataci&#243;n del paciente&#46; Si la situaci&#243;n cl&#237;nica no es buena se espera a mejorar y comprobar diuresis&#44; 323 &#40;70&#44;83&#59; IC 66&#44;65-75&#44;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; Cantidad en mililitros de ClK 2<span class="elsevierStyleHsp" style=""></span>M que a&#241;ade a la FIM&#44; 455 &#40;99&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5<span class="elsevierStyleHsp" style=""></span>ml de ClK 2<span class="elsevierStyleHsp" style=""></span>M por kg de peso del paciente en 24<span class="elsevierStyleHsp" style=""></span>horas&#44; 17 &#40;3&#44;73&#59; IC 1&#44;98-5&#44;47&#41;&#46;Seg&#250;n peso paciente<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>kg&#44; 2-3<span class="elsevierStyleHsp" style=""></span>ml de ClK 2<span class="elsevierStyleHsp" style=""></span>M por cada 500<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido a infundir&#59; m&#225;s de 10<span class="elsevierStyleHsp" style=""></span>kg&#44; 5<span class="elsevierStyleHsp" style=""></span>ml por cada 500<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido a infundir&#44; 120 &#40;26&#44;32&#59; IC 22&#44;26-30&#44;37&#41;No lo tiene en cuenta&#46; Utiliza unos fluidos est&#225;ndar con ClK incorporado&#44; 18 &#40;3&#44;95&#59; IC 2&#44;15-5&#44;74&#41;Seg&#250;n necesidades basales&#44; 20-30<span class="elsevierStyleHsp" style=""></span>mEq&#47;l de l&#237;quido a infundir&#44; 150 &#40;32&#44;89&#59; IC 28&#44;57-37&#44;22&#41;Ninguna opci&#243;n de respuesta describe mi forma de proceder&#44; 150 &#40;33&#44;11&#59; IC 28&#44;78-37&#44;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46; Cantidad de calcio en la FIM&#44; 355 &#40;77&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En ni&#241;os&#44; 20-40 mg&#47;kg&#47;d&#237;a y en lactantes&#44; 40-80<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#237;a&#44; 17 &#40;4&#44;79&#59; IC 2&#44;56-7&#44;02&#41;10<span class="elsevierStyleHsp" style=""></span>ml de gluconato c&#225;lcico por cada 500<span class="elsevierStyleHsp" style=""></span>ml de FIM&#44; 37 &#40;10&#44;40&#59; IC 7&#44;89-12&#44;91&#41;No a&#241;ado calcio a la FIM&#44; 301 &#40;84&#44;82&#59; IC 80&#44;32-89&#44;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46; Modo de mantenerse actualizado al respecto&#44; 456 &#40;100&#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">Lectura de libros y manuales&#44; 16 &#40;3&#44;51&#59; IC 1&#44;81-5&#44;20&#41;Lectura de literatura cient&#237;fica&#44; 119 &#40;26&#44;10&#59; IC 22&#44;05-30&#44;14&#41;Asistencia a cursos&#44; jornadas y congresos&#44; 60 &#40;13&#44;16&#59; IC 10&#44;04-16&#44;27&#41;&#46;Sesiones cl&#237;nicas de equipo&#44; 247 &#40;54&#44;17&#59; IC 49&#44;58-58&#44;76&#41;&#46;Conversaciones con colegas&#44; 14 &#40;3&#44;07&#59; IC 1&#44;48-4&#44;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46; Existencia de consenso en mi equipo de trabajo&#44; 456 &#40;100&#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">Existe consenso verbal &#250;nicamente&#44; 130 &#40;28&#44;51&#59; IC 24&#44;35-32&#44;67&#41;&#46;Existe consenso verbal y escrito&#44; 258 &#40;56&#44;58&#59; IC 52&#44;01-61&#44;15&#41;No existe consenso de ning&#250;n tipo&#44; ni verbal ni escrito&#44; 68 &#40;14&#44;91&#59; IC 11&#44;63-18&#44;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46; Tiempo de uso de isot&#243;nicos en caso de utilizarlos como FIM&#44; 302 &#40;66&#44;2&#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">M&#225;s de 5 a&#241;os&#44; 59 &#40;19&#44;54&#59; IC 15&#44;04-24&#44;03&#41;Entre 2 y 5 a&#241;os&#44; 112 &#40;37&#44;09&#59; IC 31&#44;61-42&#44;56&#41;Menos de 2 a&#241;os&#44; 131 &#40;43&#44;38&#59; IC 37&#44;76-49&#44;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">An&#225;lisis bivariado</th><th class="td" title="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">L&#237;mites paraIC 95&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\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">1&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;68-1&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">312 &#40;68&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;28&#44;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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Var&#243;n<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">144 &#40;31&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">41 &#40;28&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Experiencia profesional</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106 &#40;23&#44;2&#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">29 &#40;27&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;29-2&#44;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5-15 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">158 &#40;34&#44;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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Residente de pediatr&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;20-0&#44;84&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>UCIP<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;14&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">374 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Factores asociados a la prescripci&#243;n de l&#237;quidos hipot&#243;nicos en la fluidoterapia intravenosa de mantenimiento&#58; an&#225;lisis bivariado y multivariado</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AP&#58; atenci&#243;n primaria&#59; ClK&#58; cloruro pot&#225;sico&#59; FIM&#58; fluidoterapia intravenosa de mantenimiento&#59; H &#38; S&#58; Holliday and Segar&#59; UCIP&#58; unidad de cuidados intensivos pedi&#225;tricos&#59; VT&#58; volumen total&#46;</p>"
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Original
Uso de sueros hipotónicos en la prescripción de la fluidoterapia intravenosa de mantenimiento
Use of hypotonic fluids in the prescription of maintenance intravenous fluid therapy
Juan Manuel Rius Perisa,b,
Autor para correspondencia
riusjua@gmail.com

Autor para correspondencia.
, Cristina Rivas-Juesasc, Ana Isabel Maraña Péreza,b, Roi Piñeiro Pérezd, Vicente Modesto i Alaponte, Javier Miranda Malleaf, Abel Cuellar de Leóng
a Hospital Virgen de la Luz, Cuenca, España
b Instituto de Tecnología, Universidad de Castilla-La Mancha, Cuenca, España
c Hospital de Sagunto, Sagunto, Valencia, España
d Hospital General de Villalba, Collado Villalba, Madrid, España
e Hospital Universitario y Politécnico La Fe, Valencia, España
f Hospital Vithas Nisa 9 de Octubre, Valencia, España
g Unidad Móvil de Emergencias de la GUETS, Motilla del Palancar, Cuenca, España
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Adem&#225;s&#44; en este mismo estudio se constataron&#44; en la rama de los tratados con fluidos isot&#243;nicos&#44; sendos casos de hipertensi&#243;n&#44; hipernatremia y edemas&#44; poniendo en duda la rotunda afirmaci&#243;n de los metaan&#225;lisis publicados un a&#241;o antes<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">10&#44;11</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A lo largo de la &#250;ltima d&#233;cada&#44; diversas investigaciones demuestran variaciones en la pr&#225;ctica a este respecto&#44; y que la FIM seg&#250;n H &#38; S sigue estando vigente en la cl&#237;nica habitual<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;19</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En este contexto actual el objetivo de nuestra investigaci&#243;n ha sido describir los conocimientos y las actitudes de los profesionales sanitarios de nuestro pa&#237;s respecto a la FIM en pediatr&#237;a&#44; 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Habida cuenta de la ausencia de encuestas validadas para la realizaci&#243;n de un estudio de estas caracter&#237;sticas&#44; de acuerdo con los objetivos planteados y atendiendo a las pruebas cient&#237;ficas disponibles&#44; deb&#237;amos confeccionar una encuesta que recogiera&#44; a juicio del equipo investigador&#44; aspectos esenciales de la FIM&#58; volumen total a infundir en 24<span class="elsevierStyleHsp" style=""></span>horas&#44; tonicidad y composici&#243;n i&#243;nica&#46; Por otro lado&#44; deb&#237;an recogerse factores dependientes del profesional y de su &#225;mbito de trabajo que pudieran condicionar su prescripci&#243;n tal y como han sido ya comunicados en publicaciones previas<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; La encuesta elaborada finalmente se difundi&#243; v&#237;a <span class="elsevierStyleItalic">on-line</span> entre las distintas sociedades cient&#237;ficas m&#233;dicas y quir&#250;rgicas espa&#241;olas de &#225;mbito nacional y regional cuyo colectivo atiende a pacientes pedi&#225;tricos y pautan FIM&#44; solicit&#225;ndoles colaboraci&#243;n para su difusi&#243;n entre todos los asociados&#46; Tambi&#233;n se envi&#243; a la organizaci&#243;n m&#233;dica colegial de la provincia donde nace el estudio para que se difundiera al resto de organizaciones m&#233;dicas colegiales del territorio espa&#241;ol&#46; En el formulario enviado se invitaba a contestar &#250;nicamente a aquellos profesionales que pautaran FIM a pacientes pedi&#225;tricos en su pr&#225;ctica habitual&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Criterios de inclusi&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">Los destinatarios de nuestro formulario fueron todos aquellos profesionales que manejaran esta terapia en pacientes pedi&#225;tricos de un mes a 14 a&#241;os de edad&#44; en 4 contextos fundamentales&#58; pacientes atendidos en &#225;reas de urgencia&#44; pacientes ingresados en plantas hospitalarias por un proceso m&#233;dico agudo&#44; por un proceso quir&#250;rgico y los ingresados en unidades de cuidados intensivos pedi&#225;tricos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recogida de datos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Tras el env&#237;o del formulario v&#237;a <span class="elsevierStyleItalic">on-line</span> de forma protocolizada en 3 momentos diferentes&#58; primera difusi&#243;n&#44; diciembre de 2016&#59; segunda difusi&#243;n febrero-marzo de 2017&#59; tercera difusi&#243;n&#44; mayo de 2017 se recogieron encuestas hasta el 31 de diciembre de 2017&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico de los datos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Las variables estudiadas son todas cualitativas&#44; se muestran como recuentos absolutos y porcentajes con sus intervalos de confianza al 95&#37;&#44; y se analiz&#243; la asociaci&#243;n entre respuestas de estas variables de la encuesta mediante Chi cuadrado&#46; Posteriormente se realiz&#243; un an&#225;lisis multivariado mediante regresi&#243;n log&#237;stica binaria&#44; referido &#250;nicamente a la variable &#171;uso de fluidos hipot&#243;nicos como FIM habitual&#187;&#44; incluy&#233;ndose en el modelo aquellas variables que hab&#237;an resultado significativas en el an&#225;lisis bivariado&#44; las marginalmente significativas y otras que sin alcanzar significaci&#243;n estad&#237;stica se consideraron cl&#237;nicamente relevantes&#46; Se tom&#243; como nivel de significaci&#243;n p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 y de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;25 para el nivel de significaci&#243;n marginal&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se consider&#243; suficiente una muestra de 385 individuos para estimar&#44; con una confianza del 95&#37; y una precisi&#243;n de<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5 unidades porcentuales&#44; un porcentaje poblacional que previsiblemente fuera de alrededor del 50&#37;&#46; El an&#225;lisis estad&#237;stico se realiz&#243; mediante el programa SPSS para Windows versi&#243;n 21&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; Illinois&#44; Estados Unidos&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos &#233;ticos</span><p id="par0045" class="elsevierStylePara elsevierViewall">Se recibi&#243; la aprobaci&#243;n por parte del comit&#233; de &#233;tica e investigaci&#243;n del centro coordinador del estudio&#46; No se incluyen datos de pacientes y las encuestas han sido an&#243;nimas y voluntarias&#46; Los investigadores del estudio han sido los &#250;nicos que han tenido acceso a los datos de la encuesta&#44; recogidos &#250;nicamente con fines estad&#237;sticos&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se recibieron un total de 487 encuestas&#44; 456 de pediatras&#44; siendo de ellos m&#233;dicos residentes 67&#44; un 14&#44;69&#37;&#46; Bas&#225;ndonos en datos publicados por la Sociedad Espa&#241;ola de Pediatr&#237;a Hospitalaria<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a>&#44; la cifra total de pediatras que desempe&#241;an su labor asistencial en hospitales p&#250;blicos y privados de nuestro pa&#237;s&#44; en el a&#241;o 2011&#44; es de 4&#46;194 facultativos&#46; Esto supondr&#237;a una proporci&#243;n de respuesta a nuestra encuesta de aproximadamente el 10&#44;8&#37;&#46; Las 6 comunidades aut&#243;nomas desde las que se recibieron m&#225;s encuestas fueron Madrid&#44; 115&#44; un 25&#44;21&#37;&#59; Valencia&#44; 105&#44; un 23&#44;02&#37;&#59; Andaluc&#237;a&#44; 55&#44; un 12&#44;06&#37;&#59; Canarias&#44; 32&#44; un 7&#44;03&#37;&#59; Castilla La Mancha&#44; 31&#44; un 6&#44;81&#37;&#59; y Catalu&#241;a&#44; 28&#44; un 6&#44;14&#37;&#46; Las restantes agrupadas sumaron 90 encuestas&#44; un 19&#44;73&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se sintetiza la encuesta con sus opciones de respuesta&#46; De ella puede destacarse que un 7&#44;45&#37; &#40;IC 95&#37;&#58; 4&#44;22-10&#44;68&#41; de los profesionales no hace una distinci&#243;n conceptual correcta entre fluidos hipot&#243;nicos e isot&#243;nicos&#46; Los fluidos hipot&#243;nicos son utilizados de forma general por el 28&#44;95&#37; &#40;IC 95&#37;&#58; 24&#44;77-33&#44;13&#41; de los profesionales y &#250;nicamente el 14&#44;47&#37; &#40;IC 95&#37;&#58; 11&#44;23-17&#44;72&#41; utilizan vol&#250;menes inferiores a los propuestos por H &#38; S&#46; Adem&#225;s&#44; el 14&#44;91&#37; &#40;IC 95&#37;&#58; 11&#44;63-18&#44;19&#41; de los encuestados declara que en su grupo de trabajo no existe ning&#250;n tipo de consenso al respecto de este tema&#46; Por otro lado&#44; la <span class="elsevierStyleItalic">utilizaci&#243;n de fluidos hipot&#243;nicos</span> se asocia a caracter&#237;sticas del prescriptor y de su contexto de trabajo&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 2</a> puede observarse un an&#225;lisis bivariado y multivariado al respecto que muestra los factores que con una mayor fuerza se asocian a la prescripci&#243;n de fluidos hipot&#243;nicos&#46; La <span class="elsevierStyleItalic">utilizaci&#243;n de vol&#250;menes inferiores</span> a los recomendados tradicionalmente se asocia tambi&#233;n a un determinado perfil profesional&#44; destacando que los que trabajan en UCIP utilizan m&#225;s frecuentemente vol&#250;menes inferiores en comparaci&#243;n con los que no&#44; 28&#37; frente a un 11&#44;5&#37;&#46; &#218;nicamente 19 de los pediatras encuestados&#44; un 4&#44;3&#37;&#44; utilizan vol&#250;menes superiores a las recomendaciones de H &#38; S y de ellos 9&#44; un 2&#37; sobre el total&#44; prescriben adem&#225;s fluidos hipot&#243;nicos&#46; Otros aspectos relacionados con la prescripci&#243;n de la FIM y algunos factores que podr&#237;an encontrarse asociados a la misma pueden observarse en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0055" class="elsevierStylePara elsevierViewall">Existen importantes evidencias a favor del uso de fluidos isot&#243;nicos como FIM<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">10&#44;11&#44;24</span></a>&#46; Parece por tanto el momento de valorar la sustituci&#243;n de los fluidos hipot&#243;nicos &#40;ClNa<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;45&#37;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G5&#37;&#41; en favor de isot&#243;nicos &#40;ClNa 0&#44;9&#37;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G5&#37;&#41; en la mayor&#237;a de los pacientes ingresados que precisen FIM<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">25&#8211;27</span></a>&#46; No obstante&#44; estudios a nivel internacional demuestran que esto no es as&#237;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;19</span></a>&#44; siendo nuestra investigaci&#243;n ejemplo de ello&#44; pues un 28&#44;9&#37; de los encuestados declara utilizar hipot&#243;nicos de forma general en su pr&#225;ctica cl&#237;nica habitual&#46; Adem&#225;s&#44; un 7&#44;4&#37; de los profesionales de nuestro estudio no distingue correctamente los fluidos intravenosos atendiendo a su tonicidad&#46; Por otro lado&#44; existe una l&#243;gica fisiopatol&#243;gica en favor de que si tomamos como referencia los vol&#250;menes propuestos por H &#38; S&#44; basados en ni&#241;os sanos con actividad normal&#44; podr&#237;amos estar sobrestimando las necesidades de nuestros pacientes hospitalizados&#44; dada su inactividad inherente al ingreso y la retenci&#243;n de agua libre como consecuencia de un exceso de ADH asociada a varios est&#237;mulos no osm&#243;ticos presentes en estos pacientes&#46; Esto hace que algunos profesionales restrinjan el volumen total de la FIM&#44; tal y como se refleja en el estudio de Davies<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a>&#46; En nuestro caso particular es el 14&#44;4&#37; de los facultativos los que restringen de forma general el volumen de la FIM que aplican a sus pacientes&#44; y este porcentaje aumenta a un 28&#37; cuando se trata de facultativos de UCIP&#46; No obstante&#44; no podemos saber con exactitud c&#243;mo de potente es el est&#237;mulo no osm&#243;tico que cada paciente sufre durante su hospitalizaci&#243;n&#46; Probablemente los pacientes quir&#250;rgicos y los que padecen enfermedades del sistema nervioso central &#40;meningitis&#44; encefalitis y traumatismos craneoencef&#225;licos graves&#41; sean los que presenten un mayor exceso de ADH&#44; y por tanto tendr&#225;n mayor riesgo de hiponatremia dilucional si les administramos hipot&#243;nicos y con un volumen total acorde con H &#38; S&#46; No obstante&#44; tambi&#233;n hay otros pacientes hospitalizados con procesos leves&#44; no como los anteriores&#44; sin est&#237;mulos no osm&#243;ticos para la ADH&#44; en los cuales los vol&#250;menes seg&#250;n pauta de H &#38; S sean una opci&#243;n adecuada&#46; Probablemente la situaci&#243;n de mayor riesgo para que un paciente pedi&#225;trico hospitalizado presente una hiponatremia dilucional ser&#237;a la administraci&#243;n de unos fluidos intravenosos hipot&#243;nicos a vol&#250;menes por encima de H &#38; S&#44; aunque esto no lo podemos afirmar con rotundidad dadas las pruebas cient&#237;ficas de las que disponemos en la actualidad<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a>&#46; Debemos destacar que aun siendo esta pr&#225;ctica anecd&#243;tica en nuestra muestra&#44; tan solo un 2&#37; de los encuestados&#44; no podemos afirmar lo mismo a la vista de los resultados del estudio de Davies et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a>&#44; donde hasta un 38&#37; utilizaban vol&#250;menes superiores a H &#38; S&#44; que junto a unos fluidos hipot&#243;nicos lo convert&#237;an en aquel momento&#44; a&#241;o 2008&#44; en una pr&#225;ctica poco segura para el paciente&#46; As&#237;&#44; un metaan&#225;lisis reciente demuestra la asociaci&#243;n entre la sobrecarga de volumen de fluidos y el aumento de la morbimortalidad en pacientes pedi&#225;tricos cr&#237;ticamente enfermos<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">No hemos encontrado en la literatura estudios que describan la pr&#225;ctica cl&#237;nica a este respecto centrados en pediatras&#46; En la mayor&#237;a de ellos&#44; y a trav&#233;s de una encuesta&#44; se eval&#250;a mediante la propuesta de diferentes escenarios cl&#237;nicos los conocimientos de los profesionales a cerca del tipo de fluidos a infundir en cuanto a su tonicidad y volumen total&#46; En ellos&#44; el fluido utilizado var&#237;a ampliamente y&#44; en general&#44; se siguen utilizando los hipot&#243;nicos&#44; sin restringir su volumen&#46; Estas diferencias est&#225;n poco estudiadas&#44; y as&#237; Way et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> concluyen que a mayor entrenamiento espec&#237;fico y n&#250;mero de intervenciones con pacientes pedi&#225;tricos mayor probabilidad de utilizar fluidos isot&#243;nicos&#46; Keijzers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a>&#44; en una investigaci&#243;n desarrollada en un solo hospital y en un grupo heterog&#233;neo de m&#233;dicos&#44; evidenciaron que la elecci&#243;n correcta de fluidos en cuanto a su tonicidad y volumen a infundir en funci&#243;n de un determinado escenario cl&#237;nico se correlacionaba con el grado de experiencia en el manejo de pacientes pedi&#225;tricos&#44; con el hecho de ser pediatra y especialista de urgencias hospitalarias frente al resto de especialidades &#40;cirug&#237;a&#44; anestesia&#41; y con haber recibido formaci&#243;n espec&#237;fica en cuanto a la prescripci&#243;n de la FIM en pacientes pedi&#225;tricos&#46; En el resto de investigaciones &#250;nicamente evaluaron los conocimientos de los profesionales en comparaci&#243;n con las mejores pruebas disponibles en aquel momento&#44; concluyendo algunos de ellos que la tendencia a prescribir hipot&#243;nicos en lugar de isot&#243;nicos en un contexto cl&#237;nico que requer&#237;a de estos &#250;ltimos era mayor en caso de que el paciente fuera un lactante<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>12 meses en comparaci&#243;n con pacientes de mayor edad<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#8211;17&#44;19</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">En nuestro trabajo se observa c&#243;mo el desempe&#241;ar la asistencia en un centro p&#250;blico frente a privado&#44; en una UCIP frente al resto&#44; ser pediatra frente a residente de pediatr&#237;a y existir consenso en el grupo profesional son factores que podr&#237;an estar asociados a la no utilizaci&#243;n de fluidos hipot&#243;nicos&#44; utilizando isot&#243;nicos en su lugar al pautar FIM&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Hemos estudiado tambi&#233;n algunas pr&#225;cticas de prescripci&#243;n respecto a los iones potasio y calcio como componentes de la FIM&#46; No hemos encontrado literatura espec&#237;fica que clarifique determinados aspectos de este tema&#44; como el hecho de esperar a adicionar el potasio a la FIM tras corroborar diuresis en el paciente&#46; Algunos manuales recomiendan unas cantidades de ClK entre 20 y 40<span class="elsevierStyleHsp" style=""></span>mEq&#47;l<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">21&#44;22</span></a>&#44; sin que hayamos podido encontrar evidencias en la literatura de cu&#225;l es la dosis m&#225;s adecuada&#46; Llamativa es tambi&#233;n la diferencia de criterio en cuanto a la adici&#243;n de calcio&#44; siendo los intensivistas los que en mayor proporci&#243;n lo a&#241;aden&#46; La homeostasis del calcio es de gran importancia en el paciente cr&#237;tico&#44; especialmente en pacientes politraumatizados y en situaci&#243;n de shock<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a>&#46; Tal vez sea este el motivo por el cual los profesionales que trabajan en unidades cr&#237;ticas a&#241;aden este ion al gotero&#46; No obstante&#44; ser&#237;an necesarios estudios m&#225;s espec&#237;ficos para esclarecer estas motivaciones&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Nuestro trabajo presenta limitaciones&#59; la primera es que se trata de una encuesta elaborada espec&#237;ficamente por los propios autores para el desarrollo de la investigaci&#243;n y&#44; por tanto&#44; no est&#225; validada previamente&#46; Esta se autoadministr&#243; por correo electr&#243;nico&#44; teniendo cobertura y representatividad limitada&#46; Adem&#225;s&#44; presenta un sesgo de cobertura geogr&#225;fica en relaci&#243;n con la comunidad aut&#243;noma de procedencia de los diferentes autores&#44; predominando las respuestas desde la Comunidad Valenciana&#44; Madrid y Castilla La Mancha&#46; En segundo lugar presenta un sesgo de inter&#233;s dif&#237;cil de evitar en este tipo de investigaciones&#44; que hace que principalmente el profesional interesado&#44; y tal vez actualizado en este tema&#44; tienda a participar m&#225;s&#44; sobreestimando a este grupo&#44; alterando el resultado final no ajust&#225;ndose a la realidad&#46; La tercera es que lo que nos comunican los encuestados como pr&#225;ctica cl&#237;nica no tiene por qu&#233; corresponderse de forma fidedigna con su realidad&#44; ya que en ocasiones el profesional responde lo que sabe que se debe hacer&#44; y no lo que hace en realidad<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a>&#46; Adem&#225;s&#44; nuestra investigaci&#243;n se produce 14 a&#241;os despu&#233;s de que Moritz et al&#46; propusieran por primera vez la utilizaci&#243;n de isot&#243;nicos como fluidos de mantenimiento<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a>&#44; y 11 tras la primera publicaci&#243;n que analizaba la prescripci&#243;n de la FIM en pediatr&#237;a<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a>&#46; No obstante&#44; esto m&#225;s que restar valor a nuestra investigaci&#243;n nos deber&#237;a preocupar m&#225;s si cabe&#44; pues todav&#237;a a la vista de nuestros resultados quedan facultativos en nuestro pa&#237;s que podr&#237;an estar prescribiendo una FIM no ajustada a las necesidades de cada paciente en funci&#243;n de las mejores pruebas disponibles&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Querr&#237;amos destacar el hecho de ser una investigaci&#243;n realizada exclusivamente en pediatras&#44; al no haber encontrado en la literatura otro estudio sobre este tema centrado en esta especialidad m&#233;dica&#46; Por n&#250;mero de encuestas incluidas nuestro trabajo resulta ser el m&#225;s numeroso<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#8211;19</span></a>&#46; Adem&#225;s hemos investigado otros aspectos de la FIM que no han sido analizados hasta la fecha&#44; como son la adici&#243;n de potasio y calcio a estos fluidos de mantenimiento&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">M&#225;s de una cuarta parte de los pediatras espa&#241;oles siguen pautando fluidos hipot&#243;nicos como FIM&#46; Se presentan posibles factores asociados al hecho de la diferente aplicaci&#243;n de la evidencia cient&#237;fica a la pr&#225;ctica que los pediatras realizan a este respecto&#46; Investigaciones como la nuestra son reflejo de la lentitud para trasladar la evidencia cient&#237;fica a la pr&#225;ctica m&#233;dica<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a>&#46; Ser capaces de elaborar gu&#237;as de pr&#225;ctica cl&#237;nica que nos permitan sintetizar el conocimiento para transmitirlo y diseminarlo posteriormente de forma efectiva es lo que transforma nuestras organizaciones sanitarias en empresas que prestan un servicio de calidad y seguro para el paciente<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">32&#44;33</span></a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0090" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "identificador" => "sec0035"
              "titulo" => "Aspectos &#233;ticos"
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          "identificador" => "sec0040"
          "titulo" => "Resultados"
        ]
        7 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Discusi&#243;n"
        ]
        8 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflicto de intereses"
        ]
        9 => array:2 [
          "identificador" => "xack423956"
          "titulo" => "Agradecimientos"
        ]
        10 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-06-21"
    "fechaAceptado" => "2018-10-17"
    "PalabrasClave" => array:2 [
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1149564"
          "palabras" => array:6 [
            0 => "Fluidoterapia"
            1 => "Infusiones intravenosas"
            2 => "Hiponatremia"
            3 => "Encuestas de atenci&#243;n de salud"
            4 => "Pediatras"
            5 => "Pautas de pr&#225;ctica en medicina"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1149563"
          "palabras" => array:6 [
            0 => "Fluid therapy"
            1 => "Infusions intravenous"
            2 => "Hyponatraemia"
            3 => "Health care surveys"
            4 => "Paediatricians"
            5 => "Clinical practice pattern"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los fluidos isot&#243;nicos&#44; en la mayor&#237;a de los casos&#44; constituyen la forma m&#225;s segura de administraci&#243;n de l&#237;quidos por v&#237;a intravenosa&#46; Los objetivos de nuestro trabajo han sido describir las pr&#225;cticas de prescripci&#243;n de los fluidos intravenosos de mantenimiento y estudiar los posibles factores asociados&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal&#44; descriptivo&#44; multic&#233;ntrico de &#225;mbito nacional&#44; mediante encuesta <span class="elsevierStyleItalic">on-line</span>&#44; difundida a trav&#233;s de sociedades cient&#237;ficas m&#233;dicas y la Organizaci&#243;n M&#233;dica Colegial&#44; entre diciembre de 2016 y diciembre de 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Un total de 487 encuestas fueron recibidas&#44; 456 de pediatras&#46; El 28&#44;95&#37; &#40;IC 95&#37;&#58; 24&#44;77-33&#44;13&#41; de ellos prescrib&#237;an habitualmente fluidos hipot&#243;nicos y el 81&#44;14&#37; &#40;IC 95&#37;&#58; 77&#44;54-84&#44;74&#41; se basaba en la regla de Holliday y Segar para calcular el volumen total a infundir&#46; El perfil del pediatra en Espa&#241;a que utiliza fluidos hipot&#243;nicos intravenosos es el de m&#233;dico residente de pediatr&#237;a&#44; pediatra que trabaja en &#225;reas diferentes a las unidades de cuidados intensivos pedi&#225;tricos&#44; en hospitales privados&#44; y aquellos que reconocen que no existe un consenso al respecto en su grupo de trabajo&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">M&#225;s de una cuarta parte de los pediatras en nuestro pa&#237;s sigue utilizando los fluidos hipot&#243;nicos como fluidoterapia intravenosa de mantenimiento&#46; Diferentes factores podr&#237;an estar asociados a este hecho&#46; Estos estudios son prueba de las grandes dificultades existentes para trasladar el conocimiento a la pr&#225;ctica&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Isotonic fluids&#44; in most cases&#44; are the safest way to dispense fluids intravenously&#46; The aim of this study was to determine the prescription of maintenance intravenous fluids and to study possible associated factors&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A descriptive&#44; cross-sectional&#44; multi-centre study was performed&#46; A questionnaire was sent nationwide to several healthcare providers via an on-line survey&#44; sent by email through different Medical Scientific Societies&#44; and the Official Spanish Medical Association&#44; between December 2016 and December 2017&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A total of 487 questionnaires were received&#44; of which 456 were submitted by paediatricians&#46; More than one quarter &#40;28&#46;95&#37;&#41; &#40;95&#37; CI&#59; 24&#46;77-33&#46;13&#41; of the paediatricians usually dispense hypotonic fluids and 81&#46;14&#37; &#40;95&#37; CI&#59; 77&#46;54-84&#46;74&#41; prescribe infusion rates based on the Holliday and Segar protocol&#46; The general profile of paediatricians who prescribe hypotonic fluids intravenously in Spain are medical residents&#44; paediatricians working in paediatric non-intensive care units&#44; in private hospitals&#44; and those who recognise that no consensus exists among their direct work colleagues regarding this subject&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">More than twenty-five per cent of all paediatricians in our country continue to use hypotonic fluids as maintenance intravenous fluid therapy&#46; There might be several potential factors associated to this&#46; These kind of studies provide evidence of the great difficulties in transferring scientific knowledge to clinical practice&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introduction"
          ]
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            "identificador" => "abst0030"
            "titulo" => "Material and method"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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            "apendice" => "<p id="par0110" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Anexo A"
            "titulo" => "Material suplementario"
            "identificador" => "sec0060"
          ]
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">En la columna de la izquierda se presenta la pregunta planteada&#44; expres&#225;ndose el n&#250;mero absoluto de respuestas a cada una de ellas y su porcentaje respecto al total entre par&#233;ntesis&#46; En la columna de la derecha las diferentes opciones de respuesta&#44; expres&#225;ndose sus recuentos en n&#250;meros absolutos y sus porcentajes junto a su intervalo de confianza del 95&#37;&#44; entre par&#233;ntesis&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ClK&#58; cloruro pot&#225;sico&#59; FIM&#58; fluidoterapia intravenosa de mantenimiento&#59; H &#38; S&#58; Holliday and Segar&#59; IC&#58; intervalo de confianza&#59; 2<span class="elsevierStyleHsp" style=""></span>M&#58; 2 molar&#46;</p>"
          "tablatextoimagen" => array:1 [
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                  <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">1&#46; Distingue correctamente los distintos tipos de fluidos intravenosos en funci&#243;n de su tonicidad&#44; 456 &#40;100&#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">Distingue correctamente&#44; 422 &#40;92&#44;54&#59; IC 90&#44;12-94&#44;96&#41;&#46;El isot&#243;nico es el lactato de ringer&#44; 9 &#40;1&#44;97&#59; IC 0&#44;69-3&#44;26&#41;&#46;Son isot&#243;nicos los fluidos 0&#44;20&#37; &#40;1&#47;5&#41; y 0&#44;33&#37; &#40;1&#47;3&#41;&#44; 25 &#40;5&#44;48&#59; IC 3&#44;39-7&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Tipo de FIM en su pr&#225;ctica habitual en un paciente en normonatremia&#44; 455 &#40;99&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Predominantemente isot&#243;nicos&#44; 297 &#40;65&#44;13&#59; IC 60&#44;74-69&#44;52&#41;&#46;Indistintamente isot&#243;nicos e hipot&#243;nicos&#44; 27 &#40;5&#44;92&#59; IC 3&#44;75-8&#44;10&#41;&#46;Predominantemente hipot&#243;nicos&#44; 131 &#40;28&#44;95&#59; IC 24&#44;77-33&#44;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; Volumen total de FIM en 24<span class="elsevierStyleHsp" style=""></span>horas&#44; 455 &#40;99&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Siguen la regla de H &#38; S&#44; 370 &#40;81&#44;14&#59; IC 77&#44;54-84&#44;74&#41;&#46;Utilizan en general vol&#250;menes inferiores&#44; 80&#37; de esta regla&#44; 66 &#40;14&#44;47&#59; IC 11&#44;23-17&#44;72&#41;Utilizan vol&#250;menes superiores a la regla de H &#38; S&#44; 19 &#40;4&#44;39&#59; IC 2&#44;50-6&#44;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; Momento de la adici&#243;n de ClK a la FIM&#44; 456 &#40;100&#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">Siempre FIM con cloruro pot&#225;sico desde el inicio de la infusi&#243;n&#44; 33 &#40;7&#44;24&#59; IC 4&#44;85-9&#44;62&#41;Se a&#241;ade el ClK tras corroborarse diuresis del paciente&#44; 100 &#40;21&#44;93&#59; IC 18&#44;12-25&#44;74&#41;Depende del estado cl&#237;nico y grado de deshidrataci&#243;n del paciente&#46; Si la situaci&#243;n cl&#237;nica no es buena se espera a mejorar y comprobar diuresis&#44; 323 &#40;70&#44;83&#59; IC 66&#44;65-75&#44;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; Cantidad en mililitros de ClK 2<span class="elsevierStyleHsp" style=""></span>M que a&#241;ade a la FIM&#44; 455 &#40;99&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5<span class="elsevierStyleHsp" style=""></span>ml de ClK 2<span class="elsevierStyleHsp" style=""></span>M por kg de peso del paciente en 24<span class="elsevierStyleHsp" style=""></span>horas&#44; 17 &#40;3&#44;73&#59; IC 1&#44;98-5&#44;47&#41;&#46;Seg&#250;n peso paciente<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>kg&#44; 2-3<span class="elsevierStyleHsp" style=""></span>ml de ClK 2<span class="elsevierStyleHsp" style=""></span>M por cada 500<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido a infundir&#59; m&#225;s de 10<span class="elsevierStyleHsp" style=""></span>kg&#44; 5<span class="elsevierStyleHsp" style=""></span>ml por cada 500<span class="elsevierStyleHsp" style=""></span>ml de l&#237;quido a infundir&#44; 120 &#40;26&#44;32&#59; IC 22&#44;26-30&#44;37&#41;No lo tiene en cuenta&#46; Utiliza unos fluidos est&#225;ndar con ClK incorporado&#44; 18 &#40;3&#44;95&#59; IC 2&#44;15-5&#44;74&#41;Seg&#250;n necesidades basales&#44; 20-30<span class="elsevierStyleHsp" style=""></span>mEq&#47;l de l&#237;quido a infundir&#44; 150 &#40;32&#44;89&#59; IC 28&#44;57-37&#44;22&#41;Ninguna opci&#243;n de respuesta describe mi forma de proceder&#44; 150 &#40;33&#44;11&#59; IC 28&#44;78-37&#44;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46; Cantidad de calcio en la FIM&#44; 355 &#40;77&#44;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="left" valign="\n
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                  \t\t\t\t">En ni&#241;os&#44; 20-40 mg&#47;kg&#47;d&#237;a y en lactantes&#44; 40-80<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#237;a&#44; 17 &#40;4&#44;79&#59; IC 2&#44;56-7&#44;02&#41;10<span class="elsevierStyleHsp" style=""></span>ml de gluconato c&#225;lcico por cada 500<span class="elsevierStyleHsp" style=""></span>ml de FIM&#44; 37 &#40;10&#44;40&#59; IC 7&#44;89-12&#44;91&#41;No a&#241;ado calcio a la FIM&#44; 301 &#40;84&#44;82&#59; IC 80&#44;32-89&#44;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46; Modo de mantenerse actualizado al respecto&#44; 456 &#40;100&#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">Lectura de libros y manuales&#44; 16 &#40;3&#44;51&#59; IC 1&#44;81-5&#44;20&#41;Lectura de literatura cient&#237;fica&#44; 119 &#40;26&#44;10&#59; IC 22&#44;05-30&#44;14&#41;Asistencia a cursos&#44; jornadas y congresos&#44; 60 &#40;13&#44;16&#59; IC 10&#44;04-16&#44;27&#41;&#46;Sesiones cl&#237;nicas de equipo&#44; 247 &#40;54&#44;17&#59; IC 49&#44;58-58&#44;76&#41;&#46;Conversaciones con colegas&#44; 14 &#40;3&#44;07&#59; IC 1&#44;48-4&#44;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46; Existencia de consenso en mi equipo de trabajo&#44; 456 &#40;100&#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">Existe consenso verbal &#250;nicamente&#44; 130 &#40;28&#44;51&#59; IC 24&#44;35-32&#44;67&#41;&#46;Existe consenso verbal y escrito&#44; 258 &#40;56&#44;58&#59; IC 52&#44;01-61&#44;15&#41;No existe consenso de ning&#250;n tipo&#44; ni verbal ni escrito&#44; 68 &#40;14&#44;91&#59; IC 11&#44;63-18&#44;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">9&#46; Tiempo de uso de isot&#243;nicos en caso de utilizarlos como FIM&#44; 302 &#40;66&#44;2&#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">M&#225;s de 5 a&#241;os&#44; 59 &#40;19&#44;54&#59; IC 15&#44;04-24&#44;03&#41;Entre 2 y 5 a&#241;os&#44; 112 &#40;37&#44;09&#59; IC 31&#44;61-42&#44;56&#41;Menos de 2 a&#241;os&#44; 131 &#40;43&#44;38&#59; IC 37&#44;76-49&#44;00&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AP&#58; atenci&#243;n primaria&#59; IC&#58; intervalo de confianza&#59; UCIP&#58; unidad de cuidados intensivos pedi&#225;tricos&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span>Categor&#237;a de referencia para el an&#225;lisis multivariado&#46;</p>"
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                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">An&#225;lisis multivariado</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Factores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cuesti&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Usa hipot&#243;nicos comoFIM habitual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Odds ratio</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">L&#237;mites paraIC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">456&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\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">1&#44;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;68-1&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">312 &#40;68&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;28&#44;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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Var&#243;n<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">144 &#40;31&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;28&#44;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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Experiencia profesional</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">456&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106 &#40;23&#44;2&#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">29 &#40;27&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;29-2&#44;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5-15 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">158 &#40;34&#44;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="left" valign="\n
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                  \t\t\t\t">43 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;35-4&#44;13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\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">137 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">35 &#40;25&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;96&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;27-3&#44;39&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Todav&#237;a residente<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55 &#40;12&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">24 &#40;43&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referencia&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">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo centro trabajo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">456&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>P&#250;blico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">386 &#40;84&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100 &#40;25&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;28&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;13-0&#44;61&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
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Información del artículo
ISSN: 16954033
Idioma original: Español
DOI:10.1016/j.anpedi.2018.10.016
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