Safety in Dermatologic Procedures: Anaphylaxis, Vasovagal Reaction, and Hyperventilation

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"apellidos" => "Sánchez-Estella" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "†" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio ITS/Dermatología, Sección Especialidades Médicas, Organismo Autónomo Madrid Salud – Ayuntamiento de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Asistencial de Zamora, Zamora, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Seguridad en procedimientos dermatológicos: anafilaxia, reacción vasovagal e hiperventilación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2100 "Ancho" => 2175 "Tamanyo" => 539379 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Isometric counter-pressure maneuvers to prevent the progression of vasovagal reaction. A, Cross legs and engage leg muscles. B, Squeeze a rubber ball. C, Pull 2 hands in opposite directions." ] ] ] "textoCompleto" => "AnaphylaxisAnaphylaxis is a severe, life-threatening situation, albeit rare. It can be caused by immunoglobulin E (IgE)-dependent or IgE-independent mechanisms. The characteristic clinical signs are presented in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Recurrent skin and mucosal manifestations may or may not be observed, and clinical signs may be limited to arrhythmias, acute coronary syndrome, or severe asthma.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Risk factors for poor outcome include chronic respiratory diseases, certain medications (β-blockers, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, and benzodiazepines), a personal history of mastocytosis, and delayed adrenaline administration.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>Avoidance of triggers is essential for prevention. This means that the patient’s known allergies must be taken into account (e.g. latex allergies and possible cross-reactivity with foods such as kiwi, avocado, or banana).<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>When considering treatment<a class="elsevierStyleCrossRef" href="#bib0010">2</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) it is important to bear the following points in mind:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)The anesthesiology or intensive care services should be alerted as soon as anaphylaxis is suspected.</li><li class="elsevierStyleListItem" id="lsti0010">2)Adrenaline should be administered early.</li><li class="elsevierStyleListItem" id="lsti0015">3)The causative agent (e.g. antibiotics, blood products, contrast medium, latex) must be removed.</li><li class="elsevierStyleListItem" id="lsti0020">4)The risk of biphasic responses (e.g. symptom recurrence without re-exposure to the causative agent) in the first 24–72 hours, which require hospital admission in severe cases, must be considered.</li></ul><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Vasovagal reactionThis is the most frequent medical complication during dermatological surgery. It has been reported in 1 in every 160 interventions.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Although its presentation may be alarming, it usually has a benign, self-resolving course. However, in very sensitive individuals it can cause cardiac arrest due to asystole.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>It is caused by a pathological response to various stimuli of the autonomic reflexes that control blood pressure and heart rate. The Bezold-Jarisch reflex is activated, causing an initial loss of sympathetic tone (hypotension) followed by intense vagal discharge (bradycardia). Either of the two components can predominate. The resulting cerebral hypoperfusion can cause a temporary loss of consciousness (syncope).Although this type of reaction can occur in any individual in certain circumstances, predisposing factors include individual susceptibility (a history of vagal reactions to previous invasive procedures), age less than 35 years, female sex, lack of sleep, fasting, ambient heat, and standing.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>In dermatological surgery, triggers include fear, the sight of blood and needles, and pain.Due to its neurogenic mechanism, onset occurs rapidly (within seconds) and the episode duration can range from seconds to minutes. With patient monitoring, a drop in blood pressure and heart rate can be detected before the patient experiences symptoms, which include feelings of weakness and dizziness, paleness, sweating, and occasionally nausea and vomiting. If the reaction proceeds loss of consciousness may occur, followed by brief tonic–clonic contractions if the cerebral ischemia is very abrupt.Preventive measures should be applied in young patients and/or those with a history of reactions of this type. Preventive measures and treatment, to be applied after onset, are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>HyperventilationAcute hyperventilation syndrome is an abnormal response in certain individuals to a stressful event, characterized by an increase in ventilation that exceeds metabolic demand. It is more frequent in individuals with anxiety, who, in situations of fear, breathe rapidly and shallowly using the upper part of the thorax. This breathing pattern is often not apparent. This leads to a decrease in the partial pressure of CO2 in the blood, which is the main regulator of cerebral circulation, giving rise to the cerebral vasoconstriction that underlies the clinical signs.It is characterized, initially, by a dysphoric presentation, including anxiety, lightheadedness, shortness of breath and upset stomach, nausea, belching, chest tightness, perioral numbness, acral paresthesia, and even tetany of the hands. Blood pressure and heart rate are initially normal, but syncope can occur if the episode progresses.Up until several years ago breathing into a paper bag was recommended in cases of hyperventilation with no organic cause. However, this technique is no longer considered effective. Current treatment consists of guiding the patient’s breathing, applying pressure with one hand on the upper chest, and encouraging the patient to breathe more slowly using the diaphragm (abdominal breathing).<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1591555" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1430026" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1591554" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1430025" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Anaphylaxis" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Vasovagal reaction" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Hyperventilation" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of Interest" ] 8 => array:2 [ "identificador" => "xack562404" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-01-21" "fechaAceptado" => "2021-02-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1430026" "palabras" => array:6 [ 0 => "Dermatologic surgery" 1 => "Adverse events" 2 => "Complications" 3 => "Anaphylaxis" 4 => "Vasovagal syncope" 5 => "Hyperventilation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1430025" "palabras" => array:6 [ 0 => "Procedimientos quirúrgicos dermatológicos" 1 => "Efectos adversos" 2 => "Complicaciones" 3 => "Anafilaxia" 4 => "Síncope vasovagal" 5 => "Hiperventilación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "This article, part of a the series on safety in dermatologic procedures, covers the diagnosis, prevention, management, and treatment of 3 situations or conditions. The first condition we address is anaphylaxis, an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence. The second is fainting due to a vasovagal reaction, which is the most common complication in dermatologic surgery. This event, which occurs in 1 out of every 160 procedures, usually follows a benign course and resolves on its own. However, in patients susceptible to vasovagal reactions, syncope may lead to asystole and cardiac arrest. The third is acute hyperventilation syndrome, which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements. Brief practical recommendations for managing all 3 events are included." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En el presente artículo de la serie “Seguridad en procedimientos dermatológicos” se aborda el diagnóstico, prevención, manejo y tratamiento de tres situaciones. Primeramente, se aborda la anafilaxia: una situación infrecuente, grave y potencialmente mortal, que requiere una identificación ágil para un manejo urgente coordinado por parte de médicos especialistas en Anestesiología. En segundo lugar, la reacción vasovagal, que es la complicación médica más frecuente durante la cirugía dermatológica (1 de cada 160 intervenciones), con una evolución habitualmente benigna autorresolutiva, pero que en individuos muy sensibles puede provocar una parada cardiaca por asistolia. En tercer y último lugar, el síndrome de hiperventilación aguda, que es una respuesta anómala de determinados individuos a un evento estresante, con un incremento de la ventilación que excede la demanda metabólica. En los tres casos se incluyen recomendaciones que se plasman de forma práctica y somera." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "†" "nota" => "In memoriam." "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Lobo-Valbuena B, Martin-Gorgojo A, Zafra-Cobo I, Sánchez-Estella J. Seguridad en procedimientos dermatológicos: anafilaxia, reacción vasovagal e hiperventilación. ACTAS Dermo-Sifiliogr. 2021. https://doi.org/10.1016/j.ad.2021.02.010" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2487 "Ancho" => 2175 "Tamanyo" => 688113 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Clinical manifestations of suspected anaphylaxis. Adapted from Shaker et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2100 "Ancho" => 2175 "Tamanyo" => 539379 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Isometric counter-pressure maneuvers to prevent the progression of vasovagal reaction. A, Cross legs and engage leg muscles. B, Squeeze a rubber ball. C, Pull 2 hands in opposite directions." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: MAP, mean arterial pressure; SpO2, oxygen saturation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Immediate notification of the anesthesiology service if anaphylaxis is suspected</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment</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">Description \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ABC (life support)</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">• Airway: ensure airway patency.• Breathing: ensure efficient breathing, SpO2 > 95% (provide oxygen therapy at > 10 L/min).• Circulation: ensure minimum perfusion pressure (MAP > 65 mmHg). \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">First line \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">Adrenaline (as soon as possible) \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">• Intramuscular (better than subcutaneous):- Adults: 0.5 mg ( approximately equivalent to 0.01 mg/kg).- Children:< 6 y, 0.15 mg6–12 y, 0.3 mg>12 y, 0.5 mgCan be repeated after 5–15 minIntravenous: 50–200 µg in bolusCaution should be exercised to avoid overdose (arrhythmia, hypertensive crisis, and pulmonary edema), especially in patients with ischemic heart disease.Patients receiving chronic beta-blocker treatment have a poorer response. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fluid therapy \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">In the first 30 min:Adults: 1–2 LChildren: 20 mL/kg \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">Second line \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">Corticosteroids \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">At the following doses for at least 3–4 days, with subsequent progressive reduction:Methylprednisolone, 1 mg/kgHydrocortisone, 200 mg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antihistamines \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">Dexchlorpheniramine, 50 mg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchodilators \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">In case of bronchospasm \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Referral to allergology (if allergic reaction is suspected)</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">To facilitate assessment, it is recommended to determine plasma tryptase levels at 15 min, 3 h, and 24 h. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2723523.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Treatment of Anaphylaxis" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviation: IV, intravenous." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prevention \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"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative \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">Frugal intake (avoiding fasting) and good hydration (water intake) beforehand, surgical procedure permitting<a class="elsevierStyleCrossRefs" href="#bib0030">6,8</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative oral anxiolytics (in case of locoregional anesthesia).<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Rapid-acting benzodiazepines 1 h before:Short half-life: midazolam (7.5 mg)Long half-life: diazepam (5–10 mg) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In highly susceptible individuals:Atropine 0.5 mg (intramuscular or subcutaneous) 30 min to 1 h before surgery \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">Intraoperative \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">Avoid excessive ambient heat in the operating theater \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Always perform painful or invasive techniques with the patient in a supine position \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Engage in conversation (to distract, without conveying anxiety or concern) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Keep needles, blood, etc. out of patient’s line of sight \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When starting the procedure in susceptible individuals or those with initial symptoms:Perform isometric counter-pressure maneuver with force for 30 s (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>)These maneuvers, when properly executed, greatly increase venous return and are effective in 40% of individuals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In case of pain: stop the procedure and re-anesthetize \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">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial maneuvers<a class="elsevierStyleCrossRef" href="#bib0020">4</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stop the stimuli that trigger the vagal reaction:Stop surgical procedureRemove light from the patient’s face \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Trendelenburg position and/or elevation of legs (to increase venous return and cerebral perfusion), turning head to one side for safety \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Promote ventilation and/or administer oxygen via a mask \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maneuvers that induce an adrenergic reaction:Passing a cold wet compress over the faceInhalation of classic ammonium salts \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">Pharmacotherapy \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">In cases of loss of consciousness and/or persistent bradycardia < 50 bpm:IV injection of 0.5–1 mg (0.5–1 ampoule) of atropine sulfate.The onset of atropine activity occurs approximately 2–4 mL after IV injectionThe dose can be repeated every 3–5 min, up to a maximum of 3 mg (3 ampoules)If the patient does not have a venous line or venous access is not possible, other routes of administration can be used (although the effect is delayed): intramuscular (5–30 min), subcutaneous (15–30 min), and even sublingual (not predictable, but generally fast)Atropine is an essential drug in the emergency kit. It is very safe and has no absolute contraindication in emergency situations. Caution must be exercised in patients with ischemic heart disease and smooth fiber-mediated obstructive diseases. It causes frequent but mild side effects (blurred vision, dry mouth, palpitations, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with persistent hypotension:Physiological serum: 500 mL in 5–10 min \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2723522.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Prevention and Treatment of Vasovagal Reaction<a class="elsevierStyleCrossRefs" href="#bib0020">4,6–8</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.S. 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ASCIA Guidelines - Acute management of anaphylaxis. <a target="_blank" href="https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines">https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines</a>." ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatologic surgery emergencies: Complications caused by occlusion and blood pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Minkis" 1 => "A. Whittington" 2 => "M. Alam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2015.11.013" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol." 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Safety in Dermatologic Procedures: Anaphylaxis, Vasovagal Reaction, and Hyperventilation

Seguridad en procedimientos dermatológicos: anafilaxia, reacción vasovagal e hiperventilación

B. Lobo-Valbuenaa, A. Martin-Gorgojob,

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alejandromartingorgojo@aedv.es

Corresponding author.

, I. Zafra-Coboc, J. Sánchez-Estellac,†

a Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain

b Servicio ITS/Dermatología, Sección Especialidades Médicas, Organismo Autónomo Madrid Salud – Ayuntamiento de Madrid, Madrid, Spain

c Servicio de Dermatología, Complejo Asistencial de Zamora, Zamora, Spain

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        "titulo" => "Seguridad en procedimientos dermatol&#243;gicos&#58; anafilaxia&#44; reacci&#243;n vasovagal e hiperventilaci&#243;n"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Isometric counter-pressure maneuvers to prevent the progression of vasovagal reaction&#46; A&#44; Cross legs and engage leg muscles&#46; B&#44; Squeeze a rubber ball&#46; C&#44; Pull 2 hands in opposite directions&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Anaphylaxis</span><p id="par0005" class="elsevierStylePara elsevierViewall">Anaphylaxis is a severe&#44; life-threatening situation&#44; albeit rare&#46; It can be caused by immunoglobulin E &#40;IgE&#41;-dependent or IgE-independent mechanisms&#46; The characteristic clinical signs are presented in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Recurrent skin and mucosal manifestations may or may not be observed&#44; and clinical signs may be limited to arrhythmias&#44; acute coronary syndrome&#44; or severe asthma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Risk factors for poor outcome include chronic respiratory diseases&#44; certain medications &#40;&#946;-blockers&#44; angiotensin-converting enzyme inhibitors&#44; nonsteroidal anti-inflammatory drugs&#44; and benzodiazepines&#41;&#44; a personal history of mastocytosis&#44; and delayed adrenaline administration&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Avoidance of triggers is essential for prevention&#46; This means that the patient&#8217;s known allergies must be taken into account &#40;e&#46;g&#46; latex allergies and possible cross-reactivity with foods such as kiwi&#44; avocado&#44; or banana&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When considering treatment<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; it is important to bear the following points in mind&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">The anesthesiology or intensive care services should be alerted as soon as anaphylaxis is suspected&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Adrenaline should be administered early&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The causative agent &#40;e&#46;g&#46; antibiotics&#44; blood products&#44; contrast medium&#44; latex&#41; must be removed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">The risk of biphasic responses &#40;e&#46;g&#46; symptom recurrence without re-exposure to the causative agent&#41; in the first 24&#8211;72&#160;hours&#44; which require hospital admission in severe cases&#44; must be considered&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Vasovagal reaction</span><p id="par0045" class="elsevierStylePara elsevierViewall">This is the most frequent medical complication during dermatological surgery&#46; It has been reported in 1 in every 160 interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although its presentation may be alarming&#44; it usually has a benign&#44; self-resolving course&#46; However&#44; in very sensitive individuals it can cause cardiac arrest due to asystole&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is caused by a pathological response to various stimuli of the autonomic reflexes that control blood pressure and heart rate&#46; The Bezold-Jarisch reflex is activated&#44; causing an initial loss of sympathetic tone &#40;hypotension&#41; followed by intense vagal discharge &#40;bradycardia&#41;&#46; Either of the two components can predominate&#46; The resulting cerebral hypoperfusion can cause a temporary loss of consciousness &#40;syncope&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although this type of reaction can occur in any individual in certain circumstances&#44; predisposing factors include individual susceptibility &#40;a history of vagal reactions to previous invasive procedures&#41;&#44; age less than 35 years&#44; female sex&#44; lack of sleep&#44; fasting&#44; ambient heat&#44; and standing&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In dermatological surgery&#44; triggers include fear&#44; the sight of blood and needles&#44; and pain&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Due to its neurogenic mechanism&#44; onset occurs rapidly &#40;within seconds&#41; and the episode duration can range from seconds to minutes&#46; With patient monitoring&#44; a drop in blood pressure and heart rate can be detected before the patient experiences symptoms&#44; which include feelings of weakness and dizziness&#44; paleness&#44; sweating&#44; and occasionally nausea and vomiting&#46; If the reaction proceeds loss of consciousness may occur&#44; followed by brief tonic&#8211;clonic contractions if the cerebral ischemia is very abrupt&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Preventive measures should be applied in young patients and&#47;or those with a history of reactions of this type&#46; Preventive measures and treatment&#44; to be applied after onset&#44; are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Hyperventilation</span><p id="par0075" class="elsevierStylePara elsevierViewall">Acute hyperventilation syndrome is an abnormal response in certain individuals to a stressful event&#44; characterized by an increase in ventilation that exceeds metabolic demand&#46; It is more frequent in individuals with anxiety&#44; who&#44; in situations of fear&#44; breathe rapidly and shallowly using the upper part of the thorax&#46; This breathing pattern is often not apparent&#46; This leads to a decrease in the partial pressure of CO<span class="elsevierStyleInf">2</span> in the blood&#44; which is the main regulator of cerebral circulation&#44; giving rise to the cerebral vasoconstriction that underlies the clinical signs&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is characterized&#44; initially&#44; by a dysphoric presentation&#44; including anxiety&#44; lightheadedness&#44; shortness of breath and upset stomach&#44; nausea&#44; belching&#44; chest tightness&#44; perioral numbness&#44; acral paresthesia&#44; and even tetany of the hands&#46; Blood pressure and heart rate are initially normal&#44; but syncope can occur if the episode progresses&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Up until several years ago breathing into a paper bag was recommended in cases of hyperventilation with no organic cause&#46; However&#44; this technique is no longer considered effective&#46; Current treatment consists of guiding the patient&#8217;s breathing&#44; applying pressure with one hand on the upper chest&#44; and encouraging the patient to breathe more slowly using the diaphragm &#40;abdominal breathing&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Dermatologic surgery"
            1 => "Adverse events"
            2 => "Complications"
            3 => "Anaphylaxis"
            4 => "Vasovagal syncope"
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            0 => "Procedimientos quir&#250;rgicos dermatol&#243;gicos"
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            2 => "Complicaciones"
            3 => "Anafilaxia"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This article&#44; part of a the series on safety in dermatologic procedures&#44; covers the diagnosis&#44; prevention&#44; management&#44; and treatment of 3 situations or conditions&#46; The first condition we address is anaphylaxis&#44; an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence&#46; The second is fainting due to a vasovagal reaction&#44; which is the most common complication in dermatologic surgery&#46; This event&#44; which occurs in 1 out of every 160 procedures&#44; usually follows a benign course and resolves on its own&#46; However&#44; in patients susceptible to vasovagal reactions&#44; syncope may lead to asystole and cardiac arrest&#46; The third is acute hyperventilation syndrome&#44; which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements&#46; Brief practical recommendations for managing all 3 events are included&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En el presente art&#237;culo de la serie &#8220;Seguridad en procedimientos dermatol&#243;gicos&#8221; se aborda el diagn&#243;stico&#44; prevenci&#243;n&#44; manejo y tratamiento de tres situaciones&#46; Primeramente&#44; se aborda la anafilaxia&#58; una situaci&#243;n infrecuente&#44; grave y potencialmente mortal&#44; que requiere una identificaci&#243;n &#225;gil para un manejo urgente coordinado por parte de m&#233;dicos especialistas en Anestesiolog&#237;a&#46; En segundo lugar&#44; la reacci&#243;n vasovagal&#44; que es la complicaci&#243;n m&#233;dica m&#225;s frecuente durante la cirug&#237;a dermatol&#243;gica &#40;1 de cada 160 intervenciones&#41;&#44; con una evoluci&#243;n habitualmente benigna autorresolutiva&#44; pero que en individuos muy sensibles puede provocar una parada cardiaca por asistolia&#46; En tercer y &#250;ltimo lugar&#44; el s&#237;ndrome de hiperventilaci&#243;n aguda&#44; que es una respuesta an&#243;mala de determinados individuos a un evento estresante&#44; con un incremento de la ventilaci&#243;n que excede la demanda metab&#243;lica&#46; En los tres casos se incluyen recomendaciones que se plasman de forma pr&#225;ctica y somera&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lobo-Valbuena B&#44; Martin-Gorgojo A&#44; Zafra-Cobo I&#44; S&#225;nchez-Estella J&#46; Seguridad en procedimientos dermatol&#243;gicos&#58; anafilaxia&#44; reacci&#243;n vasovagal e hiperventilaci&#243;n&#46; ACTAS Dermo-Sifiliogr&#46; 2021&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.ad.2021.02.010">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;ad&#46;2021&#46;02&#46;010</span></p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; MAP&#44; mean arterial pressure&#59; SpO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#8226; Airway</span>&#58; ensure airway patency&#46;<span class="elsevierStyleItalic">&#8226; Breathing</span>&#58; ensure efficient breathing&#44; SpO<span class="elsevierStyleInf">2</span> &#62; 95&#37; &#40;provide oxygen therapy at &#62; 10 L&#47;min&#41;&#46;<span class="elsevierStyleItalic">&#8226; Circulation</span>&#58; ensure minimum perfusion pressure &#40;MAP&#160;&#62;&#160;65&#160;mmHg&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Adrenaline &#40;as soon as possible&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#8226; Intramuscular &#40;better than subcutaneous&#41;&#58;</span>- Adults&#58; 0&#46;5&#160;mg &#40; approximately equivalent to 0&#46;01&#160;mg&#47;kg&#41;&#46;- Children&#58;&#60; 6 y&#44; 0&#46;15&#160;mg6&#8211;12 y&#44; 0&#46;3&#160;mg&#62;12 y&#44; 0&#46;5&#160;mgCan be repeated after 5&#8211;15&#160;minIntravenous&#58; 50&#8211;200&#160;&#181;g in bolus<span class="elsevierStyleItalic">Caution should be exercised to avoid overdose &#40;arrhythmia&#44; hypertensive crisis&#44; and pulmonary edema&#41;&#44; especially in patients with ischemic heart disease&#46;</span><span class="elsevierStyleItalic">Patients receiving chronic beta-blocker treatment have a poorer response&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">In the first 30&#160;min&#58;Adults&#58; 1&#8211;2 LChildren&#58; 20&#160;mL&#47;kg&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">At the following doses for at least 3&#8211;4 days&#44; with subsequent progressive reduction&#58;Methylprednisolone&#44; 1&#160;mg&#47;kgHydrocortisone&#44; 200 mg&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">&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">Antihistamines&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">Dexchlorpheniramine&#44; 50 mg&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">&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">Bronchodilators&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">In case of bronchospasm&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 " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to allergology &#40;if allergic reaction is suspected&#41;</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">To facilitate assessment&#44; it is recommended to determine plasma tryptase levels at 15&#160;min&#44; 3&#160;h&#44; and 24&#160;h&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Treatment of Anaphylaxis</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; IV&#44; intravenous&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prevention&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Preoperative</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frugal intake &#40;avoiding fasting&#41; and good hydration &#40;water intake&#41; beforehand&#44; surgical procedure permitting<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a>&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">&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">Preoperative oral anxiolytics &#40;in case of locoregional anesthesia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Rapid-acting benzodiazepines 1&#160;h before&#58;Short half-life&#58; midazolam &#40;7&#46;5&#160;mg&#41;Long half-life&#58; diazepam &#40;5&#8211;10&#160;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">In highly susceptible individuals&#58;Atropine 0&#46;5&#160;mg &#40;intramuscular or subcutaneous&#41; 30&#160;min to 1&#160;h before surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Intraoperative</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid excessive ambient heat in the operating theater&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">&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">Always perform painful or invasive techniques with the patient in a supine position&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">&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">Engage in conversation &#40;to distract&#44; without conveying anxiety or concern&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">Keep needles&#44; blood&#44; etc&#46; out of patient&#8217;s line of sight&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">&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">When starting the procedure in susceptible individuals or those with initial symptoms&#58;Perform isometric counter-pressure maneuver with force for 30&#160;s &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;<span class="elsevierStyleItalic">These maneuvers&#44; when properly executed&#44; greatly increase venous return and are effective in</span> 40&#37; <span class="elsevierStyleItalic">of individuals</span>&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">&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">In case of pain&#58; stop the procedure and re-anesthetize&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Initial maneuvers</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&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">Stop the stimuli that trigger the vagal reaction&#58;Stop surgical procedureRemove light from the patient&#8217;s face&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">&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">Trendelenburg position and&#47;or elevation of legs &#40;to increase venous return and cerebral perfusion&#41;&#44; turning head to one side for safety&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">&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">Promote ventilation and&#47;or administer oxygen via a mask&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">&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">Maneuvers that induce an adrenergic reaction&#58;Passing a cold wet compress over the faceInhalation of classic ammonium salts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pharmacotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">In cases of loss of consciousness and&#47;or persistent bradycardia &#60; 50 bpm&#58;</span>IV injection of 0&#46;5&#8211;1&#160;mg &#40;0&#46;5&#8211;1 ampoule&#41; of atropine sulfate&#46;The onset of atropine activity occurs approximately 2&#8211;4&#160;mL after IV injectionThe dose can be repeated every 3&#8211;5&#160;min&#44; up to a maximum of 3&#160;mg &#40;3 ampoules&#41;If the patient does not have a venous line or venous access is not possible&#44; other routes of administration can be used &#40;although the effect is delayed&#41;&#58; intramuscular &#40;5&#8211;30&#160;min&#41;&#44; subcutaneous &#40;15&#8211;30&#160;min&#41;&#44; and even sublingual &#40;not predictable&#44; but generally fast&#41;<span class="elsevierStyleItalic">Atropine is an essential drug in the emergency kit&#46; It is very safe and has no absolute contraindication in emergency situations&#46; Caution must be exercised in patients with ischemic heart disease and smooth fiber-mediated obstructive diseases&#46; It causes frequent but mild side effects &#40;blurred vision&#44; dry mouth&#44; palpitations&#44; etc&#46;&#41;</span>&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">&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"><span class="elsevierStyleItalic">In patients with persistent hypotension&#58;</span>Physiological serum&#58; 500&#160;mL in 5&#8211;10 min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prevention and Treatment of Vasovagal Reaction<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#8211;8</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:8 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anaphylaxis-a 2020 practice parameter update&#44; systematic review&#44; and Grading of Recommendations&#44; Assessment&#44; Development and Evaluation &#40;GRADE&#41; analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;S&#46; Shaker"
                            1 => "D&#46;V&#46; Wallace"
                            2 => "D&#46;B&#46;K&#46; Golden"
                            3 => "J&#46; Oppenheimer"
                            4 => "J&#46;A&#46; Bernstein"
                            5 => "R&#46;L&#46; Campbell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaci.2020.01.017"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Allergy Clin Immunol&#46;"
                        "fecha" => "2020"
                        "volumen" => "145"
                        "paginaInicial" => "1082"
                        "paginaFinal" => "1123"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32001253"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Australasian Society of Clinical Immunology and Allergy&#46; ASCIA Guidelines - Acute management of anaphylaxis&#46; <a target="_blank" href="https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines">https&#58;&#47;&#47;www&#46;allergy&#46;org&#46;au&#47;hp&#47;papers&#47;acute-management-of-anaphylaxis-guidelines</a>&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatologic surgery emergencies&#58; Complications caused by occlusion and blood pressure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46; Minkis"
                            1 => "A&#46; Whittington"
                            2 => "M&#46; Alam"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2015.11.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2016"
                        "volumen" => "75"
                        "paginaInicial" => "243"
                        "paginaFinal" => "262"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27444068"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review of the Evaluation and Treatment of Vasovagal Reactions in Outpatient Procedures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "W&#46;J&#46; Wu"
                            1 => "L&#46;H&#46; Goldberg"
                            2 => "M&#46;K&#46; Rubenzik"
                            3 => "B&#46;R&#46; Zelickson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/DSS.0000000000001598"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Surg&#46;"
                        "fecha" => "2018"
                        "volumen" => "44"
                        "paginaInicial" => "1483"
                        "paginaFinal" => "1488"
                        "link" => array:1 [
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        "texto" => "<p id="par0095" class="elsevierStylePara elsevierViewall">The authors thank all speakers and participants in the series of conferences on safety in dermatological procedures&#44; as well as all members of the Dermachat dermatological forum&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several weeks after submitting this article Dr&#46; S&#225;nchez-Estella died of COVID-19&#46; He will be remembered with the deepest gratitude and admiration&#46;</p>"
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2021.06.003

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Year/Month	Html	Pdf	Total

2024 November	13	5	18
2024 October	81	39	120
2024 September	76	38	114
2024 August	93	56	149
2024 July	88	35	123
2024 June	96	51	147
2024 May	81	31	112
2024 April	98	29	127
2024 March	73	26	99
2024 February	81	29	110
2024 January	83	32	115
2023 December	78	18	96
2023 November	91	25	116
2023 October	72	16	88
2023 September	74	26	100
2023 August	42	24	66
2023 July	64	46	110
2023 June	61	30	91
2023 May	76	31	107
2023 April	56	24	80
2023 March	76	39	115
2023 February	76	16	92
2023 January	45	22	67
2022 December	72	41	113
2022 November	49	26	75
2022 October	37	26	63
2022 September	50	38	88
2022 August	27	43	70
2022 July	35	43	78
2022 June	22	31	53
2022 May	72	44	116
2022 April	95	30	125
2022 March	81	71	152
2022 February	83	41	124
2022 January	54	36	90
2021 December	41	37	78
2021 November	61	57	118
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