Severe hypertension and tachycardia during transforaminal endoscopic discectomy – Is indigocarmine to blame?

array:22 ["pii" => "S1130147318300915" "issn" => "11301473" "doi" => "10.1016/j.neucir.2018.08.004" "estado" => "S300" "fechaPublicacion" => "2019-01-01" "aid" => "351" "copyright" => "Sociedad Española de Neurocirugía" "copyrightAnyo" => "2018" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Neurocirugia. 2019;30:50-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 15 "formatos" => array:2 [ "HTML" => 8 "PDF" => 7 ] ] "itemAnterior" => array:18 [ "pii" => "S1130147318300289" "issn" => "11301473" "doi" => "10.1016/j.neucir.2018.03.002" "estado" => "S300" "fechaPublicacion" => "2019-01-01" "aid" => "327" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Neurocirugia. 2019;30:44-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 20 "formatos" => array:2 [ "HTML" => 16 "PDF" => 4 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Caso clínico" "titulo" => "Resección completa de neurocitoma extraventricular hipervascularizado tras embolización preoperatoria" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "49" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Complete resection of hypervascularised extraventricular neurocytoma after preoperative embolisation" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1342 "Ancho" => 1200 "Tamanyo" => 132928 ] ] "descripcion" => array:1 [ "es" => "A y B) Imágenes de angiografía pre y postembolización parcial de la lesión respectivamente. C y D) Imágenes de secuencias T1 de RM con Gd axial y coronal, respectivamente, tras la segunda cirugía con la resección de la lesión de forma completa." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Majed Katati, Isabel Ortiz García, Clara Isabel Chamorro, Ángel Horcajadas, Alicia Hurtado, Carlos Sánchez, Benjamín Iañez, Enrique Saura, Ernesto García, Heriberto Busquier" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Majed" "apellidos" => "Katati" ] 1 => array:2 [ "nombre" => "Isabel" "apellidos" => "Ortiz García" ] 2 => array:2 [ "nombre" => "Clara Isabel" "apellidos" => "Chamorro" ] 3 => array:2 [ "nombre" => "Ángel" "apellidos" => "Horcajadas" ] 4 => array:2 [ "nombre" => "Alicia" "apellidos" => "Hurtado" ] 5 => array:2 [ "nombre" => "Carlos" "apellidos" => "Sánchez" ] 6 => array:2 [ "nombre" => "Benjamín" "apellidos" => "Iañez" ] 7 => array:2 [ "nombre" => "Enrique" "apellidos" => "Saura" ] 8 => array:2 [ "nombre" => "Ernesto" "apellidos" => "García" ] 9 => array:2 [ "nombre" => "Heriberto" "apellidos" => "Busquier" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147318300289?idApp=UINPBA00004B" "url" => "/11301473/0000003000000001/v1_201901030610/S1130147318300289/v1_201901030610/es/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "Case Report" "titulo" => "Severe hypertension and tachycardia during transforaminal endoscopic discectomy – Is indigocarmine to blame?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "50" "paginaFinal" => "52" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Baturay Kansu Kazbek, Hakan Yılmaz, Burak Kazancı, Perihan Ekmekçi, Hakan Sabuncuoğlu" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Baturay Kansu" "apellidos" => "Kazbek" "email" => array:1 [ 0 => "bkkazbek@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Hakan" "apellidos" => "Yılmaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Burak" "apellidos" => "Kazancı" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Perihan" "apellidos" => "Ekmekçi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Hakan" "apellidos" => "Sabuncuoğlu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Ufuk University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Ufuk University, Faculty of Medicine, Department of Neurosurgery, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipertensión severa y taquicardia durante la discectomía endoscópica transforaminal: ¿se puede culpar a la indigocarmina?" ] ] "textoCompleto" => "Endoscopic transforaminal discectomy is a minimally invasive technique used for the surgical treatment of herniated discs. This technique has advantages like suitability for outpatient surgery, shorter operation time, less exposure to anesthetic agents, faster recovery and less postoperative pain. Usage of volatile agents or intravenous anesthetics is a matter of choice and comorbidities usually play an important role in deciding on the type of anesthesia.Indigocarmine (5,5′ sodium salt of indigodisulphonic acid or indigotine) is a blue colored dye which is widely used to identify the ureteral orifice in urologic procedures. In endoscopic discectomies, indigocarmine is absorbed by the degenerative nucleus pulposus while normal tissue is not stained. Compared to direct visualization, removal of the stained tissue enables the surgeon to perform a selective endoscopic discectomy.Nowadays dyes such as indigocarmine are being used to visualize damaged tissue in transforaminal surgery. The identification of disc space was done with assistance of fluoroscopy. During the instillation of indigocarmine, we employed continuous fluoroscopy shooting to avoid overstaining of epidural tissues. It is enough to see the proper disc space with filling of indigocarmine. We interrupted the instillation of indigocarmine when it attained the posterior margin of annulus fibrosus.Indigocarmine is structurally similar to two serotonine molecules which are mirror images of each other and thus it has a known positive inotropic and chronotropic effect on the heart and a vasoconstrictive effect on peripheral vessels. Hemodynamic effects such as hypotension and anaphylaxis<a class="elsevierStyleCrossRefs" href="#bib0060">1,2</a> in addition to hypertension, bradycardia and atrioventricular block<a class="elsevierStyleCrossRefs" href="#bib0070">3,4</a> have been reported in intravenous application of indigocarmine. The hemodynamic disturbance observed in two cases reported here following transforaminal injection is of interest. The aim of this case report is to prepare anesthesiologists for such cases and make them consider invasive blood pressure monitorization. Both patients reported here have given written informed consent.Case 1The patient was referred to the neurosurgery clinic with back pain radiating to right leg and MRI findings of radiculopathy and elective endoscopic disc surgery was planned. The patient was a hypertensive 59 years old female and had no known allergies and was using ACE inhibitor. Induction was carried out with 3mg/kg propofol, 1mcg/kg fentanyl and 0.6mg/kg rocuronium and the patient was turned prone following intubation. Maintenance was carried out with total intravenous anesthesia (5mg/kg/h propofol and 1mcg/kg/h remifentanil) and 50% oxygen–50% air with BIS monitorization. The foramen was accessed endoscopically using a 6mm–1cm incision made 13cm laterally with a 45° angle targeting the L4-5 foramen. Following the identification of the disc space using fluoroscopy, 3ml of a sterile solution (2ml/16mg indigocarmine, 2ml normal saline, 2ml meglumine amidotrizoate) was injected. The patient was hemodynamically stable until the solution was injected, approximately 1min after the injection bigeminated ventricular extrasystoles were observed and noninvasive blood pressure was 230/120mmHg while BIS was 24 while the heart rate was 42/min. Cardiac rhythm returned to normal following a 100mg intravenous bolus of lidocaine and the patient was given 5mg of nitroglycerine bolus twice. Hemodynamics remained within normal limits throughout the remainder of the procedure. The patient was returned to the supine position at the end of surgery and was extubated. The patient was monitorized for 8h in the ward. Her vital signs and control ECG were within normal limits. She was discharged on the second postoperateive day.Case 2Endoscopic disc surgery was planned for the patient who was referred to the neurosurgery clinic with back pain radiating to right foot and MRI findings of radiculopathy. The patient was a 54 years old female who had allergic asthma but was not using any medications. Anesthesia induction was carried out with 3mg/kg propofol, 1mcg/kg fentanyl and 0.6mg/kg rocuronium and the patient was turned prone following intubation. Maintenance was carried out using total intravenous anesthesia (5mg/kg/h propofol and 1mcg/kg/h remifentanil) and 50% oxygen–50% air under BIS monitorization. The foramen was accessed endoscopically using a 6mm–1cm incision made 13cm laterally with a 45° angle targeting the L4-5 foramen. Following the identification of the disc space using fluoroscopy, 3ml of a sterile solution (2ml/16mg indigocarmine, 2ml normal saline, 2ml meglumine amidotrizoate) was injected. The patient was hemodynamically stable until the solution was injected, approximately 2min after the injection sinus tachycardia (140beats/min) was observed and non invasive blood pressure was measured as 220/120mmHg while BIS was 28. Hemodynamic parameters returned to normal after 100mg lidocaine and 5mg nitroglycerine bolus which was given three times and remained within normal limits until the end of surgery. The patient was returned to supine at the end of surgery and was extubated. Vital signs and ECG were monitorized for 8h in the ward and all values were within normal limits. She was discharged on the second postoperative day.DiscussionAlthough its indications are more limited compared to open microdiscectomy, endoscopic spinal surgery has become a technique that is more often chosen by neurosurgeons. Sparing of the multifidus muscle during foraminal surgery maintains motion and negates or delays the need for fusion. In this context, it can be considered as completely minimally invasive.<a class="elsevierStyleCrossRef" href="#bib0080">5</a>There are case reports in the literature concerning anaphylactic reactions resulting in deep hypotension which state that the exact pathological mechanism responsible is still not clear enough.<a class="elsevierStyleCrossRefs" href="#bib0085">6,7</a> Although there are reports of anaphylaxis following the intravenous injection of indigocarmine, the absence of hypotension, bronchospasm, wheezing or urticaria in our cases has made a diagnosis of anaphylaxis less likely. Drugs used in both cases were checked for past expiry date. On the other hand, indigocarmine has been held responsible from a rise in blood pressure followed by a bradycardic reflex due to its chemical structure which is similar to serotonine.<a class="elsevierStyleCrossRef" href="#bib0095">8</a>Hypertension and bradyarrhythmia was observed in the first case while hypertension and sinus tachycardia was observed in the second of two cases. These two distinctly different clinical pictures support the notion that indigocarmine causes this hemodynamic deterioration via an unknown mechanism. Moreover, we believe that intradiscal injection of indigocarmine may have caused sympathetic activation of pain pathways even though preemptive analgesia was employed, total intravenous anesthesia under BIS monitorization was used and the disturbance resolved rapidly after lidocaine injection. In fact, recent studies reveal sensory innervation of the intervertebral discs that also show ingrowth to the inner layers<a class="elsevierStyleCrossRef" href="#bib0100">9</a> which support formation of pain due to intervertebral injection.In this case report hypertension and arryhthmia have been treated symptomatically. Nitroglycerin, which is a weak arteriolar vasodilator primarily effecting venous capacitance vessels, has been preferred because of its short duration of action and easy titrability for intraoperative hypertension.<a class="elsevierStyleCrossRef" href="#bib0105">10</a> Lidocaine has been preferred because it decreases activity in spinal cord neurons and post-synaptic depolarization mediated by NMDA and neurokinin receptors and thus has an intraoperative analgesic activity.<a class="elsevierStyleCrossRef" href="#bib0110">11</a>ConclusionsConsidering that transforaminal discectomy operations are going to become more frequent, we believe that anesthesiologists should keep in mind that indigocarmine can cause serious hemodynamic disturbances not only in intravenous but also in transforaminal injection and invasive blood pressure monitorization should be considered and necessary precautions taken for emergency interventions prior to indigocarmine usage.FundingThe authors declare that they have not received funding of any kind for this manuscript.Conflict of interestThe authors declare no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1132664" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1065261" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1132665" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1065262" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-07" "fechaAceptado" => "2018-08-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1065261" "palabras" => array:3 [ 0 => "Transforaminal endoscopic discectomy" 1 => "Indigocarmine" 2 => "Hemodynamics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1065262" "palabras" => array:3 [ 0 => "Discectomía endoscópica transforaminal" 1 => "Indigocarmina" 2 => "Hemodinámica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Endoscopic transforaminal discectomy is a minimally invasive technique used for the surgical treatment of herniated discs. Indigocarmine is a dye which is widely used to identify the ureteral orifice in urologic procedures. Hemodynamic effects such as hypotension and anaphylaxis in addition to hypertension, bradycardia and atrioventricular block have been reported in intravenous application of indigocarmine. The aim of this case report is to prepare anesthesiologists for such cases and make them consider invasive blood pressure monitorization. Both patients had radicular pain radiating to the leg and scheduled to undergo transforaminal endoscopic discectomy. Intraoperative vital signs were within normal limits, however severe hypertension and tachyarrhythmia developed following the injection. Hemodynamics in both patients returned to normal following lidocaine and nitroglycerine injection." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La discectomía endoscópica transforaminal es una técnica mínimamente invasiva utilizada para el tratamiento quirúrgico de discos herniados. Indigocarmine es un tinte que se usa ampliamente para identificar el orificio ureteral en procedimientos urológicos. Se han informado efectos hemodinámicos como hipotensión y anafilaxia además de hipertensión, bradicardia y bloqueo auriculoventricular en la aplicación intravenosa de indigocarmina. El objetivo de este informe de caso es preparar a los anestesiólogos para tales casos y hacer que consideren la monitorización invasiva de la presión sanguínea. Ambos pacientes tenían dolor radicular que irradiaba a la pierna y se programaron para recibir una discectomía endoscópica transforaminal. Los signos vitales intraoperatorios se encontraron dentro de los límites normales, sin embargo, la hipertensión severa y la taquiarritmia se desarrollaron después de la inyección. La hemodinámica en ambos pacientes volvió a la normalidad después de la inyección de lidocaína y nitroglicerina." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Repetitive severe hypotension induced by indigo carmine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.H. Lee" 1 => "D.J. Baek" 2 => "S.Y. Jeon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00540-014-1859-x" "Revista" => array:5 [ "tituloSerie" => "J Anesth" "fecha" => "2015" "volumen" => "29" "paginaInicial" => "156" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24952427" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0065" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe hypotension, hypoxia, and subcutaneous erythema induced by indigo carmine administration during open prostatectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Nandate" 1 => "B.B. Voelzke" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Case Rep Urol" "fecha" => "2016" "paginaInicial" => "523738" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0070" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrioventricular block induced by indigo carmine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I.A. Hobai" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/BF03017750" "Revista" => array:6 [ "tituloSerie" => "Can J Anaesth" "fecha" => "2008" "volumen" => "55" "paginaInicial" => "717" "paginaFinal" => "718" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18835972" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0075" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Indigo carmine-induced polymorphic supraventricular bigeminy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Fujii" 1 => "H. Yoshinuma" 2 => "O. Kobayashi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1399-6576.2008.01877.x" "Revista" => array:6 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2009" "volumen" => "53" "paginaInicial" => "417" "paginaFinal" => "418" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19243347" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0080" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The evolution and advancement of endoscopic foraminal surgery: one surgeon's experience incorporating adjunctive technologies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.T. Yeung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/SASJ-2006-0014-RR" "Revista" => array:6 [ "tituloSerie" => "SAS J" "fecha" => "2007" "volumen" => "1" "paginaInicial" => "108" "paginaFinal" => "117" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25802587" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0085" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe hypotension, hypoxia, and subcutaneous erythema induced by indigo carmine administration during open prostatectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Nandate" 1 => "B.B. Voelzke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2016/5237387" "Revista" => array:5 [ "tituloSerie" => "Case Rep Urol" "fecha" => "2016" "volumen" => "2016" "paginaInicial" => "5237387" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27610263" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0090" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac arrest from intravenous indigo carmine during laparoscopic surgery – a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W.J. Lee" 1 => "H.S. Jang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4097/kjae.2012.62.1.87" "Revista" => array:6 [ "tituloSerie" => "Korean J Anesthesiol" "fecha" => "2012" "volumen" => "62" "paginaInicial" => "87" "paginaFinal" => "90" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22323961" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0095" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Electrical velocimetry elucidates the hemodynamics of hypertension caused by indigo carmine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T.L. Archer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jclinane.2010.02.013" "Revista" => array:6 [ "tituloSerie" => "J Clin Anesth" "fecha" => "2011" "volumen" => "23" "paginaInicial" => "166" "paginaFinal" => "168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21377084" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0100" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathomechanisms of discogenic low back pain in humans and animal models" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Ohtori" 1 => "G. Inoue" 2 => "M. Miyagi" 3 => "K. Takahashi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.spinee.2013.07.490" "Revista" => array:6 [ "tituloSerie" => "Spine J" "fecha" => "2015" "volumen" => "15" "paginaInicial" => "1347" "paginaFinal" => "1355" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24657737" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0105" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ECLIPSE trials: comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Aronson" 1 => "C.M. Dyke" 2 => "K.A. Stierer" 3 => "J.H. Levy" 4 => "A.T. Cheung" 5 => "P.D. Lumb" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Anesth Analg" "fecha" => "2008" "volumen" => "107" "paginaInicial" => "1110" "paginaFinal" => "1121" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0110" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative intravenous lidocaine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.M. de Oliveira" 1 => "A.M. Issy" 2 => "R.K. Sakata" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0034-7094(10)70041-6" "Revista" => array:6 [ "tituloSerie" => "Rev Bras Anestesiol" "fecha" => "2010" "volumen" => "60" "paginaInicial" => "325" "paginaFinal" => "333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20682165" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/11301473/0000003000000001/v1_201901030610/S1130147318300915/v1_201901030610/en/main.assets" "Apartado" => array:4 [ "identificador" => "392" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Casos Clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/11301473/0000003000000001/v1_201901030610/S1130147318300915/v1_201901030610/en/main.pdf?idApp=UINPBA00004B&text.app=https://revistaneurocirugia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147318300915?idApp=UINPBA00004B"]