Post-surgery fluid therapy: the debate on tonicity is still open
Fluidoterapia postcirugía: El debate sobre la tonicidad continúa.
Read
12640
Timeswas read the article
2738
Total PDF
9902
Total HTML
Share statistics
array:21 [ "pii" => "X2013251408033464" "issn" => "20132514" "doi" => " " "estado" => "S300" "fechaPublicacion" => "2008-02-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2008;28:25-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5068 "formatos" => array:3 [ "EPUB" => 284 "HTML" => 4072 "PDF" => 712 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699508033467" "issn" => "02116995" "doi" => " " "estado" => "S300" "fechaPublicacion" => "2008-02-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2008;28:25-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 12588 "formatos" => array:3 [ "EPUB" => 270 "HTML" => 11432 "PDF" => 886 ] ] "es" => array:9 [ "idiomaDefecto" => true "titulo" => "Fluidoterapia postcirugía: El debate sobre la tonicidad continúa." "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "25" "paginaFinal" => "27" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Post-surgery fluid therapy: the debate on tonicity is still open" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Roberto Alcázar Arroyo" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Roberto" "apellidos" => "Alcázar Arroyo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X2013251408033464" "doi" => " " "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033464?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033467?idApp=UINPBA000064" "url" => "/02116995/0000002800000001/v0_201502091349/X0211699508033467/v0_201502091349/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251408033456" "issn" => "20132514" "doi" => " " "estado" => "S300" "fechaPublicacion" => "2008-02-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2008;28:28-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3873 "formatos" => array:3 [ "EPUB" => 300 "HTML" => 3042 "PDF" => 531 ] ] "en" => array:9 [ "idiomaDefecto" => true "titulo" => "Hemodialysis dose. Difficulty in measuring it" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "28" "paginaFinal" => "29" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dosis de hemodiálisis. Dificultad de su medida" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jose Luis Teruel Briones, M. Fernández Lucas" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Jose Luis" "apellidos" => "Teruel Briones" ] 1 => array:2 [ "Iniciales" => "M." "apellidos" => "Fernández Lucas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699508033459" "doi" => " " "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033459?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033456?idApp=UINPBA000064" "url" => "/20132514/0000002800000001/v0_201502091616/X2013251408033456/v0_201502091616/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X2013251408033472" "issn" => "20132514" "doi" => " " "estado" => "S300" "fechaPublicacion" => "2008-02-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2008;28:20-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4912 "formatos" => array:3 [ "EPUB" => 271 "HTML" => 4042 "PDF" => 599 ] ] "en" => array:9 [ "idiomaDefecto" => true "titulo" => "Uremic calcifying arteriolopathy (calciphylaxis) with metabolic syndrome and diabetes mellitus. The current perspective" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "20" "paginaFinal" => "24" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La arteriolopatía calcificante urémica (calcifilaxis) en el contexto del síndrome metabólico y la diabetes mellitus. Perspectiva actual" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elvira Fernández" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Elvira" "apellidos" => "Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699508033475" "doi" => " " "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033475?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033472?idApp=UINPBA000064" "url" => "/20132514/0000002800000001/v0_201502091616/X2013251408033472/v0_201502091616/en/main.assets" ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Post-surgery fluid therapy: the debate on tonicity is still open" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "25" "paginaFinal" => "27" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Roberto Alcázar Arroyo" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Roberto" "apellidos" => "Alcázar Arroyo" "email" => array:1 [ 0 => "ralcazar@senefro.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Unidad de Nefrología, Hospital de Fuenlabrada, Madrid, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fluidoterapia postcirugía: El debate sobre la tonicidad continúa." ] ] "textoCompleto" => "<p class="elsevierStylePara">The administration of fluids to the postsurgical patient is a routinary practice that is usually dictated by practices learned during specialized training and, with the exception of children, it usually is the same irrespective of age, gender, and body size of the patient. Since the mortality secondary to fluid therapy is perceived by the clinician as being relatively low, concerns are not generated nor clinical studies on whether volume or composition of the fluids administered may be improved or not. For several years ago, the clinician has been put on alert about the risk for hyponatremia associated to the administration of hypotonic solutions, particularly at the post-surgical setting and in childbearing-aged women.<span class="elsevierStyleSup">1</span> In a recent review<span class="elsevierStyleSup">2</span> Dr. Moritz and Dr. Ayús question the use of hypotonic solutions at the hospital setting since hospitalized patients, especially post-surgical patients, receive several stimuli for nonosmotic release of vasopressin, so that the administration of fluids other than normal saline increases the risk for hyponatremia occurrence that may be fatal. In the review here commented, it is proposed to avoid any type of hypotonic solution in hospitalized patients. Although there are data suggesting the severe hyponatremia is less likely to occur in patients having not received hypotonic solutions, there are, however, no studies confirming that routinary administration of normal saline may be safer than hypotonic solutions.</p><p class="elsevierStylePara">In the work by Caramelo et al. published in this issue of NEFROLOGÍA,<span class="elsevierStyleSup">3</span> the authors look deeper into this topic, analyzing the reposition of water and electrolytes and its consequences in the internal milieu in 112 patients submitted to elective surgeries under general anesthesia. In these patients, the average volume of fluids administered was 4.6 liters for the first 24 hours, with a mean proportion of isotonic fluids/water of approximately 2:1, that is to say, a hypotonic combination. Twentysix cases of either hyponatremia (n = 12, Na+ < 135) or Na+ decrease > 6 mmol/L although without hyponatremic values (n = 14) were detected. These patients did not receive, however, higher amounts of free water than the remaining ones, three patients even only received normal saline during fluid reposition. The authors conclude that there is not a significant relationship between the type of fluids administered and hyponatremia occurrence, and that the latter would be more related to the existence of renal impairment in free water clearance.</p><p class="elsevierStylePara">These results suggest that the type of reposition used after surgery is neither the main nor the critical factor in the genesis of post-surgical hyponatremia. Besides, they highlight the arbitrariness with which fluids are administered in clinical practice. In fact, there still are important questions to which an appropriate answer cannot be found in the literature, such as how much volume? With what tonicity? In what type of surgeries?</p><p class="elsevierStylePara">Fluid reposition regimens currently used at post-surgery came up in the 1950s because of the need to maintain post-surgical fasting, and have not substantially being modified to date.<span class="elsevierStyleSup">4, 5</span> These regimens were calculated according to estimations on daily needs of water and electrolytes and reposition of losses through drainages or fistulae. They generally establish volumes of 2.5-6 liters of fluids for the first 24 hours with sodium concentrations of 30-100 mmol/L (normal saline has a sodium concentration of 154 mmol/L). One liter of Ringer lactate ([Na+]: 130 mmol/L) and 2.5 liters of 5% dextrose, that is to say an overtly hypotonic solution is established as proper intake in some textbooks on electrolytes and acid-base balance.<span class="elsevierStyleSup">6</span> Other textbooks, such as the one by Kokko and Tannen,<span class="elsevierStyleSup">7</span> also establish hypotonic reposition regimens, although they underline the need for close supervision for the first 24 hours after surgery, during which there is renal inability to eliminate free water due to non-osmotic release of vasopressin; this release may be sustained up to one week after surgery.</p><p class="elsevierStylePara">In the daily practice there exist high variability in fluids prescription, both in their volume and in their composition. A survey done among 200 surgeons from the United Kingdom<span class="elsevierStyleSup">8</span> showed that education on fluid therapy was insufficient, the prescription being mainly done by training physicians, being highly variable, the most prescribed regimen being 1 liter of normal saline (0.9%) and 2 liters of 5% dextrose. In an analysis carried out by the Pharmacy Department of the «12 de Octubre» Hospital in Madrid,<span class="elsevierStyleSup">9</span> the most used regimen was 1.5 liters of normal saline and 1.5 liters of dextrose. In spite of this striking diversity of regimens, as also reflected in the study by Caramelo et al., it seems that the mortality secondary to electrolytic impairments during postsurgery is low, or at least these impairments are not reported, which reflects that in most of the cases the kidney response to hypotonic solutions overload is adequate, and although there exists a net gain of free water it does not seem to have a clinical relevance.</p><p class="elsevierStylePara">An important problem with post-surgery fluid therapy is that generic regimens are used in very different clinical conditions. So that a surgery needing prolonged gastric drainage will have increased reposition requirements as compared with a gynecologic surgery without paralytic ileus. During surgery itself, there are fluid losses that should be estimated and replaced. So, in those surgeries in which the peritoneal cavity or the thorax are exposed for a long time, it is estimated that 4.5 mL/kg of free water per hour of surgery are lost.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Controlled studies allowing reaching any conclusion only exist in particular groups of patients. Several controlled studies and one meta-analysis in minor ambulatory surgery and in laparoscopic surgery have shown that the administration of 20-40 mL/kg of normal saline vs. 1-15 mL/kg before the surgery decrease dizziness, thirst, and vomiting after surgery.<span class="elsevierStyleSup">11-14</span> There are fewer data in major surgery to reach conclusions. In a Cochrane review from the year 2000, in surgery of the abdominal aortic artery,<span class="elsevierStyleSup">15</span> no significant differences were found between different fluid therapy regimens. The authors conclude that more studies are required in order to establish additional conclusions. In a controlled study on parenteral fluids regimens in patients submitted to hemicolectomy,<span class="elsevierStyleSup">16</span> the administration of a restricted regimen of 2 liters/day (0.5 liters of normal saline + 1.5 L of 5% dextrose vs. 3 liters (1 liter of normal saline and 2 L of 5% dextrose) decreased perioperative complications and hospitalization days. Surprisingly, the group with a restricted regimen presented less hyponatremia episodes in spite of receiving lower sodium concentration (37.5 vs 51 mmol/L), which again reflects that the issue of post-surgical hyponatremia is probably more related with the volume of fluid administered and renal retention of free water than with the concentration of sodium administered. In children, the data available are in favor of administering normal saline as the reposition fluid, for both surgeries and other circumstances requiring fluid therapy such as dehydration due to gastroenteritis. A systematic review from the year 2006<span class="elsevierStyleSup">17</span> concludes that the experimental evidence in childhood is limited, the studies having a heterogeneous design and low power, although a higher risk for hyponatremia episodes is detected in children receiving hypotonic solutions, which may be anticipated and prevented by the administration of isotonic solutions.</p><p class="elsevierStylePara">Given the lack of robust evidence, at least in adult patients, about the type of fluid therapy to be administered during the post-surgical period and given the description of severe hyponatremia episodes, some of them fatal, the question to be answered is whether or not the use of only isotonic solutions is justified. Until controlled studies analyzing this issue will not be available, observational studies as the one published in this issue of NEFROLOGÍA deserve great interest. Caramelo et al. show how free water gain is not correlated with the tonicity of the fluids administered. Other observational studies show how postsurgical complications are related with the volume of fluids and the amount of sodium administered and not with the fluids tonicity. So, in an analysis of 100 surgeries of the colon and rectum,<span class="elsevierStyleSup">18</span> there were 44 complications, of which 11 were cardiopulmonary. The group having complications received higher amount of Na (149 vs 115 mmol/day) and more volume (2000 vs 1700 mL/ day). In a similar prospective study on 106 patients submitted to laparotomy,<span class="elsevierStyleSup">19</span> there were 55% complications, including 4 hypernatremia episodes, <span class="elsevierStyleSup">17</span> hyponatremia episodes, and 19 episodes of cardiac failure. The risk for complications was very much higher (67 vs 45%) in the group receiving more than 200 mmol of Na per day. The importance of Na intake is essential in the elderly due to his/her decreased cardiopulmonar capacity. In an analysis from the year 1999 about hospital mortality in the elderly population from the United Kingdom<span class="elsevierStyleSup">20</span> it was concluded that errors in parenteral fluids prescription (usually due to an excess) represent the main preventable perioperative morbimortality cause in the elderly.</p><p class="elsevierStylePara">Within this context, the debate on tonicity still goes on. To assume the recommendations proposed by Ayús et al. to prevent post-surgical hyponatremia and giving only normal saline without controlling the volume and amount of sodium administered may generate higher morbidity due to volume overload than to hyponatremia itself, which usually has little clinical relevance. Besides, and according to the results by Caramelo et al., this is not a regimen allowing for the prevention of hyponatremia occurrence since some patients develop the phenomenon known as «desalination » or inappropriate natriuresis.<span class="elsevierStyleSup">21</span></p><p class="elsevierStylePara">Until more information is available on the risks derived from the tonicity and fluid volume to be prescribed in the post-surgical setting, it is judicious to establish strategies allowing preventing the complications, which are as simple as: regularly assessing the patient, from both a clinical and laboratory perspective (electrolytes in blood and urine during all the time that fluid therapy remains in order to adequate the tonicity of the reposition regimen), and keeping a careful water balance, with estimates of intakes and losses, and avoiding unnecessary overhydration, specially in children and the elderly.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">NOTE TO THE EDITOR:</span> The topic discussed in the article by Dr. Caramelo,<span class="elsevierStyleSup">3 </span>being the object of this editorial, is of great interest. Despite the continuous use, post-surgical fluid therapy constitutes a very little studied intervention, sometimes with controversial opinions. NEFROLOGÍA considers that it may be extremely useful to promote the debate on this issue, so the Journal will try to get the opinion from experts on this topic. From here we invite Spanish nephrologists having an opinion on the topic, based on their own work or analysis of the literature, to send us their opinions as a «Letter to the Editor». <br></br></p>" "pdfFichero" => "P-E-S-A527-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ayus JC, Arieff Al. Postoperative hyponatremia. Ann Intern Med 126: 1005-1006, 1997. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9182467" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Moritz ML, Ayus JC. Hospital-acquired hyponatremia - why are hypotonic parenteral fluids still being used? Nat Clin Pract Nephrol 3: 374-382, 2007. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17592470" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Caramelo C, Tejedor A, Criado C, Alexandru S, Rivas S, Casares ML, Cifuentes S, Albalate M. Sueros empleados en enfermos quirúrgicos: composición y efectos sobre el medio interno. Nefrología (1):37-42, 2008." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Shidler FP. Considerations of postoperative electrolyte and fluid replacement. Calif Med 73: 309-311, 1950. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14772652" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "McCorriston JR, Miller GG. Practical aspects of fluid and electrolyte balance. Canad MAJ 66: 237-246, 1952." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Brensilver JM, Goldberger E. A Primer of Water, Electrolyte and Acid-base syndromes. 8th Ed, FA Davis Company, Philadelphia, 1996." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Greco BA, Jacobson HR. Fluid and Electrolyte problems with surgery, trauma, and burns. En: Kokko JP, Tanne RL eds. Fluids and Electrolytes, 3rd ed. Saunders, Philadelphia, pp. 729-758, 1996." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lobo DN, Dube MG, Neal KR; Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clinical Nutrition 20: 125-130, 2001. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11327739" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Campo M, García Rodríguez P, Martínez Díaz C, Serrano O, Herreros de Tejada A, López Coterilla. Utilización de fluidoterapia de mantenimiento en cirugía. Farm Hosp (Madrid) 28: 84-89, 2004." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Finsterer U, Weber W, Lühr HG. Electrolyte balance in mayor abdominal surgery. On insensible water losses from the peritoneal cavity. Anaesthesist 29: 59-70, 1980. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7377525" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Holte K, Kehlet H. Compensatory fluid administration for preoperative dehydration - does it improve outcome? Acta Anaesthesiol Scand 46: 1089-1093, 2002. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12366503" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Chohedri AH, Martin M, Khosravi A. The impact of operative fluids on the prevention of postoperative anesthetic complication sin ambulatory surgery ¿high dose vs low dose. Middle East J Anesthesiol 18: 1147-1156, 2006. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17263269" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Magner JJ, McCaul C, Carton E, Gardiner J, Buggy D. Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecologial laparoscopy: comparison of 30 and 10 ml/kg. Br J Anaesth 2004; 93: 381-85, 2004." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Holte K, Klarskov B, Christensen DS y cols. Liberal vs restrictive fluid administration to improve recovery after laparoscopic cholecystectomy. A randomized, double-blind study. Ann Surg 240: 892-899,2004. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15492573" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Zavrakidis N. Líquidos intravenosos para cirugía de aorta abdominal (Revisió Cochrane traducida). En: La biblioteca Cochrane Plus, 2007 Número 3. Oxford: Update Software ltd. Disponible en: http://www.update-software.com/" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomized controlled trial. Lancet 359: 1812-1818, 2002. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12044376" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Choong K, Kho ME, Menon K, Bohn D. Hypotonic versus isotonic saline in hospitalized children: a systematic review. Arch Dis Child 91: 28-835, 2006." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Tambyraja AL, Sengupta GSF, MacGregor AB, Chir B, Bartolo DCC, Fearon KCH. Patterns and clinical otucomes associated with routine intravenous sodium and fluid administration after colorectal resection. World J Surg 28: 1046-1052, 2004." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Walsh SR, Cook EJ, Farooq N, Gardner- Thorpe J, Tang T, Gaunt ME, Coveney EC. Perioperative fluid management. Prospective audit. Int J Clin Pract May 30, 2007 (prepublicacion online)." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Callum KG, Gray AJG, Hoile RW y cols. Extremes of age: the 1999 report of the National Confidential Enquiry into Perioperative Deaths. London: National Confidential Enquiry into Perioperative Deaths, 1999." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Steele A, Gowrishankar M, Abrahamson S, Mazer D, Feldman R, Halperin ML. Postoperative hyponatremia despite near-siotonic saline infusion: a phenomenon of desalination. Ann Intern Med 126: 20-25, 1997. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8992919" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002800000001/v0_201502091616/X2013251408033464/v0_201502091616/en/main.assets" "Apartado" => array:4 [ "identificador" => "35428" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial Comments" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000001/v0_201502091616/X2013251408033464/v0_201502091616/en/P-E-S-A527-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033464?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 24 | 10 | 34 |
| 2024 October | 122 | 64 | 186 |
| 2024 September | 156 | 48 | 204 |
| 2024 August | 152 | 69 | 221 |
| 2024 July | 131 | 41 | 172 |
| 2024 June | 154 | 56 | 210 |
| 2024 May | 140 | 46 | 186 |
| 2024 April | 136 | 27 | 163 |
| 2024 March | 119 | 21 | 140 |
| 2024 February | 81 | 30 | 111 |
| 2024 January | 75 | 35 | 110 |
| 2023 December | 109 | 34 | 143 |
| 2023 November | 85 | 46 | 131 |
| 2023 October | 129 | 52 | 181 |
| 2023 September | 102 | 38 | 140 |
| 2023 August | 90 | 31 | 121 |
| 2023 July | 123 | 38 | 161 |
| 2023 June | 119 | 25 | 144 |
| 2023 May | 121 | 29 | 150 |
| 2023 April | 107 | 16 | 123 |
| 2023 March | 116 | 25 | 141 |
| 2023 February | 83 | 23 | 106 |
| 2023 January | 95 | 25 | 120 |
| 2022 December | 78 | 42 | 120 |
| 2022 November | 124 | 25 | 149 |
| 2022 October | 107 | 42 | 149 |
| 2022 September | 104 | 50 | 154 |
| 2022 August | 123 | 45 | 168 |
| 2022 July | 93 | 51 | 144 |
| 2022 June | 110 | 39 | 149 |
| 2022 May | 108 | 36 | 144 |
| 2022 April | 102 | 45 | 147 |
| 2022 March | 116 | 49 | 165 |
| 2022 February | 111 | 39 | 150 |
| 2022 January | 117 | 43 | 160 |
| 2021 December | 105 | 47 | 152 |
| 2021 November | 114 | 41 | 155 |
| 2021 October | 108 | 39 | 147 |
| 2021 September | 100 | 49 | 149 |
| 2021 August | 110 | 46 | 156 |
| 2021 July | 116 | 48 | 164 |
| 2021 June | 95 | 34 | 129 |
| 2021 May | 73 | 40 | 113 |
| 2021 April | 184 | 55 | 239 |
| 2021 March | 123 | 70 | 193 |
| 2021 February | 117 | 25 | 142 |
| 2021 January | 105 | 16 | 121 |
| 2020 December | 61 | 32 | 93 |
| 2020 November | 57 | 14 | 71 |
| 2020 October | 58 | 15 | 73 |
| 2020 September | 51 | 14 | 65 |
| 2020 August | 43 | 7 | 50 |
| 2020 July | 43 | 14 | 57 |
| 2020 June | 70 | 21 | 91 |
| 2020 May | 42 | 22 | 64 |
| 2020 April | 84 | 27 | 111 |
| 2020 March | 69 | 8 | 77 |
| 2020 February | 96 | 26 | 122 |
| 2020 January | 87 | 27 | 114 |
| 2019 December | 101 | 22 | 123 |
| 2019 November | 142 | 32 | 174 |
| 2019 October | 88 | 20 | 108 |
| 2019 September | 72 | 21 | 93 |
| 2019 August | 57 | 24 | 81 |
| 2019 July | 99 | 26 | 125 |
| 2019 June | 66 | 14 | 80 |
| 2019 May | 92 | 30 | 122 |
| 2019 April | 149 | 34 | 183 |
| 2019 March | 30 | 16 | 46 |
| 2019 February | 34 | 12 | 46 |
| 2019 January | 38 | 16 | 54 |
| 2018 December | 91 | 32 | 123 |
| 2018 November | 99 | 18 | 117 |
| 2018 October | 75 | 12 | 87 |
| 2018 September | 59 | 22 | 81 |
| 2018 August | 44 | 22 | 66 |
| 2018 July | 44 | 20 | 64 |
| 2018 June | 26 | 17 | 43 |
| 2018 May | 39 | 12 | 51 |
| 2018 April | 36 | 10 | 46 |
| 2018 March | 41 | 12 | 53 |
| 2018 February | 37 | 6 | 43 |
| 2018 January | 42 | 7 | 49 |
| 2017 December | 53 | 9 | 62 |
| 2017 November | 35 | 15 | 50 |
| 2017 October | 26 | 6 | 32 |
| 2017 September | 40 | 12 | 52 |
| 2017 August | 29 | 9 | 38 |
| 2017 July | 32 | 14 | 46 |
| 2017 June | 19 | 31 | 50 |
| 2017 May | 41 | 28 | 69 |
| 2017 April | 33 | 13 | 46 |
| 2017 March | 12 | 7 | 19 |
| 2017 February | 23 | 11 | 34 |
| 2017 January | 17 | 7 | 24 |
| 2016 December | 59 | 13 | 72 |
| 2016 November | 60 | 11 | 71 |
| 2016 October | 82 | 14 | 96 |
| 2016 September | 133 | 4 | 137 |
| 2016 August | 222 | 3 | 225 |
| 2016 July | 172 | 2 | 174 |
| 2016 June | 121 | 0 | 121 |
| 2016 May | 143 | 0 | 143 |
| 2016 April | 107 | 0 | 107 |
| 2016 March | 78 | 0 | 78 |
| 2016 February | 99 | 0 | 99 |
| 2016 January | 86 | 0 | 86 |
| 2015 December | 121 | 0 | 121 |
| 2015 November | 91 | 0 | 91 |
| 2015 October | 85 | 0 | 85 |
| 2015 September | 72 | 0 | 72 |
| 2015 August | 72 | 0 | 72 |
| 2015 July | 62 | 0 | 62 |
| 2015 June | 43 | 0 | 43 |
| 2015 May | 55 | 0 | 55 |
| 2015 April | 5 | 0 | 5 |
Show all
