BRILMA and PEC blocks: Simpler and more adequate options in radical breast surgery

Fernández Martín, M.T.; López Álvarez, S.

doi:10.1016/j.redare.2018.08.004

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Veiga et al. titled “Erector spinae plane block for radical mastectomy: A new indication?”.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> We would like to congratulate the authors on their description of the erector spinae plane (ESP) block as an analgesic technique in radical breast surgery.The ESP is a fascial block performed in the deep plane of the posterior thoracic wall.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> We agree with the authors that acting on the dorsal and ventral rami of the spinal nerves produces a sensory blockade caused by the local anaesthetic spreading in a caudal and cranial direction and into the paravertebral space. The anaesthetic enters this space through existing openings in the wall of the anterior fascia, which facilitates the spread of the anaesthetic.We are aware of its analgesic efficacy, but we question when it should form part of our anaesthetic–analgesic strategy in breast cancer surgery. Firstly, we doubt that intercostal nerve block will provide sufficient analgesia for radical mastectomy: although the chest wall is innervated by the first intercostal nerves (T2–T6), the deep muscles are innervated by the pectoral nerves, which have their origin in the lateral and medial fascicles of the brachial plexus.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> Even so, we agree that the ESP block is an opioid-saving multimodal analgesia strategy. Secondly, we would draw attention to the difficulty and possible complications of ESP. In our opinion, this block requires extensive training in regional anaesthesia, and although the complications are probably similar to other nerve blocks, it is difficult to predict its extension due to the spread of the anaesthetic in the paravertebral space. Finally, with respect to patient comfort, this technique has the disadvantage of being performed in an awake patient placed in the prone or lateral decubitus position. Being a deep block, it can be painful to perform, and many of the female patients have high levels of anxiety as a result of their oncological process.The ESP block is a recent technique that raises questions that need to be explored in clinical studies. In breast surgery, we routinely use different, easy-to-perform nerve blocks with proven analgesic efficacy<a class="elsevierStyleCrossRefs" href="#bib0045">4,5</a> and few complications. They require a short learning curve and are performed on the anaesthetised patient in the supine position. Based on our experience, we believe a simpler option for the case described by the authors, and one that would probably provide better analgesia is the serratus-intercostal fascial block at the level of the fourth rib (BRILMA) associated with an interpectoral block (PEC). Both are superficial blocks that are performed with a high-frequency linear transducer, after anaesthesia induction, with the patient in the supine position (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández Martín MT, López Álvarez S. Bloqueos BRILMA y PEC: opciones más sencillas y adecuadas en cirugía radical de mama. Rev Esp Anestesiol Reanim. 2018;65:478–479." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 721 "Ancho" => 2000 "Tamanyo" => 123414 ] ] "descripcion" => array:1 [ "en" => "Approach and ultrasound image of the BRILMA blockade.C4, 4th rib; AML, mid-axillary line; pl, pleura; sc, subcutaneous cellular tissue; serr, serratus muscle." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bloqueo en el plano del músculo erector de la columna para mastectomía radical: ¿una nueva indicación?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Veiga" 1 => "D. Costa" 2 => "I. Brazão" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2017.08.004" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2018" "volumen" => "65" "paginaInicial" => "112" "paginaFinal" => "115" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29102405" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Forero" 1 => "S.D. Adhikary" 2 => "H. Lopez" 3 => "C. Tsui" 4 => "K.J. Chin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/AAP.0000000000000451" "Revista" => array:6 [ "tituloSerie" => "Reg Anesth Pain Med" "fecha" => "2016" "volumen" => "41" "paginaInicial" => "621" "paginaFinal" => "627" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27501016" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative breast analgesia: a qualitative review of anatomy and regional techniques" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G.E. Woodworth" 1 => "R.M.J. Ivie" 2 => "S.M. Nelson" 3 => "C.M. Walker" 4 => "R.B. Maniker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/AAP.0000000000000641" "Revista" => array:6 [ "tituloSerie" => "Reg Anesth Pain Med" "fecha" => "2017" "volumen" => "42" "paginaInicial" => "609" "paginaFinal" => "631" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28820803" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abordaje guiado por ultrasonidos de los nervios intercostales en la línea medio axilar para cirugía de mama no reconstructiva y axila" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Diéguez" 1 => "M. Fajardo" 2 => "S. López" 3 => "P. Alfaro" 4 => "A. Pensado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2013.04.002" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2013" "volumen" => "60" "paginaInicial" => "365" "paginaFinal" => "370" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23742791" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound description of Pecs II (modified Pecs I): anovel approach to breast surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Blanco" 1 => "M. Fajardo" 2 => "T. 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 65. Issue 8.