Ultrasound guided nerve block for breast surgery | Revista Española de Anestesiología y Reanimación (English Edition)

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A. Colocación del transductor e introducción de la aguja en el abordaje descrito por Blanco. B. Imagen de ultrasonidos obtenida mediante la localización descrita por Blanco; la flecha señala la arteria acromiotorácica. C. Colocación del transductor e introducción de la aguja en el abordaje descrito por Fajardo. D. Imagen de ultrasonidos obtenida mediante localización descrita por Fajardo; la flecha indica la localización de inyección del anestésico local entre el músculo pectoral mayor y el menor. a: arteria acromiotorácica; aa: arteria axilar; asub: arteria subclavia; pm: músculo pectoral menor, pM: músculo pectoral mayor; va: vena axilar." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Diéguez, P. Casas, S. López, M. Fajardo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Diéguez" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Casas" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "López" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Fajardo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192916000093" "doi" => "10.1016/j.redare.2015.11.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192916000093?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935615002418?idApp=UINPBA00004N" "url" => "/00349356/0000006300000003/v1_201602190102/S0034935615002418/v1_201602190102/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S2341192915000864" "issn" => "23411929" "doi" => "10.1016/j.redare.2015.10.002" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "631" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2016;63:149-58" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 96 "formatos" => array:3 [ "EPUB" => 7 "HTML" => 72 "PDF" => 17 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Dynamic muscle O2 saturation response is impaired during major non-cardiac surgery despite goal-directed haemodynamic therapy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "149" "paginaFinal" => "158" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La respuesta de la saturación dinámica muscular en cirugía no cardiaca se altera pese a la terapia hemodinámica dirigida por objetivos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1838 "Ancho" => 3063 "Tamanyo" => 317301 ] ] "descripcion" => array:1 [ "en" => "Changes over time in heart rate (A), mean arterial pressure (B), systolic volume index (C), norepinephrine administration (D), temperature (E), and central venous saturation (F). Data are shown as median (interquartile range) during surgery and the nonparametric analysis of systemic changes over time in longitudinal data is shown as the corresponding p value." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Feldheiser, O. Hunsicker, L. Kaufner, J. Köhler, H. Sieglitz, R. Casans Francés, K.-D. Wernecke, J. Sehouli, C. Spies" "autores" => array:9 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Feldheiser" ] 1 => array:2 [ "nombre" => "O." "apellidos" => "Hunsicker" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Kaufner" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Köhler" ] 4 => array:2 [ "nombre" => "H." "apellidos" => "Sieglitz" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Casans Francés" ] 6 => array:2 [ "nombre" => "K.-D." "apellidos" => "Wernecke" ] 7 => array:2 [ "nombre" => "J." "apellidos" => "Sehouli" ] 8 => array:2 [ "nombre" => "C." "apellidos" => "Spies" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493561500170X" "doi" => "10.1016/j.redar.2015.06.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561500170X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192915000864?idApp=UINPBA00004N" "url" => "/23411929/0000006300000003/v1_201603020056/S2341192915000864/v1_201603020056/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Continuing education" "titulo" => "Ultrasound guided nerve block for breast surgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "159" "paginaFinal" => "167" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Diéguez, P. Casas, S. López, M. Fajardo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Diéguez" "email" => array:1 [ 0 => "pauladieguez@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Casas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Fajardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Abente y Lago, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario de Móstoles, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueos guiados por ultrasonidos para cirugía mamaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1882 "Ancho" => 2917 "Tamanyo" => 648295 ] ] "descripcion" => array:1 [ "en" => "BRILMA or serratus-intercostal block. (A) Position of the transducer. Sequence of 3 ultrasound images. (B) Insertion of the needle, indicated by the arrow. (C) Injection of local anaesthetic. (D) Diffusion of local anaesthetic. LA: local anaesthetic; 5r: 5th rib; Ic m: intercostal muscles; Serr m: serratus muscle; pl: pleura." ] ] ] "textoCompleto" => "IntroductionRecent advances in breast surgery have aimed at conserving the breast without causing deformities. This new approach has generalised the use of techniques such as oncoplastic breast surgery or mastectomy with breast reconstruction. Anaesthetic management during these less invasive procedures focuses on specific objectives: optimal anaesthesia, early recovery, overall satisfaction before, during and after surgery, minimal postoperative complications, and early hospital discharge. Regional anaesthesia is important in helping anaesthetists achieve these goals: it provides excellent analgesia, facilitates early recovery, and reduces the number of postoperative complications, such as cardiovascular and pulmonary problems, among others. Patients receiving regional anaesthesia are usually discharged earlier and are more satisfied with their surgery.The regional anaesthesia of choice in thoracic surgery is still thoracic paravertebral block.<a class="elsevierStyleCrossRefs" href="#bib0170">1,2</a> Nevertheless, the 2011 study published by Blanco et al.<a class="elsevierStyleCrossRefs" href="#bib0180">3–6</a> ushered in a number of ultrasound-guided nerve blocks using a peripheral approach. These new techniques are equally effective as the peripheral block, but are associated with fewer complications.These new approaches consist in the administration of a local anaesthetic (LA) between 2 interfascial planes, thus blocking innervation of the entire breast area. The primary aim is to achieve blockade of the pectoral nerves, and then of the intercostal nerves. Fajardo et al.<a class="elsevierStyleCrossRef" href="#bib0200">7</a> reported their experience in blockade of the lateral (LCB) and anterior (ACB) branches of the intercostal nerves.Nevertheless, some clinicians are still unsure of the technique and new concerns have been raised. A detailed literature search, a review of anaesthesia techniques used in breast surgery, an in-depth study of the anatomy of the anterior thorax (including dissection of cadavers and magnetic resonance imaging with contrast agents) and advanced ultrasound techniques, has shown the feasibility of a peripheral approach to block the cutaneous branches of the 2nd to 6th intercostal nerves as an alternative to neuroaxial blockade. This leads to the description of the intercostal branches block in the midaxillary line (BRILMA, in its Spanish acronym),<a class="elsevierStyleCrossRefs" href="#bib0205">8,9</a> which consists in administration of LA between the anterior serratus and external intercostal muscles in the midaxillary line. In a parallel development, another study described serratus plane blockade<a class="elsevierStyleCrossRef" href="#bib0215">10</a> in 4 healthy volunteers, involving administration of LA between the anterior serratus and latissimus dorsi muscles.Following reports in the literature of excellent results in small series,<a class="elsevierStyleCrossRefs" href="#bib0210">9–12</a> efforts are now focussed on developing clinical trials that would confirm the effectiveness and safety of these new approaches vs the paravertebral block.These novel techniques have not been limited to breast surgery, but have also been used in critically ill patients with thoracic injuries.<a class="elsevierStyleCrossRefs" href="#bib0230">13–15</a> Delivery of LA via a catheter for continuous nerve block has also been described.<a class="elsevierStyleCrossRef" href="#bib0195">6</a> Use of these novel interfascial nerve block techniques is spreading, and the proliferation of studies using different nomenclature has created a certain amount of confusion. The aim of this article is to explain the technique, clearly define the site of the LA infusion, and clarify the indications for each of these procedures. There are major methodological shortcomings in the studies published to date, and the type of nerve block chosen in some cases does not seem the most appropriate for the procedure undertaken.Clinical trials comparing the new chest wall interfascial blocks with the more traditional paravertebral technique will no doubt throw light on the subject. These new approaches have several advantages over neuroaxial blocks, including absence of sympathetic blockade, which reduces incidence of anaesthesia-induced arterial hypotension (reported to range from 4% to 21% in some series<a class="elsevierStyleCrossRefs" href="#bib0245">16,17</a>) and the high rate (up to 24%) of failure due to catheter migration.<a class="elsevierStyleCrossRefs" href="#bib0255">18,19</a> In free-flap reconstruction surgery in the thoracic region using, for example, the latissimus dorsi muscle, sympathetic block, which optimises analgesia perfusion through vasodilation, is an important factor.Overview of regional anatomyThe mammary glands situated in the anterior chest wall are bounded by structures that are key to anaesthesia and analgesia techniques. The glands extend vertically from the 2nd to the 6th rib, and horizontally from the sternum (parasternal line) to the midaxillary line. The breast lies on the pectoralis major muscle. The lateral border overlies the anterior serratus and the inferior border overlies the superior portion of the external oblique muscle of the abdomen. The glandular tissue is denser in the superior-lateral quadrant of the breast, and extends towards the axilla (Spence's tail).The axilla is a pyramidal space, situated between the arm and the chest wall. The base is formed by the skin of the axilla and the inferior border is formed by the clavipectoral fascia or aponeurosis, which is called the suspensory ligament of axilla, or Gerdy's ligament. The base of the axilla is innervated by the intercostobrachial nerve, which anastomoses with the medial cutaneous brachial nerve to innervate the skin of the axilla and the interior of the upper arm. These nerves can be damaged during surgical dissection of the axilla. The axilla is bordered anteriorly by the clavicle, posteriorly by the scapula, and medially by the first rib, forming the cervicoaxillary canal. The anterior wall comprises 3 muscles: the subclavian, pectoralis major and pectoralis minor, and has 2 layers: superficial and deep. The superficial layer, formed by the pectoralis major, is covered by the clavipectoral fascia. The deep layer lies posterior to the pectoralis major and its deep fascial layer. It comprises the subclavian and pectoralis minor muscles, both of which are surrounded by the clavipectoral fascia. The posterior wall of the axilla comprises the subscapularis, teres major, and latissimus dorsi muscles. The lateral wall is formed by the bicipital groove of the humerus, a thin strip that lies between the insertions of the muscles of the anterior and posterior walls. The medial wall comprises the serratus major muscle, which overlies the 4th or 5th ribs and their corresponding intercostal muscles.The clavipectoral fascia is triangular in shape, with its base facing medial, extending from the clavicle to the 1st rib, running from the sternum to the axilla. Its superior border inserts into the inferior surface of the clavicle, enveloping the subclavian muscle in a sheath. This sheath extends inferiorly to the superior border of the pectoralis minor, thus forming the clavipectoral segment. It is pierced by the cephalic vein, the thoracoacromial artery and the lateral pectoral nerve. Superficially, the clavipectoral fascia continues into the anterior abdominal wall. The deep layer is pierced by vessel branches and nerves emerging from the pectoral fascia. The 2 borders of the fascia that form the apex of the triangle do not join completely, but are partially separated by an intersticial space, and sometimes by a thick adipose layer located at the lower border of the pectoralis minor. This is called the suspensory ligament of axilla, or Gerdy's ligament.In terms of innervation, the thoracic nerves can be divided into 3 major groups: those arising from the superficial cervical plexus, those arising from the brachial plexus, and those extending from the anterior branches of the thoracic nerves. The supraclavicular nerves that innervate the upper pole of the mammary region arise mainly from the superficial cervical plexus (C1–C4). The lateral (C5–C7) and medial (C8–T1) pectoral nerves, the long thoracic or anterior serratus nerve (C5–C7) and the thoracodorsal nerve (C6–C8) arise from the brachial plexus. The intercostal nerves (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) arise from the anterior divisions of the 1st to 11th thoracic nerves. The anterior division of the 12th thoracic nerve is called the subcostal nerve. The 1st to 11th intercostal nerves innervate the sternum, while the breast is innervated by the 2nd to 6th intercostal nerves. The intercostobrachial nerve is a lateral cutaneous branch of the 2nd intercostal nerve that innervates the interior of the upper arm. This nerve is important, as it pierces the axillary compartment. Acute and even chronic postoperative pain following breast surgery is often caused by damage or even sectioning of this nerve during axillary dissection.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The pectoral nerves are both sensory and motor, with a predominance of motor nerves. The lateral pectoral nerve is larger than the medial. It arises from the lateral cord of the brachial plexus and traverses the clavipectoral fascia under the clavicle following the course of the thoracoacromial artery towards the deep layer of the pectoralis major. At this level, it merges with branches of the medial pectoral nerve to form a loop, and innervates the pectoralis major and minor muscles. The medial pectoral nerve arises from the medial cord of the brachial plexus and divides to form two branches: one innervates the pectoralis minor, and another forms the pectoral loop.The long thoracic, anterior serratus or long thoracic nerve of Bell, is a motor nerve that innervates the anterior serratus muscle. Damage to this nerve leads to atrophy of the muscle, causing winged scapula and difficulty in raising the arm. The long thoracic nerve runs vertically along the side of the thorax.The thoracodorsal nerve runs along the posterior wall of the axillary compartment near the lateral border of the scapula and innervates the latissimus dorsi muscle. Damage to this nerve causes atrophy of the posterior axillary wall, preventing abduction and extension of the upper limb.The intercostal nerves run between the internal and innermost intercostal muscles. These nerves divide into 2 branches, called the perforating or cutaneous branches of the intercostal nerve. They are the lateral and anterior branches. The lateral cutaneous branch of the intercostal nerve emerges from between the internal and innermost intercostal muscles and extends to the skin. It traverses the external intercostal muscles and the anterior serratus muscle along the midaxillary line. At the level of the subcutaneous tissue, it divides to form the anterior and posterior lateral cutaneous branches of the intercostal nerve. The anterior cutaneous branch of the intercostal nerve runs between the internal and innermost intercostal muscles towards the paresteral line. At this point it emerges to continue towards the skin and divides into branches, some of which cross the contralaterals at the level of the sternum, and others innervate the mid thoracic region. The nipple-areolar complex is an important landmark, as it is the site of the anastomsis of the anterior and lateral cutaneous branches of the 4th intercostal nerve, although branches of the 3rd and 5th intercostal nerves can also be involved.Ultrasound-guided nerve block in breast surgeryMost nerve blocks used in breast surgery are superficial, except in the case of obese patients, and require a high frequency linear transducer. Nerve blocks, being easily mastered and performed, are entirely reproducible. They are interfascial techniques, in which the LA is injected between the fascia enclosing 2 muscles. This facilitates dispersion of the anaesthetic and allows it to reach several different targets. Conceptually, the technique is similar to transversus abdominis plane (TAP) block.Paravertebral blockThe paravertebral block is the standard nerve blockade used in breast surgery. Needle placement is ultrasound-guided,<a class="elsevierStyleCrossRefs" href="#bib0255">18,19</a> making the technique both effective and safe. Despite this, the use of ultrasound during paravertebral block does not guarantee correct diffusion of the LA or prevent the risk of catheter migration.Paravertebral block is a central block in which LA is injected into the triangular paravertebral space located on either side of the spinal column. The walls of this space are formed by the intervertebral foramen medially, and by the transverse process laterally. The anterior wall is formed by adipose tissue and the parietal pleura, and the posterior wall by the costotransverse ligament and the transverse process. Cranially and caudally, the space is continuous with the adjacent superior and inferior paravetebral spaces. These anatomical relations are the most probable sites of catheter migration. Administration of LA in a particular paravertebral space will block the sympathetic thoracic ganglion and intercostal nerves at that level. Studies comparing multiple, small volume (1.5–3ml) injections vs single large volume (15ml) injection for paravertebral nerve block report better spread of anaesthetic drug and absence of sensation in the former.<a class="elsevierStyleCrossRef" href="#bib0265">20</a> Current guidelines, therefore, recommend the multiple injection technique.Ultrasound location of the costotransverse ligament and pleura will ensure the block is performed correctly and reduce the risk of complications. Although various techniques for accessing the paravertebral space have been described, the following 2 are probably the best known: sagittal approach, in which the tranducer is placed vertically, parallel to the longitudinal axis of the spinal column, and needle is inserted in a caudal-cranial orientation; and the transversal approach, in which the transducer is placed horizontally and the needle is inserted in plane from lateral to medial.Pectoral nerve block and modified pectoral nerve block (Pecs I and II)Pectoral block, or Pecs 1, consists in injecting LA below the clavicle, between the deep pectoral and the clavipectoral fascia, usually between the pectoralis major and minor muscles. It is important to identify the thoracoacromial artery at this level, even using doppler, in order to avoid accidental puncture. In most cases, the lateral pectoral nerve, which is larger than the medial pectoral nerve, can be seen adjacent to the artery. Administration of anaesthesia at this level will block the lateral and medial pectoral nerves (predominantly motor). This block can be used in the case of reconstructive breast surgery, and the option of ultrasound-guided placement of a catheter for continuous blockade can also be considered.<a class="elsevierStyleCrossRef" href="#bib0195">6</a> We usually perform pecs block immediately following breast reconstruction surgery. This is because inter-individual sensation of acute postoperative pain caused by the pectoral nerves can vary considerably, ranging from no pain to diffuse mild pain in the infraclavicular region, to severe pain. In the foregoing case, a single injection of approximately 10ml of long-acting LA, such as ropivacaine or levobupivacaine is administered. If continuous blockade is required, an elastomeric delivery device can be used after preliminary injection of a 10ml bolus.The first description of this technique involved a caracoid approach<a class="elsevierStyleCrossRefs" href="#bib0180">3,4</a> similar to that used in infraclavicular block, with the transducer placed vertically. The needle is inserted in plane at a cranio-caudal angle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), Following this,<a class="elsevierStyleCrossRefs" href="#bib0270">21,22</a> a new approach was described in which the transducer was placed under and parallel to the clavicle and the needle inserted in plane at a medial-lateral angle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) (Video 1 [additional material online]).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The modified pectoral nerve block, or Pecs II<a class="elsevierStyleCrossRef" href="#bib0190">5</a> consists in 2 LA injections at the same site, one between the deep layer of the pectoralis major muscle and the clavipectoral fascia, and the other in the interfascial plane between pectoralis minor and anterior serratus muscles. These injections are administered at a different level from that used in Pecs I. The transducer is placed obliquely on the lateral third of the clavicle (Video 2 [additional material online]), showing the 2nd, 3rd and 4th ribs, the attachment of the major and minor pecoralis muscles, the clavipectoral (Grady's) ligament, and the start of the anterior serratus muscle. There is as yet no firm evidence regarding the volume of LA for this technique, although various authors have used 10ml between the major and minor pectoralis muscles and a further 10ml between the pectoralis minor and anterior serratus muscle. The aim of this technique is to block innervation of the entire breast with a single injection. However, the following nerves are blocked: lateral and medial pectoral nerves, intercostobrachial nerve, superior lateral cutaneous branches of the intecostal nerves (depending on the volume administered, blockade can extend from the 2nd to 8th intercostal nerves) and the long thoracic nerve. This approach cannot anesthetise the anterior branches of the intercostal nerves or the entire nipple-areolar complex. Pecs II anaesthetises the axillary compartment and blocks the dermatomes affected by surgical procedures, such as lymphadenectomy, using a medial axillary approach (T2–T3).Intercostal branches or serratus-intercostal plane block in the midaxillary lineIn the intercostal branches block in the midaxillary line (BRILMA, in its Spanish acronym<a class="elsevierStyleCrossRefs" href="#bib0205">8,9,12</a>) or serratus-intercostal plane block, a single bolus of LA is administered in the interfascial plane between the anterior serratus and external intercostal muscles on the midaxillary line, between the 5th and 6th rib. With this technique, the lateral cutaneous branches of the intercostal nerves are blocked and, by diffusion, the anterior cutaneous branches of the intercostal nerves running between the internal and innermost intercostal muscles. This blocks the main nerves innervating the breast, including the entire nipple-areolar complex. Due to its medial approach, this block also anaesthetises the axillary compartment, the T2–T3 dermatome, and the intercostobrachial nerve. The transducer is placed vertically on the midaxillary line, showing the ribs, pleura, intercostal muscles, anterior serratus muscle and the subcutaneous tissue. The needle is inserted in plane at a craniocaudal angle to administer approximately 15ml LA (around 3ml per target segment). The needle can be repositioned at a more superior angle with no need for further punctures, if required. However, when the tip is correctly positioned in the interfascial plane, dispersion of the LA is clearly seen. The authors recommend locating the rib with the tip of the needle to avoid accidental puncture of the intercostal muscles or even the pleura. Using the rib as a landmark ensures that the LA is injected under the anterior serratus, and diffusion of the LA can be seen in the interfascial plane between the target anterior serratus and external intercostal muscles (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) (Video 3 [additional material online]). The intercostal muscles act as bundles that are highly porous and facilitate LA diffusion, while the serratus muscle acts as a more impenetrable barrier.<a class="elsevierStyleCrossRefs" href="#bib0280">23,24</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>This technique has a specific advantage over intercostal blocks, insofar as the BRILMA block requires a single puncture to administer LA above the intercostal muscles and below the anterior serratus muscle. In intercostal blocks, however, LA must be injected into the intercostal muscles using multiple punctures at different intercostal spaces. This causes the muscles to swell, and unlike the interfascial space used in the BRILMA block, the extensive vascularisation of these muscles raises the risk of toxicity, although more studies are needed to confirm this hypothesis.Serratus plane blockThis nerve block was described in 4 healthy volunteers.<a class="elsevierStyleCrossRef" href="#bib0215">10</a> It consists in administration of LA between the anterior serratus and the latissimus dorsi muscle on the midaxillary line, at a point below the anterior serratus muscle. The transducer is held at a slightly oblique angle at the level of the 4th and 5th rib, with the upper edge superoanterior and the lower edge inferoanterior (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) (Video 4 [additional material online]). The needle is inserted in plane, at a craniocaudal angle. This technique blocks the lateral and anterior branches of the intercostal nerves, the thoracodorsal nerve, and the axillary compartment. It has been used successfully to provide postoperative analgesia in shoulder surgery,<a class="elsevierStyleCrossRef" href="#bib0290">25</a> following thoracotomy for esophagectomy<a class="elsevierStyleCrossRef" href="#bib0295">26</a> or for rib fractures.<a class="elsevierStyleCrossRef" href="#bib0240">15</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>IndicationsDue to the confusion caused by recent studies in respect of the terms used to describe these new nerve block approaches and their effectiveness, we believe it is important to establish the indications for these techniques in different surgical procedures. Based on our experience, we propose the recommendations listed in the following table (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>When considering these indications, it is important to be aware of the level of pain to be expected in each intervention. For surgery associated with mild pain (lumpectomy, oncoplastic surgery involving the skin and subcutaneous tissue, quadrantectomy, etc.), a multimodal analgesic strategy, such as wound infiltration<a class="elsevierStyleCrossRef" href="#bib0300">27</a> combined with analgesics such as paracetamol and/or nonsteroidal anti-inflammatory drugs, could be the best choice. Patients expected to experience moderate to severe pain (oncoplastic surgery involving the nipple-areolar complex, axillary lymphadenectomy, mastectomy, breast reconstruction surgery, etc.), would benefit from nerve block combined with general anaesthesia and/or intraoperative sedation.Contrary to the literature,<a class="elsevierStyleCrossRef" href="#bib0305">28</a> our experience has taught us that single-dose Pecs I is of little use in non-reconstructive breast surgery. This is because, as described above, the mammary region is innervated by the intercostal nerves (T2–T6), and T2–T3 dermatomes must also be anaesthetised in patients undergoing axillary clearance. Pecs I blocks the predominantly motor (medial and lateral) pectoral nerves, and we believe that the main indication for this block is reconstructive breast surgery with subpectoral implant placement.ConclusionsTodays anaesthetists must be aware of the different approaches to managing postoperative pain using ultrasound-guided techniques. Knowledge of these techniques and of the anatomy of the mammary region is essential, as there is strong (grade A) scientific evidence to support use of regional techniques as an adjuvant to general anaesthesia in breast surgery<a class="elsevierStyleCrossRefs" href="#bib0175">2,29,30</a>: improved management of severe postoperative pain, lower incidence of chronic pain, better postoperative rehabilitation, fewer pulmonary and cardiovascular complications, etc. More importantly, some studies suggest that regional anaesthesia in breast cancer surgery can be associated with a lower rate of recurrence and metastasis.<a class="elsevierStyleCrossRefs" href="#bib0320">31–33</a>Although further studies are needed in this regard, and conclusive evidence is still lacking, the results reported to date are promising.These new ultrasound-guided techniques have a short learning curve. Thorough knowledge of the regional anatomy and proficiency in identifying structures on ultrasound images is required, and anaesthetists must be skilled in using ultrasound to identify the position of the needle and delivery of LA. Complications that can arise following ultrasound-guided nerve block in breast surgery are divided into 2 groups: those associated with the nerve block per se, and those that are specific to the puncture site. The first group includes the risk of local anaesthetic toxicity due to the extensive vascularisation of the mammary region, which contains arteries such as the thoracoacromial artery in the infraclavicular region, the parasternal internal thoracic artery, or the intercostal arteries. The second group includes the risk of pneumothorax due to the proximity of the pleura.Conflict of interestsThe authors declare they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres611619" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec625591" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres611620" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec625590" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Overview of regional anatomy" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Ultrasound-guided nerve block in breast surgery" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Paravertebral block" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Pectoral nerve block and modified pectoral nerve block (Pecs I and II)" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Intercostal branches or serratus-intercostal plane block in the midaxillary line" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Serratus plane block" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Indications" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-26" "fechaAceptado" => "2015-11-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec625591" "palabras" => array:4 [ 0 => "Mastectomy" 1 => "Ultrasound" 2 => "Postoperative pain" 3 => "Nerve block" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec625590" "palabras" => array:4 [ 0 => "Mastectomía" 1 => "Ultrasonografía" 2 => "Dolor postoperatorio" 3 => "Bloqueo nervioso" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The breast surgery has undergone changes in recent years, encouraging new initiatives for the anaesthetic management of these patients in order to achieve maximum quality and rapid recovery. The fundamental tool that has allowed a significant improvement in the progress of regional anaesthesia for breast disease has been ultrasound, boosting the description and introduction into clinical practice of interfascial chest wall blocks, although the reference standard is still the paravertebral block. It is very likely that these blocks will change the protocols in the coming years. A review is presented of the anatomy of the breast region, description of nerve blocks and techniques, as well as their indications, all according to published articles and the opinion of the authors based on their experience." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La cirugía mamaria ha experimentado cambios en los últimos años motivando nuevas iniciativas para el manejo anestésico de estos pacientes, en aras de lograr la mayor calidad y una rápida recuperación. La herramienta fundamental que ha permitido una mejora significativa en los avances de la anestesia regional para enfermedad mamaria ha sido la ultrasonografía, impulsando la descripción e incorporación a la práctica clínica de los bloqueos interfasciales de la pared torácica, pese a que todavía el gold standard siga considerándose el bloqueo paravertebral. Es muy probable que estos bloqueos produzcan cambios en los protocolos de actuación en los próximos años. Se realiza una revisión de la anatomía de la región mamaria, descripción de los bloqueos y técnicas de realización, así como sus indicaciones, todo ello según los artículos disponibles y la opinión de los autores en función de su experiencia." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Diéguez P, Casas P, López S, Fajardo M. Bloqueos guiados por ultrasonidos para cirugía mamaria. Rev Esp Anestesiol Reanim. 2016;63:159–167." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <a class="elsevierStyleInterRef" id="intr0005" href="http://www.elsevier.es/redar">www.elsevier.es/redar</a>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0060" ] ] ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2150 "Ancho" => 2423 "Tamanyo" => 398844 ] ] "descripcion" => array:1 [ "en" => "Diagram of the course and divisions of the anterior and lateral cutaneous branches of the intercostal nerves on the midaxillary line. At the level of the skin, the lateral cutaneous intercostal nerve divides into the anterior and posterior branches. Observe how the anterior cutaneous branch of the intercostal nerve continues its course towards the skin at the parasternal level." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2234 "Ancho" => 2917 "Tamanyo" => 527838 ] ] "descripcion" => array:1 [ "en" => "Comparison of approaches to interpectoral block, or Pecs I. (A) Position of the transducer and introduction of the needle as described by Blanco. (B) Ultrasound image of the technique described by Blanco. The arrow indicates the thoracoacromial artery. (C) Position of the transducer and introduction of the needle in the approach described by Fajardo. (D) Ultrasound image of the technique described by Fajardo. The arrow indicates the site of local anaesthetic injection, between the pectoralis major and minor muscles. a: thoracoacromial artery; aa: axillary artery; asub; subclavian artery; pm: pectoralis minor muscle; pM: pectoralis major muscle; va: axillary vein." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1882 "Ancho" => 2917 "Tamanyo" => 648295 ] ] "descripcion" => array:1 [ "en" => "BRILMA or serratus-intercostal block. (A) Position of the transducer. Sequence of 3 ultrasound images. (B) Insertion of the needle, indicated by the arrow. (C) Injection of local anaesthetic. (D) Diffusion of local anaesthetic. LA: local anaesthetic; 5r: 5th rib; Ic m: intercostal muscles; Serr m: serratus muscle; pl: pleura." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1010 "Ancho" => 2917 "Tamanyo" => 212476 ] ] "descripcion" => array:1 [ "en" => "Serratus plane block. (A) Position of the transducer. (B) Ultrasound image. The arrow indicates the angle of the needle and the target space for local anaesthetic injection. 4r: 4th rib: 5r: 5th rib; LD m: latissimus dorsi muscle; Serr m: anterior serratus muscle; pl: pleura." ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ACBB: anterior cutaneous intercostal nerve branches block; BRILMA: intercostal branches block in the midaxillary line." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical innervation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Regional technique \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complex breast reconstruction surgeryMastectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paravertebral block orBRILMA orSerratus plane block \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breast reconstruction surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The foregoing combined with Pecs I in the immediate postoperative period \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bilateral intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider bilateral technique orEpidural instead of paravertebral block \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paravertebral block orBRILMA orSerratus plane block orPecs II \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1001907.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Surgical innervations and recommended regional technique." ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 2833705 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] 6 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 2822484 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] ] 7 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 2624992 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 8 => array:5 [ "identificador" => "upi0020" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 2672681 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. 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Continuing education

Ultrasound guided nerve block for breast surgery

Bloqueos guiados por ultrasonidos para cirugía mamaria

P. Diégueza,

Corresponding author

pauladieguez@yahoo.com

Corresponding author.

, P. Casasa, S. Lópeza, M. Fajardob

a Servicio de Anestesiología, Hospital Abente y Lago, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain

b Servicio de Anestesiología, Hospital Universitario de Móstoles, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Recent advances in breast surgery have aimed at conserving the breast without causing deformities&#46; This new approach has generalised the use of techniques such as oncoplastic breast surgery or mastectomy with breast reconstruction&#46; Anaesthetic management during these less invasive procedures focuses on specific objectives&#58; optimal anaesthesia&#44; early recovery&#44; overall satisfaction before&#44; during and after surgery&#44; minimal postoperative complications&#44; and early hospital discharge&#46; Regional anaesthesia is important in helping anaesthetists achieve these goals&#58; it provides excellent analgesia&#44; facilitates early recovery&#44; and reduces the number of postoperative complications&#44; such as cardiovascular and pulmonary problems&#44; among others&#46; Patients receiving regional anaesthesia are usually discharged earlier and are more satisfied with their surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The regional anaesthesia of choice in thoracic surgery is still thoracic paravertebral block&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;2</span></a> Nevertheless&#44; the 2011 study published by Blanco et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#8211;6</span></a> ushered in a number of ultrasound-guided nerve blocks using a peripheral approach&#46; These new techniques are equally effective as the peripheral block&#44; but are associated with fewer complications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These new approaches consist in the administration of a local anaesthetic &#40;LA&#41; between 2 interfascial planes&#44; thus blocking innervation of the entire breast area&#46; The primary aim is to achieve blockade of the pectoral nerves&#44; and then of the intercostal nerves&#46; Fajardo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> reported their experience in blockade of the lateral &#40;LCB&#41; and anterior &#40;ACB&#41; branches of the intercostal nerves&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nevertheless&#44; some clinicians are still unsure of the technique and new concerns have been raised&#46; A detailed literature search&#44; a review of anaesthesia techniques used in breast surgery&#44; an in-depth study of the anatomy of the anterior thorax &#40;including dissection of cadavers and magnetic resonance imaging with contrast agents&#41; and advanced ultrasound techniques&#44; has shown the feasibility of a peripheral approach to block the cutaneous branches of the 2nd to 6th intercostal nerves as an alternative to neuroaxial blockade&#46; This leads to the description of the intercostal branches block in the midaxillary line &#40;BRILMA&#44; in its Spanish acronym&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9</span></a> which consists in administration of LA between the anterior serratus and external intercostal muscles in the midaxillary line&#46; In a parallel development&#44; another study described serratus plane blockade<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> in 4 healthy volunteers&#44; involving administration of LA between the anterior serratus and latissimus dorsi muscles&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Following reports in the literature of excellent results in small series&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">9&#8211;12</span></a> efforts are now focussed on developing clinical trials that would confirm the effectiveness and safety of these new approaches vs the paravertebral block&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">These novel techniques have not been limited to breast surgery&#44; but have also been used in critically ill patients with thoracic injuries&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13&#8211;15</span></a> Delivery of LA via a catheter for continuous nerve block has also been described&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> Use of these novel interfascial nerve block techniques is spreading&#44; and the proliferation of studies using different nomenclature has created a certain amount of confusion&#46; The aim of this article is to explain the technique&#44; clearly define the site of the LA infusion&#44; and clarify the indications for each of these procedures&#46; There are major methodological shortcomings in the studies published to date&#44; and the type of nerve block chosen in some cases does not seem the most appropriate for the procedure undertaken&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical trials comparing the new chest wall interfascial blocks with the more traditional paravertebral technique will no doubt throw light on the subject&#46; These new approaches have several advantages over neuroaxial blocks&#44; including absence of sympathetic blockade&#44; which reduces incidence of anaesthesia-induced arterial hypotension &#40;reported to range from 4&#37; to 21&#37; in some series<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;17</span></a>&#41; and the high rate &#40;up to 24&#37;&#41; of failure due to catheter migration&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">18&#44;19</span></a> In free-flap reconstruction surgery in the thoracic region using&#44; for example&#44; the latissimus dorsi muscle&#44; sympathetic block&#44; which optimises analgesia perfusion through vasodilation&#44; is an important factor&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Overview of regional anatomy</span><p id="par0040" class="elsevierStylePara elsevierViewall">The mammary glands situated in the anterior chest wall are bounded by structures that are key to anaesthesia and analgesia techniques&#46; The glands extend vertically from the 2nd to the 6th rib&#44; and horizontally from the sternum &#40;parasternal line&#41; to the midaxillary line&#46; The breast lies on the pectoralis major muscle&#46; The lateral border overlies the anterior serratus and the inferior border overlies the superior portion of the external oblique muscle of the abdomen&#46; The glandular tissue is denser in the superior-lateral quadrant of the breast&#44; and extends towards the axilla &#40;Spence&#39;s tail&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The axilla is a pyramidal space&#44; situated between the arm and the chest wall&#46; The base is formed by the skin of the axilla and the inferior border is formed by the clavipectoral fascia or aponeurosis&#44; which is called the suspensory ligament of axilla&#44; or Gerdy&#39;s ligament&#46; The base of the axilla is innervated by the intercostobrachial nerve&#44; which anastomoses with the medial cutaneous brachial nerve to innervate the skin of the axilla and the interior of the upper arm&#46; These nerves can be damaged during surgical dissection of the axilla&#46; The axilla is bordered anteriorly by the clavicle&#44; posteriorly by the scapula&#44; and medially by the first rib&#44; forming the cervicoaxillary canal&#46; The anterior wall comprises 3 muscles&#58; the subclavian&#44; pectoralis major and pectoralis minor&#44; and has 2 layers&#58; superficial and deep&#46; The superficial layer&#44; formed by the pectoralis major&#44; is covered by the clavipectoral fascia&#46; The deep layer lies posterior to the pectoralis major and its deep fascial layer&#46; It comprises the subclavian and pectoralis minor muscles&#44; both of which are surrounded by the clavipectoral fascia&#46; The posterior wall of the axilla comprises the subscapularis&#44; teres major&#44; and latissimus dorsi muscles&#46; The lateral wall is formed by the bicipital groove of the humerus&#44; a thin strip that lies between the insertions of the muscles of the anterior and posterior walls&#46; The medial wall comprises the serratus major muscle&#44; which overlies the 4th or 5th ribs and their corresponding intercostal muscles&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The clavipectoral fascia is triangular in shape&#44; with its base facing medial&#44; extending from the clavicle to the 1st rib&#44; running from the sternum to the axilla&#46; Its superior border inserts into the inferior surface of the clavicle&#44; enveloping the subclavian muscle in a sheath&#46; This sheath extends inferiorly to the superior border of the pectoralis minor&#44; thus forming the clavipectoral segment&#46; It is pierced by the cephalic vein&#44; the thoracoacromial artery and the lateral pectoral nerve&#46; Superficially&#44; the clavipectoral fascia continues into the anterior abdominal wall&#46; The deep layer is pierced by vessel branches and nerves emerging from the pectoral fascia&#46; The 2 borders of the fascia that form the apex of the triangle do not join completely&#44; but are partially separated by an intersticial space&#44; and sometimes by a thick adipose layer located at the lower border of the pectoralis minor&#46; This is called the suspensory ligament of axilla&#44; or Gerdy&#39;s ligament&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In terms of innervation&#44; the thoracic nerves can be divided into 3 major groups&#58; those arising from the superficial cervical plexus&#44; those arising from the brachial plexus&#44; and those extending from the anterior branches of the thoracic nerves&#46; The supraclavicular nerves that innervate the upper pole of the mammary region arise mainly from the <span class="elsevierStyleItalic">superficial cervical plexus</span> &#40;C1&#8211;C4&#41;&#46; The lateral &#40;C5&#8211;C7&#41; and medial &#40;C8&#8211;T1&#41; pectoral nerves&#44; the long thoracic or anterior serratus nerve &#40;C5&#8211;C7&#41; and the thoracodorsal nerve &#40;C6&#8211;C8&#41; arise from the <span class="elsevierStyleItalic">brachial plexus</span>&#46; The intercostal nerves &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; arise from the <span class="elsevierStyleItalic">anterior divisions of the 1st to 11th thoracic nerves</span>&#46; The anterior division of the 12th thoracic nerve is called the subcostal nerve&#46; The 1st to 11th intercostal nerves innervate the sternum&#44; while the breast is innervated by the 2nd to 6th intercostal nerves&#46; The intercostobrachial nerve is a lateral cutaneous branch of the 2nd intercostal nerve that innervates the interior of the upper arm&#46; This nerve is important&#44; as it pierces the axillary compartment&#46; Acute and even chronic postoperative pain following breast surgery is often caused by damage or even sectioning of this nerve during axillary dissection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The pectoral nerves are both sensory and motor&#44; with a predominance of motor nerves&#46; The lateral pectoral nerve is larger than the medial&#46; It arises from the lateral cord of the brachial plexus and traverses the clavipectoral fascia under the clavicle following the course of the thoracoacromial artery towards the deep layer of the pectoralis major&#46; At this level&#44; it merges with branches of the medial pectoral nerve to form a loop&#44; and innervates the pectoralis major and minor muscles&#46; The medial pectoral nerve arises from the medial cord of the brachial plexus and divides to form two branches&#58; one innervates the pectoralis minor&#44; and another forms the pectoral loop&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The long thoracic&#44; anterior serratus or long thoracic nerve of Bell&#44; is a motor nerve that innervates the anterior serratus muscle&#46; Damage to this nerve leads to atrophy of the muscle&#44; causing winged scapula and difficulty in raising the arm&#46; The long thoracic nerve runs vertically along the side of the thorax&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The thoracodorsal nerve runs along the posterior wall of the axillary compartment near the lateral border of the scapula and innervates the latissimus dorsi muscle&#46; Damage to this nerve causes atrophy of the posterior axillary wall&#44; preventing abduction and extension of the upper limb&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The intercostal nerves run between the internal and innermost intercostal muscles&#46; These nerves divide into 2 branches&#44; called the perforating or cutaneous branches of the intercostal nerve&#46; They are the lateral and anterior branches&#46; The lateral cutaneous branch of the intercostal nerve emerges from between the internal and innermost intercostal muscles and extends to the skin&#46; It traverses the external intercostal muscles and the anterior serratus muscle along the midaxillary line&#46; At the level of the subcutaneous tissue&#44; it divides to form the anterior and posterior lateral cutaneous branches of the intercostal nerve&#46; The anterior cutaneous branch of the intercostal nerve runs between the internal and innermost intercostal muscles towards the paresteral line&#46; At this point it emerges to continue towards the skin and divides into branches&#44; some of which cross the contralaterals at the level of the sternum&#44; and others innervate the mid thoracic region&#46; The nipple-areolar complex is an important landmark&#44; as it is the site of the anastomsis of the anterior and lateral cutaneous branches of the 4th intercostal nerve&#44; although branches of the 3rd and 5th intercostal nerves can also be involved&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ultrasound-guided nerve block in breast surgery</span><p id="par0080" class="elsevierStylePara elsevierViewall">Most nerve blocks used in breast surgery are superficial&#44; except in the case of obese patients&#44; and require a high frequency linear transducer&#46; Nerve blocks&#44; being easily mastered and performed&#44; are entirely reproducible&#46; They are interfascial techniques&#44; in which the LA is injected between the fascia enclosing 2 muscles&#46; This facilitates dispersion of the anaesthetic and allows it to reach several different targets&#46; Conceptually&#44; the technique is similar to transversus abdominis plane &#40;TAP&#41; block&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Paravertebral block</span><p id="par0085" class="elsevierStylePara elsevierViewall">The paravertebral block is the standard nerve blockade used in breast surgery&#46; Needle placement is ultrasound-guided&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">18&#44;19</span></a> making the technique both effective and safe&#46; Despite this&#44; the use of ultrasound during paravertebral block does not guarantee correct diffusion of the LA or prevent the risk of catheter migration&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Paravertebral block is a central block in which LA is injected into the triangular paravertebral space located on either side of the spinal column&#46; The walls of this space are formed by the intervertebral foramen medially&#44; and by the transverse process laterally&#46; The anterior wall is formed by adipose tissue and the parietal pleura&#44; and the posterior wall by the costotransverse ligament and the transverse process&#46; Cranially and caudally&#44; the space is continuous with the adjacent superior and inferior paravetebral spaces&#46; These anatomical relations are the most probable sites of catheter migration&#46; Administration of LA in a particular paravertebral space will block the sympathetic thoracic ganglion and intercostal nerves at that level&#46; Studies comparing multiple&#44; small volume &#40;1&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>ml&#41; injections vs single large volume &#40;15<span class="elsevierStyleHsp" style=""></span>ml&#41; injection for paravertebral nerve block report better spread of anaesthetic drug and absence of sensation in the former&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> Current guidelines&#44; therefore&#44; recommend the multiple injection technique&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Ultrasound location of the costotransverse ligament and pleura will ensure the block is performed correctly and reduce the risk of complications&#46; Although various techniques for accessing the paravertebral space have been described&#44; the following 2 are probably the best known&#58; sagittal approach&#44; in which the tranducer is placed vertically&#44; parallel to the longitudinal axis of the spinal column&#44; and needle is inserted in a caudal-cranial orientation&#59; and the transversal approach&#44; in which the transducer is placed horizontally and the needle is inserted in plane from lateral to medial&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pectoral nerve block and modified pectoral nerve block &#40;Pecs I and II&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Pectoral block&#44; or Pecs 1&#44; consists in injecting LA below the clavicle&#44; between the deep pectoral and the clavipectoral fascia&#44; usually between the pectoralis major and minor muscles&#46; It is important to identify the thoracoacromial artery at this level&#44; even using doppler&#44; in order to avoid accidental puncture&#46; In most cases&#44; the lateral pectoral nerve&#44; which is larger than the medial pectoral nerve&#44; can be seen adjacent to the artery&#46; Administration of anaesthesia at this level will block the lateral and medial pectoral nerves &#40;predominantly motor&#41;&#46; This block can be used in the case of reconstructive breast surgery&#44; and the option of ultrasound-guided placement of a catheter for continuous blockade can also be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> We usually perform pecs block immediately following breast reconstruction surgery&#46; This is because inter-individual sensation of acute postoperative pain caused by the pectoral nerves can vary considerably&#44; ranging from no pain to diffuse mild pain in the infraclavicular region&#44; to severe pain&#46; In the foregoing case&#44; a single injection of approximately 10<span class="elsevierStyleHsp" style=""></span>ml of long-acting LA&#44; such as ropivacaine or levobupivacaine is administered&#46; If continuous blockade is required&#44; an elastomeric delivery device can be used after preliminary injection of a 10<span class="elsevierStyleHsp" style=""></span>ml bolus&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The first description of this technique involved a caracoid approach<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;4</span></a> similar to that used in infraclavicular block&#44; with the transducer placed vertically&#46; The needle is inserted in plane at a cranio-caudal angle &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; Following this&#44;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">21&#44;22</span></a> a new approach was described in which the transducer was placed under and parallel to the clavicle and the needle inserted in plane at a medial-lateral angle &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; &#40;Video 1 &#91;additional material online&#93;&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The modified pectoral nerve block&#44; or Pecs II<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> consists in 2 LA injections at the same site&#44; one between the deep layer of the pectoralis major muscle and the clavipectoral fascia&#44; and the other in the interfascial plane between pectoralis minor and anterior serratus muscles&#46; These injections are administered at a different level from that used in Pecs I&#46; The transducer is placed obliquely on the lateral third of the clavicle &#40;Video 2 &#91;additional material online&#93;&#41;&#44; showing the 2nd&#44; 3rd and 4th ribs&#44; the attachment of the major and minor pecoralis muscles&#44; the clavipectoral &#40;Grady&#39;s&#41; ligament&#44; and the start of the anterior serratus muscle&#46; There is as yet no firm evidence regarding the volume of LA for this technique&#44; although various authors have used 10<span class="elsevierStyleHsp" style=""></span>ml between the major and minor pectoralis muscles and a further 10<span class="elsevierStyleHsp" style=""></span>ml between the pectoralis minor and anterior serratus muscle&#46; The aim of this technique is to block innervation of the entire breast with a single injection&#46; However&#44; the following nerves are blocked&#58; lateral and medial pectoral nerves&#44; intercostobrachial nerve&#44; superior lateral cutaneous branches of the intecostal nerves &#40;depending on the volume administered&#44; blockade can extend from the 2nd to 8th intercostal nerves&#41; and the long thoracic nerve&#46; This approach cannot anesthetise the anterior branches of the intercostal nerves or the entire nipple-areolar complex&#46; Pecs II anaesthetises the axillary compartment and blocks the dermatomes affected by surgical procedures&#44; such as lymphadenectomy&#44; using a medial axillary approach &#40;T2&#8211;T3&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Intercostal branches or serratus-intercostal plane block in the midaxillary line</span><p id="par0115" class="elsevierStylePara elsevierViewall">In the intercostal branches block in the midaxillary line &#40;BRILMA&#44; in its Spanish acronym<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9&#44;12</span></a>&#41; or serratus-intercostal plane block&#44; a single bolus of LA is administered in the interfascial plane between the anterior serratus and external intercostal muscles on the midaxillary line&#44; between the 5th and 6th rib&#46; With this technique&#44; the lateral cutaneous branches of the intercostal nerves are blocked and&#44; by diffusion&#44; the anterior cutaneous branches of the intercostal nerves running between the internal and innermost intercostal muscles&#46; This blocks the main nerves innervating the breast&#44; including the entire nipple-areolar complex&#46; Due to its medial approach&#44; this block also anaesthetises the axillary compartment&#44; the T2&#8211;T3 dermatome&#44; and the intercostobrachial nerve&#46; The transducer is placed vertically on the midaxillary line&#44; showing the ribs&#44; pleura&#44; intercostal muscles&#44; anterior serratus muscle and the subcutaneous tissue&#46; The needle is inserted in plane at a craniocaudal angle to administer approximately 15<span class="elsevierStyleHsp" style=""></span>ml LA &#40;around 3<span class="elsevierStyleHsp" style=""></span>ml per target segment&#41;&#46; The needle can be repositioned at a more superior angle with no need for further punctures&#44; if required&#46; However&#44; when the tip is correctly positioned in the interfascial plane&#44; dispersion of the LA is clearly seen&#46; The authors recommend locating the rib with the tip of the needle to avoid accidental puncture of the intercostal muscles or even the pleura&#46; Using the rib as a landmark ensures that the LA is injected under the anterior serratus&#44; and diffusion of the LA can be seen in the interfascial plane between the target anterior serratus and external intercostal muscles &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; &#40;Video 3 &#91;additional material online&#93;&#41;&#46; The intercostal muscles act as bundles that are highly porous and facilitate LA diffusion&#44; while the serratus muscle acts as a more impenetrable barrier&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#44;24</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">This technique has a specific advantage over intercostal blocks&#44; insofar as the BRILMA block requires a single puncture to administer LA above the intercostal muscles and below the anterior serratus muscle&#46; In intercostal blocks&#44; however&#44; LA must be injected into the intercostal muscles using multiple punctures at different intercostal spaces&#46; This causes the muscles to swell&#44; and unlike the interfascial space used in the BRILMA block&#44; the extensive vascularisation of these muscles raises the risk of toxicity&#44; although more studies are needed to confirm this hypothesis&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Serratus plane block</span><p id="par0125" class="elsevierStylePara elsevierViewall">This nerve block was described in 4 healthy volunteers&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> It consists in administration of LA between the anterior serratus and the latissimus dorsi muscle on the midaxillary line&#44; at a point below the anterior serratus muscle&#46; The transducer is held at a slightly oblique angle at the level of the 4th and 5th rib&#44; with the upper edge superoanterior and the lower edge inferoanterior &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; &#40;Video 4 &#91;additional material online&#93;&#41;&#46; The needle is inserted in plane&#44; at a craniocaudal angle&#46; This technique blocks the lateral and anterior branches of the intercostal nerves&#44; the thoracodorsal nerve&#44; and the axillary compartment&#46; It has been used successfully to provide postoperative analgesia in shoulder surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> following thoracotomy for esophagectomy<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> or for rib fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Indications</span><p id="par0130" class="elsevierStylePara elsevierViewall">Due to the confusion caused by recent studies in respect of the terms used to describe these new nerve block approaches and their effectiveness&#44; we believe it is important to establish the indications for these techniques in different surgical procedures&#46; Based on our experience&#44; we propose the recommendations listed in the following table &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">When considering these indications&#44; it is important to be aware of the level of pain to be expected in each intervention&#46; For surgery associated with mild pain &#40;lumpectomy&#44; oncoplastic surgery involving the skin and subcutaneous tissue&#44; quadrantectomy&#44; etc&#46;&#41;&#44; a multimodal analgesic strategy&#44; such as wound infiltration<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> combined with analgesics such as paracetamol and&#47;or nonsteroidal anti-inflammatory drugs&#44; could be the best choice&#46; Patients expected to experience moderate to severe pain &#40;oncoplastic surgery involving the nipple-areolar complex&#44; axillary lymphadenectomy&#44; mastectomy&#44; breast reconstruction surgery&#44; etc&#46;&#41;&#44; would benefit from nerve block combined with general anaesthesia and&#47;or intraoperative sedation&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Contrary to the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> our experience has taught us that single-dose Pecs I is of little use in non-reconstructive breast surgery&#46; This is because&#44; as described above&#44; the mammary region is innervated by the intercostal nerves &#40;T2&#8211;T6&#41;&#44; and T2&#8211;T3 dermatomes must also be anaesthetised in patients undergoing axillary clearance&#46; Pecs I blocks the predominantly motor &#40;medial and lateral&#41; pectoral nerves&#44; and we believe that the main indication for this block is reconstructive breast surgery with subpectoral implant placement&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Todays anaesthetists must be aware of the different approaches to managing postoperative pain using ultrasound-guided techniques&#46; Knowledge of these techniques and of the anatomy of the mammary region is essential&#44; as there is strong &#40;grade A&#41; scientific evidence to support use of regional techniques as an adjuvant to general anaesthesia in breast surgery<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;29&#44;30</span></a>&#58; improved management of severe postoperative pain&#44; lower incidence of chronic pain&#44; better postoperative rehabilitation&#44; fewer pulmonary and cardiovascular complications&#44; etc&#46; More importantly&#44; some studies suggest that regional anaesthesia in breast cancer surgery can be associated with a lower rate of recurrence and metastasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">31&#8211;33</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Although further studies are needed in this regard&#44; and conclusive evidence is still lacking&#44; the results reported to date are promising&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">These new ultrasound-guided techniques have a short learning curve&#46; Thorough knowledge of the regional anatomy and proficiency in identifying structures on ultrasound images is required&#44; and anaesthetists must be skilled in using ultrasound to identify the position of the needle and delivery of LA&#46; Complications that can arise following ultrasound-guided nerve block in breast surgery are divided into 2 groups&#58; those associated with the nerve block per se&#44; and those that are specific to the puncture site&#46; The first group includes the risk of local anaesthetic toxicity due to the extensive vascularisation of the mammary region&#44; which contains arteries such as the thoracoacromial artery in the infraclavicular region&#44; the parasternal internal thoracic artery&#44; or the intercostal arteries&#46; The second group includes the risk of pneumothorax due to the proximity of the pleura&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2015-07-26"
    "fechaAceptado" => "2015-11-09"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec625591"
          "palabras" => array:4 [
            0 => "Mastectomy"
            1 => "Ultrasound"
            2 => "Postoperative pain"
            3 => "Nerve block"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec625590"
          "palabras" => array:4 [
            0 => "Mastectom&#237;a"
            1 => "Ultrasonograf&#237;a"
            2 => "Dolor postoperatorio"
            3 => "Bloqueo nervioso"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The breast surgery has undergone changes in recent years&#44; encouraging new initiatives for the anaesthetic management of these patients in order to achieve maximum quality and rapid recovery&#46; The fundamental tool that has allowed a significant improvement in the progress of regional anaesthesia for breast disease has been ultrasound&#44; boosting the description and introduction into clinical practice of interfascial chest wall blocks&#44; although the reference standard is still the paravertebral block&#46; It is very likely that these blocks will change the protocols in the coming years&#46; A review is presented of the anatomy of the breast region&#44; description of nerve blocks and techniques&#44; as well as their indications&#44; all according to published articles and the opinion of the authors based on their experience&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a mamaria ha experimentado cambios en los &#250;ltimos a&#241;os motivando nuevas iniciativas para el manejo anest&#233;sico de estos pacientes&#44; en aras de lograr la mayor calidad y una r&#225;pida recuperaci&#243;n&#46; La herramienta fundamental que ha permitido una mejora significativa en los avances de la anestesia regional para enfermedad mamaria ha sido la ultrasonograf&#237;a&#44; impulsando la descripci&#243;n e incorporaci&#243;n a la pr&#225;ctica cl&#237;nica de los bloqueos interfasciales de la pared tor&#225;cica&#44; pese a que todav&#237;a el <span class="elsevierStyleItalic">gold standard</span> siga consider&#225;ndose el bloqueo paravertebral&#46; Es muy probable que estos bloqueos produzcan cambios en los protocolos de actuaci&#243;n en los pr&#243;ximos a&#241;os&#46; Se realiza una revisi&#243;n de la anatom&#237;a de la regi&#243;n mamaria&#44; descripci&#243;n de los bloqueos y t&#233;cnicas de realizaci&#243;n&#44; as&#237; como sus indicaciones&#44; todo ello seg&#250;n los art&#237;culos disponibles y la opini&#243;n de los autores en funci&#243;n de su experiencia&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Di&#233;guez P&#44; Casas P&#44; L&#243;pez S&#44; Fajardo M&#46; Bloqueos guiados por ultrasonidos para cirug&#237;a mamaria&#46; Rev Esp Anestesiol Reanim&#46; 2016&#59;63&#58;159&#8211;167&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58; <a class="elsevierStyleInterRef" id="intr0005" href="http://www.elsevier.es/redar">www&#46;elsevier&#46;es&#47;redar</a></p>"
      ]
    ]
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            "apendice" => "<p id="par0170" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0060"
          ]
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      ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Diagram of the course and divisions of the anterior and lateral cutaneous branches of the intercostal nerves on the midaxillary line&#46; At the level of the skin&#44; the lateral cutaneous intercostal nerve divides into the anterior and posterior branches&#46; Observe how the anterior cutaneous branch of the intercostal nerve continues its course towards the skin at the parasternal level&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comparison of approaches to interpectoral block&#44; or Pecs I&#46; &#40;A&#41; Position of the transducer and introduction of the needle as described by Blanco&#46; &#40;B&#41; Ultrasound image of the technique described by Blanco&#46; The arrow indicates the thoracoacromial artery&#46; &#40;C&#41; Position of the transducer and introduction of the needle in the approach described by Fajardo&#46; &#40;D&#41; Ultrasound image of the technique described by Fajardo&#46; The arrow indicates the site of local anaesthetic injection&#44; between the pectoralis major and minor muscles&#46; a&#58; thoracoacromial artery&#59; aa&#58; axillary artery&#59; asub&#59; subclavian artery&#59; pm&#58; pectoralis minor muscle&#59; pM&#58; pectoralis major muscle&#59; va&#58; axillary vein&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BRILMA or serratus-intercostal block&#46; &#40;A&#41; Position of the transducer&#46; Sequence of 3 ultrasound images&#46; &#40;B&#41; Insertion of the needle&#44; indicated by the arrow&#46; &#40;C&#41; Injection of local anaesthetic&#46; &#40;D&#41; Diffusion of local anaesthetic&#46; LA&#58; local anaesthetic&#59; 5r&#58; 5th rib&#59; Ic m&#58; intercostal muscles&#59; Serr m&#58; serratus muscle&#59; pl&#58; pleura&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Serratus plane block&#46; &#40;A&#41; Position of the transducer&#46; &#40;B&#41; Ultrasound image&#46; The arrow indicates the angle of the needle and the target space for local anaesthetic injection&#46; 4r&#58; 4th rib&#58; 5r&#58; 5th rib&#59; LD m&#58; latissimus dorsi muscle&#59; Serr m&#58; anterior serratus muscle&#59; pl&#58; pleura&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ACBB&#58; anterior cutaneous intercostal nerve branches block&#59; BRILMA&#58; intercostal branches block in the midaxillary line&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Regional technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complex breast reconstruction surgeryMastectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paravertebral block orBRILMA orSerratus plane block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breast reconstruction surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The foregoing combined with Pecs I in the immediate postoperative period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bilateral intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider bilateral technique orEpidural instead of paravertebral block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphadenectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paravertebral block orBRILMA orSerratus plane block orPecs II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:33 [
            0 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of paravertebral blocks in breast surgery&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Schnabel"
                            1 => "S&#46;U&#46; Reichl"
                            2 => "P&#46; Kranke"
                            3 => "E&#46;M&#46; Pogatzki-Zahn"
                            4 => "P&#46;K&#46; Zahn"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1093/bja/aeq265"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2010"
                        "volumen" => "105"
                        "paginaInicial" => "842"
                        "paginaFinal" => "852"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20947592"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Regional anaesthesia to prevent chronic pain after surgery&#58; a Cochrane systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;H&#46; Andreae"
                            1 => "D&#46;A&#46; Andreae"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aet213"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2013"
                        "volumen" => "111"
                        "paginaInicial" => "711"
                        "paginaFinal" => "720"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23811426"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The pec&#39;s block&#58; novel technique for providing analgesia after breast surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Blanco"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2044.2011.06838.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesthesia"
                        "fecha" => "2011"
                        "volumen" => "66"
                        "paginaInicial" => "847"
                        "paginaFinal" => "848"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21831090"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eficacia analg&#233;sica del bloqueo de los nervios pectorales en cirug&#237;a de mama"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Blanco"
                            1 => "M&#46; Garrido Garc&#237;a"
                            2 => "P&#46; Di&#233;guez"
                            3 => "P&#46;B&#46; Acea Nebril"
                            4 => "S&#46; L&#243;pez &#193;lvarez"
                            5 => "A&#46; Pensado"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cir May Amb"
                        "fecha" => "2011"
                        "volumen" => "16"
                        "paginaInicial" => "89"
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                      ]
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                  ]
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              "identificador" => "bib0190"
              "etiqueta" => "5"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound description of the Pecs II &#40;modified Pecs I&#41;&#58; a novel approach into breast surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Blanco D&#225;vila"
                            1 => "M&#46; Fajardo P&#233;rez"
                            2 => "T&#46; Parras Maldonado"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.redar.2012.07.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Anestesiol Reanim"
                        "fecha" => "2012"
                        "volumen" => "59"
                        "paginaInicial" => "470"
                        "paginaFinal" => "475"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22939099"
                            "web" => "Medline"
                          ]
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                ]
              ]
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            5 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bloqueo continuo de los nervios pectorales para cirug&#237;a de mama"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Fajardo P&#233;rez"
                            1 => "C&#46; Cucchi"
                            2 => "M&#46;A&#46; Paniagua Montes"
                            3 => "J&#46; Garc&#237;a Miguel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cir May Amb"
                        "fecha" => "2011"
                        "volumen" => "16"
                        "paginaInicial" => "191"
                        "paginaFinal" => "192"
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              "identificador" => "bib0200"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bloqueo de las ramas cut&#225;neas laterales y anteriores de los nervios intercostales para analgesia de mama"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Fajardo P&#233;rez"
                            1 => "F&#46;J&#46; Garc&#237;a Miguel"
                            2 => "S&#46; L&#243;pez &#193;lvarez"
                            3 => "P&#46; Di&#233;guez Garc&#237;a"
                            4 => "P&#46; Alfaro de la Torre"
                          ]
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                      ]
                    ]
                  ]
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              "etiqueta" => "8"
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                    0 => array:2 [
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Article information

ISSN: 23411929
Original language: English

DOI:10.1016/j.redare.2015.11.002

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