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Fue trasladada a UCI&#44; requiriendo de inmediato intubaci&#243;n orotraqueal y ventilaci&#243;n mec&#225;nica invasiva &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>B&#41;&#46; Durante las siguientes 72<span class="elsevierStyleHsp" style=""></span>h se instaur&#243; bloqueo neuromuscular&#44; presi&#243;n positiva al final de la espiraci&#243;n &#40;PEEP&#41; de 12-14<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; &#243;xido n&#237;trico inhalado y ventilaci&#243;n en dec&#250;bito prono &#40;2<span class="elsevierStyleHsp" style=""></span>sesiones&#41;&#46; Transcurridos 4<span class="elsevierStyleHsp" style=""></span>d&#237;as en UCI&#44; la PaO<span class="elsevierStyleInf">2</span> y la PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> empeoraron &#40;esta &#250;ltima a 70<span class="elsevierStyleHsp" style=""></span>mmHg durante 6<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; por lo que se activ&#243; al equipo ECMO-m&#243;vil del hospital terciario de referencia en nuestra comunidad aut&#243;noma&#46; Se coloc&#243; <span class="elsevierStyleItalic">in situ</span> una ECMO veno-venosa femoral-yugular &#40;Cardiohelp&#174;&#44; Maquet Cardiopulmonary AG&#44; Hirrlingen&#44; Alemania&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>C&#41;&#58; c&#225;nula de succi&#243;n multiperforada 21<span class="elsevierStyleHsp" style=""></span>F y retorno yugular 19<span class="elsevierStyleHsp" style=""></span>F&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Tras el implante fue trasladada a la UCI del hospital de referencia&#46; A su llegada&#44; el pulso era de 77<span class="elsevierStyleHsp" style=""></span>latidos&#47;min y la presi&#243;n arterial de 131&#47;61<span class="elsevierStyleHsp" style=""></span>mmHg con noradrenalina a 0&#44;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#46; Fue ventilada con un volumen corriente de 3<span class="elsevierStyleHsp" style=""></span>ml&#47;kg peso&#44; FiO<span class="elsevierStyleInf">2</span> 50&#37; y PEEP 14<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; Flujo sangu&#237;neo inicial de la ECMO de 4&#44;2<span class="elsevierStyleHsp" style=""></span>l&#47;min con FiO<span class="elsevierStyleInf">2</span> 100&#37; &#40;a 4<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41;&#46; Destacaba una linfopenia&#44; una marcada elevaci&#243;n de interleucina-6&#44; prote&#237;na C reactiva&#44; ferritina y d&#237;meros<span class="elsevierStyleHsp" style=""></span>D&#44; con troponina negativa &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Al ingreso en nuestra UCI iniciamos tocilizumab &#40;600<span class="elsevierStyleHsp" style=""></span>mg primera dosis y 400<span class="elsevierStyleHsp" style=""></span>mg 12<span class="elsevierStyleHsp" style=""></span>h despu&#233;s&#41;&#44; metilprednisolona &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; 3 dosis&#41; y cambiamos el tratamiento antiviral a remdesivir &#40;200<span class="elsevierStyleHsp" style=""></span>mg primera dosis y 100<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; 4<span class="elsevierStyleHsp" style=""></span>d&#237;as&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">La evoluci&#243;n posterior fue favorable&#46; Las citoquinas proinflamatorias disminuyeron y mejor&#243; la funci&#243;n pulmonar&#58; aument&#243; la relaci&#243;n PaO<span class="elsevierStyleInf">2</span>&#58;FiO<span class="elsevierStyleInf">2</span> y mejor&#243; la <span class="elsevierStyleItalic">compliance</span> din&#225;mica con menor PEEP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Despu&#233;s de 180<span class="elsevierStyleHsp" style=""></span>h pudo retirarse la ECMO y ser extubada&#46; Tras 8<span class="elsevierStyleHsp" style=""></span>d&#237;as en la UCI y 7 en planta del hospital de referencia&#44; fue dada de alta sin oxigenoterapia suplementaria y deambulando sin ayuda &#40;PCR SARS-CoV-2 negativa&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>D&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La ECMO debe considerarse como una terapia de rescate en casos refractarios a la ventilaci&#243;n mec&#225;nica convencional&#44; ventilaci&#243;n en prono y&#47;o a maniobras de reclutamiento<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a>&#46; La tasa de utilizaci&#243;n de la ECMO durante la pandemia COVID-19 es del 0&#44;5-1&#37; del total de los pacientes ingresados&#46; En Europa&#44; hasta el 7 de mayo de 2020&#44; 1&#46;068 pacientes adultos han necesitado soporte ECMO<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>&#46; Aunque se han descrito casos de neumon&#237;a por SARS CoV-2 en neonatos<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a>&#44; ni&#241;os<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> y adultos j&#243;venes<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a>&#44; su evoluci&#243;n ha sido&#44; generalmente&#44; favorable&#44; siendo marginal la necesidad de apoyo extracorp&#243;reo&#46; Nuestra paciente sufri&#243; una neumon&#237;a grave&#44; refractaria a la terapia convencional&#44; y requiri&#243; ECMO&#46; Un escaso n&#250;mero de enfermos est&#225;n incluidos en el registro europeo de ECMO neonatal-pedi&#225;trico &#40;entre ellos nuestra paciente&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>&#46; Los pacientes COVID-19 adultos necesitan entre 20 y 50<span class="elsevierStyleHsp" style=""></span>d&#237;as de soporte extracorp&#243;reo para recuperarse&#46; En este caso&#44; la ECMO durante 7<span class="elsevierStyleHsp" style=""></span>d&#237;as fue suficiente para mantener la oxigenaci&#243;n y permiti&#243; realizar una ventilaci&#243;n ultraprotectora hasta que la respuesta inflamatoria disminuy&#243;&#46; No detectamos efectos adversos en la combinaci&#243;n de los tratamientos antivirales y antiinflamatorios utilizados&#46; Tampoco tuvimos que modificar su posolog&#237;a&#44; por lo que consideramos que no ha habido alteraciones farmacocin&#233;ticas relacionadas con el circuito o con la membrana extracorp&#243;rea&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Muchos art&#237;culos publicados durante la actual pandemia muestran el curso cl&#237;nico de pacientes que todav&#237;a est&#225;n en UCI &#40;incluso en ECMO&#41;&#46; La nuestra es la primera paciente pedi&#225;trica sometida a ECMO veno-venosa totalmente recuperada y dada de alta a su domicilio sin secuelas&#46; La terapia extracorp&#243;rea en su caso se ha mostrado eficaz y segura &#40;incluyendo un traslado interhospitalario&#41;&#44; por lo es una opci&#243;n terap&#233;utica para ni&#241;os y adolescentes en el tratamiento de la COVID-19 si su condici&#243;n cl&#237;nica as&#237; lo requiriese&#46;</p></span>"
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    "fechaRecibido" => "2020-05-18"
    "fechaAceptado" => "2020-05-31"
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          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiograf&#237;a simple de t&#243;rax&#46; A&#41; <span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax en urgencias del hospital departamental&#46; B&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax al ingreso en la UCI del hospital departamental &#40;prono&#41;&#46; C&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax al ingreso en la UCI tras el traslado interhospitalario al hospital de referencia &#40;d&#237;a<span class="elsevierStyleHsp" style=""></span>0 de ECMO&#41;&#46; D&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax en la planta del hospital de referencia &#40;d&#237;a del alta hospitalaria&#41;&#46;</p>"
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">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" scope="col" style="border-bottom: 2px solid black">ECMO d&#237;a 0&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">ECMO d&#237;a 1&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">ECMO d&#237;a 2&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">ECMO d&#237;a 3&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">ECMO d&#237;a 4&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">ECMO d&#237;a 5&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">ECMO d&#237;a 6&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">ECMO d&#237;a 7&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">ECMO d&#237;a 8&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Post-ECMO&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">Hemoglobina &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12-14&#44;5&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">9&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;6&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">9&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">9&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;8&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">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Leucocitos &#40;&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;5-10&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;88&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#44;84&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">5&#44;91&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">5&#44;34&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">15&#44;95&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">4&#44;81&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">Neutr&#243;filos &#40;&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#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;8-8&#44;0&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">7&#44;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#44;06&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">Linfocitos &#40;&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#41;&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-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">Plaquetas &#40;&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150-400&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</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">192&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Alb&#250;mina &#40;g&#47;dl&#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</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">Potasio&#40;mmol&#47;l&#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</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">Calcio i&#243;nico &#40;mg&#47;dl&#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">ALT &#40;U&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Urea &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10-50&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-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">Creatinina &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Lactato arterial &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\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">Prote&#237;na C reactiva &#40;mg&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Interleucina-6 &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fibrin&#243;geno &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">D&#237;meros D &#40;ng&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;386<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Complianza din&#225;mica &#40;ml&#47;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">Flujo sangu&#237;neo ECMO &#40;l&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mezcla gas &#40;l&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">FiO<span class="elsevierStyleInf">2</span> ECMO&#40;&#37;&#41;&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-with-role" title="\n
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                  \t\t\t\t">Volumen <span class="elsevierStyleItalic">tidal</span> &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#44;02&nbsp;\t\t\t\t\t\t\n
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                  """
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                          "etal" => true
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                            4 => "C&#46; Ou"
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                        0 => array:2 [
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                            0 => "X&#46; Lu"
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                            4 => "B&#46; Zakhary"
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Carta científica
Insuficiencia respiratoria COVID-19: soporte con ECMO para niños y adultos jóvenes
COVID-19 respiratory failure: ECMO support for children and young adult patients
Ricardo Gimeno-Costaa,
Autor para correspondencia
gimeno_ric@gva.es

Autor para correspondencia.
, Marcos Barriosa, Tomás Herediab, Carmen Garcíac, Luís de Heviaa
a Área de Medicina Intensiva, Hospital Universitari i Politècnic la Fe, Valencia, España
b Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic la Fe, Valencia, España
c Servicio de Medicina Intensiva, Hospital de La Ribera, Alzira, Valencia, España
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          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiograf&#237;a simple de t&#243;rax&#46; A&#41; <span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax en urgencias del hospital departamental&#46; B&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax al ingreso en la UCI del hospital departamental &#40;prono&#41;&#46; C&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax al ingreso en la UCI tras el traslado interhospitalario al hospital de referencia &#40;d&#237;a<span class="elsevierStyleHsp" style=""></span>0 de ECMO&#41;&#46; D&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax en la planta del hospital de referencia &#40;d&#237;a del alta hospitalaria&#41;&#46;</p>"
        ]
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El SARS-CoV-2 afecta principalmente a adultos&#44; y en ellos se produce el mayor n&#250;mero de ingresos en UCI y la mayor mortalidad<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a>&#46; Aunque en ni&#241;os la enfermedad se describe como menos grave y con un tiempo de recuperaci&#243;n m&#225;s corto<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a>&#44; presentamos el caso de una paciente de 16<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; sana y sin contactos conocidos con COVID-19&#44; que sufri&#243; una neumon&#237;a grave por SARS-CoV-2 que requiri&#243; ECMO veno-venosa y que se ha recuperado por completo&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La enferma acudi&#243; a Urgencias del hospital de su Departamento de Salud por presentar tos y fiebre persistente durante 6<span class="elsevierStyleHsp" style=""></span>d&#237;as&#46; La radiograf&#237;a de t&#243;rax mostr&#243; una neumon&#237;a &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>A&#41;&#44; e ingres&#243; en la sala de hospitalizaci&#243;n&#46; A las 48<span class="elsevierStyleHsp" style=""></span>h del ingreso se constat&#243; la positividad de la PCR SARS-CoV-2&#44; por lo que se le prescribi&#243; ritonavir&#47;lopinavir &#40;hasta 7<span class="elsevierStyleHsp" style=""></span>d&#237;as&#41;&#44; hidroxicloroquina &#40;hasta 10<span class="elsevierStyleHsp" style=""></span>d&#237;as&#41;&#44; azitromicina &#40;hasta 5<span class="elsevierStyleHsp" style=""></span>d&#237;as&#41; e interfer&#243;n &#946;-1b &#40;hasta 7<span class="elsevierStyleHsp" style=""></span>d&#237;as&#41;&#46; Ese mismo d&#237;a empeor&#243;&#44; con taquicardia&#44; taquipnea&#44; disnea&#44; fiebre &#40;39&#44;9<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; y SaO<span class="elsevierStyleInf">2</span> de 90&#37; &#40;4<span class="elsevierStyleHsp" style=""></span>l&#47;min de ox&#237;geno suplementario&#41;&#46; Fue trasladada a UCI&#44; requiriendo de inmediato intubaci&#243;n orotraqueal y ventilaci&#243;n mec&#225;nica invasiva &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>B&#41;&#46; Durante las siguientes 72<span class="elsevierStyleHsp" style=""></span>h se instaur&#243; bloqueo neuromuscular&#44; presi&#243;n positiva al final de la espiraci&#243;n &#40;PEEP&#41; de 12-14<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; &#243;xido n&#237;trico inhalado y ventilaci&#243;n en dec&#250;bito prono &#40;2<span class="elsevierStyleHsp" style=""></span>sesiones&#41;&#46; Transcurridos 4<span class="elsevierStyleHsp" style=""></span>d&#237;as en UCI&#44; la PaO<span class="elsevierStyleInf">2</span> y la PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> empeoraron &#40;esta &#250;ltima a 70<span class="elsevierStyleHsp" style=""></span>mmHg durante 6<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; por lo que se activ&#243; al equipo ECMO-m&#243;vil del hospital terciario de referencia en nuestra comunidad aut&#243;noma&#46; Se coloc&#243; <span class="elsevierStyleItalic">in situ</span> una ECMO veno-venosa femoral-yugular &#40;Cardiohelp&#174;&#44; Maquet Cardiopulmonary AG&#44; Hirrlingen&#44; Alemania&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>C&#41;&#58; c&#225;nula de succi&#243;n multiperforada 21<span class="elsevierStyleHsp" style=""></span>F y retorno yugular 19<span class="elsevierStyleHsp" style=""></span>F&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Tras el implante fue trasladada a la UCI del hospital de referencia&#46; A su llegada&#44; el pulso era de 77<span class="elsevierStyleHsp" style=""></span>latidos&#47;min y la presi&#243;n arterial de 131&#47;61<span class="elsevierStyleHsp" style=""></span>mmHg con noradrenalina a 0&#44;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#46; Fue ventilada con un volumen corriente de 3<span class="elsevierStyleHsp" style=""></span>ml&#47;kg peso&#44; FiO<span class="elsevierStyleInf">2</span> 50&#37; y PEEP 14<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; Flujo sangu&#237;neo inicial de la ECMO de 4&#44;2<span class="elsevierStyleHsp" style=""></span>l&#47;min con FiO<span class="elsevierStyleInf">2</span> 100&#37; &#40;a 4<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41;&#46; Destacaba una linfopenia&#44; una marcada elevaci&#243;n de interleucina-6&#44; prote&#237;na C reactiva&#44; ferritina y d&#237;meros<span class="elsevierStyleHsp" style=""></span>D&#44; con troponina negativa &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Al ingreso en nuestra UCI iniciamos tocilizumab &#40;600<span class="elsevierStyleHsp" style=""></span>mg primera dosis y 400<span class="elsevierStyleHsp" style=""></span>mg 12<span class="elsevierStyleHsp" style=""></span>h despu&#233;s&#41;&#44; metilprednisolona &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; 3 dosis&#41; y cambiamos el tratamiento antiviral a remdesivir &#40;200<span class="elsevierStyleHsp" style=""></span>mg primera dosis y 100<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; 4<span class="elsevierStyleHsp" style=""></span>d&#237;as&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">La evoluci&#243;n posterior fue favorable&#46; Las citoquinas proinflamatorias disminuyeron y mejor&#243; la funci&#243;n pulmonar&#58; aument&#243; la relaci&#243;n PaO<span class="elsevierStyleInf">2</span>&#58;FiO<span class="elsevierStyleInf">2</span> y mejor&#243; la <span class="elsevierStyleItalic">compliance</span> din&#225;mica con menor PEEP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Despu&#233;s de 180<span class="elsevierStyleHsp" style=""></span>h pudo retirarse la ECMO y ser extubada&#46; Tras 8<span class="elsevierStyleHsp" style=""></span>d&#237;as en la UCI y 7 en planta del hospital de referencia&#44; fue dada de alta sin oxigenoterapia suplementaria y deambulando sin ayuda &#40;PCR SARS-CoV-2 negativa&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>D&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La ECMO debe considerarse como una terapia de rescate en casos refractarios a la ventilaci&#243;n mec&#225;nica convencional&#44; ventilaci&#243;n en prono y&#47;o a maniobras de reclutamiento<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a>&#46; La tasa de utilizaci&#243;n de la ECMO durante la pandemia COVID-19 es del 0&#44;5-1&#37; del total de los pacientes ingresados&#46; En Europa&#44; hasta el 7 de mayo de 2020&#44; 1&#46;068 pacientes adultos han necesitado soporte ECMO<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>&#46; Aunque se han descrito casos de neumon&#237;a por SARS CoV-2 en neonatos<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a>&#44; ni&#241;os<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> y adultos j&#243;venes<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a>&#44; su evoluci&#243;n ha sido&#44; generalmente&#44; favorable&#44; siendo marginal la necesidad de apoyo extracorp&#243;reo&#46; Nuestra paciente sufri&#243; una neumon&#237;a grave&#44; refractaria a la terapia convencional&#44; y requiri&#243; ECMO&#46; Un escaso n&#250;mero de enfermos est&#225;n incluidos en el registro europeo de ECMO neonatal-pedi&#225;trico &#40;entre ellos nuestra paciente&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>&#46; Los pacientes COVID-19 adultos necesitan entre 20 y 50<span class="elsevierStyleHsp" style=""></span>d&#237;as de soporte extracorp&#243;reo para recuperarse&#46; En este caso&#44; la ECMO durante 7<span class="elsevierStyleHsp" style=""></span>d&#237;as fue suficiente para mantener la oxigenaci&#243;n y permiti&#243; realizar una ventilaci&#243;n ultraprotectora hasta que la respuesta inflamatoria disminuy&#243;&#46; No detectamos efectos adversos en la combinaci&#243;n de los tratamientos antivirales y antiinflamatorios utilizados&#46; Tampoco tuvimos que modificar su posolog&#237;a&#44; por lo que consideramos que no ha habido alteraciones farmacocin&#233;ticas relacionadas con el circuito o con la membrana extracorp&#243;rea&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Muchos art&#237;culos publicados durante la actual pandemia muestran el curso cl&#237;nico de pacientes que todav&#237;a est&#225;n en UCI &#40;incluso en ECMO&#41;&#46; La nuestra es la primera paciente pedi&#225;trica sometida a ECMO veno-venosa totalmente recuperada y dada de alta a su domicilio sin secuelas&#46; La terapia extracorp&#243;rea en su caso se ha mostrado eficaz y segura &#40;incluyendo un traslado interhospitalario&#41;&#44; por lo es una opci&#243;n terap&#233;utica para ni&#241;os y adolescentes en el tratamiento de la COVID-19 si su condici&#243;n cl&#237;nica as&#237; lo requiriese&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-05-18"
    "fechaAceptado" => "2020-05-31"
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiograf&#237;a simple de t&#243;rax&#46; A&#41; <span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax en urgencias del hospital departamental&#46; B&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax al ingreso en la UCI del hospital departamental &#40;prono&#41;&#46; C&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax al ingreso en la UCI tras el traslado interhospitalario al hospital de referencia &#40;d&#237;a<span class="elsevierStyleHsp" style=""></span>0 de ECMO&#41;&#46; D&#41;<span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a de t&#243;rax en la planta del hospital de referencia &#40;d&#237;a del alta hospitalaria&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at1"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">Referencia&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO d&#237;a 0&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">ECMO d&#237;a 1&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO d&#237;a 2&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">ECMO d&#237;a 3&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">ECMO d&#237;a 4&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">ECMO d&#237;a 5&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">ECMO d&#237;a 6&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO d&#237;a 7&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ECMO d&#237;a 8&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Post-ECMO&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">Hemoglobina &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12-14&#44;5&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">9&#44;2&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">8&#44;1&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">8&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Leucocitos &#40;&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#44;5-10&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;88&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">5&#44;84&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;31&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  " align="left" valign="\n
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                  \t\t\t\t">4&#44;81&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">Neutr&#243;filos &#40;&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#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\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Alb&#250;mina &#40;g&#47;dl&#41;&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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></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">Potasio&#40;mmol&#47;l&#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">3&#44;5-5&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;47&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;53&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">Lactato arterial &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;3-1&#44;6&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">0&#44;9&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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\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">0&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4&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;5&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">Prote&#237;na C reactiva &#40;mg&#47;l&#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">0-5&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">192&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">98&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22&#44;8&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">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
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                  \t\t\t\t">8&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;4&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</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;9&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">Interleucina-6 &#40;pg&#47;ml&#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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">125&#44;9&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">782&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">273&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&#44;3&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">Ferritina &#40;ng&#47;ml&#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">15-150&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-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">Procalcitonina &#40;ng&#47;ml&#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</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrin&#243;geno &#40;mg&#47;dl&#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">170-437&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Volumen <span class="elsevierStyleItalic">tidal</span> &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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                          "autores" => array:6 [
                            0 => "W&#46;J&#46; Guan"
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                            2 => "Y&#46; Hu"
                            3 => "W&#46; Liang"
                            4 => "C&#46; Ou"
                            5 => "L&#46; He"
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Información del artículo
ISSN: 16954033
Idioma original: Español
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