The usefulness of interpectoral block as an analgesic technique in breast cancer surgery | Revista Española de Anestesiología y Reanimación (English Edition)

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Ortiz de la Tabla González, P. Gómez Reja, D. Moreno Rey, C. Pérez Naranjo, I. Sánchez Martín, M. Echevarría Moreno" "autores" => array:6 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Ortiz de la Tabla González" "email" => array:1 [ 0 => "raquelortizdelat@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Gómez Reja" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Moreno Rey" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Pérez Naranjo" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Sánchez Martín" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Echevarría Moreno" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "UGCBQ Área Sur de Sevilla, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad del bloqueo interpectoral continuo como técnica analgésica en cirugía oncológica de mama" ] ] "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" => 833 "Ancho" => 1240 "Tamanyo" => 39890 ] ] "descripcion" => array:1 [ "en" => "Pain on movement on the numerical verbal scale (0–10) at all data collection time points. No statistically significant differences (p>0.05)." ] ] ] "textoCompleto" => "IntroductionBreast cancer is the most common type of cancer among women. In the United States, 1 in 8 women will develop breast cancer at some time during their life.<a class="elsevierStyleCrossRef" href="#bib0175">1</a> In Spain, it affects 50.9 women/100,000 inhabitants, and around 26,000 new cases are diagnosed each year. Breast cancer currently accounts for almost 30% of female tumours in Spain, and incidence is expected to increase by 1–2% annually.<a class="elsevierStyleCrossRef" href="#bib0180">2</a>After breast cancer surgery, 40% of women will present severe acute postoperative pain, and at 6 months 50% will develop chronic pain that will affect their quality of life.<a class="elsevierStyleCrossRef" href="#bib0185">3</a> In recent years, regional anaesthesia has been used in breast cancer surgery to improve the speed and quality of their recovery. These techniques have a number of beneficial effects: they provide effective relief of acute perioperative pain and avoid central sensitisation and opioid-induced hyperalgesia, which are considered risk factors for the onset of chronic pain<a class="elsevierStyleCrossRef" href="#bib0190">4</a>; and they also reduce the volume of general anaesthetics and opioids required, particularly morphine, thus attenuating the opioid-induced immunosuppression that some studies have linked to local recurrence and/or tumour metastasis.<a class="elsevierStyleCrossRefs" href="#bib0195">5,6</a>The use of ultrasound has been a key factor in the development of this type of regional anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0205">7</a> The standard technique has always been the paravertebral block, which has been shown to provide better analgesia.<a class="elsevierStyleCrossRef" href="#bib0210">8</a> One study has even shown this nerve block to reduce recurrence of breast cancer, although these finding should be interpreted with caution.<a class="elsevierStyleCrossRef" href="#bib0215">9</a> However, in the last few years, ultrasound-guided interfascial thoracic wall blocks have been described and are now used in clinical practice. One such approach is the pectoral nerve block or interpectoral block (PEC), which has been described as a safer, less invasive technique with fewer complications.<a class="elsevierStyleCrossRef" href="#bib0220">10</a>The aim of our study was to compare the efficacy and side effects of continuous interpectoral block (CPEC) versus conventional intravenous (i.v.) analgesia after breast cancer surgery.Material and methodThis is a prospective, comparative, randomised study of women undergoing breast cancer. The study was approved by the local Institutional Review Board and complies with the ethical standards of the Helsinki declaration of 1975, revised in 2000 (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.wma.net/s/policy/17-c_s.html">http://www.wma.net/s/policy/17-c_s.html</a>), with the new Royal Decree 1090/2015 of December 4, replacing Royal Decree 223/2004, regulating clinical trials with medicinal products, ethics committees for investigation with medicinal products and the Spanish Clinical Studies Registry, and approved by the Spanish Agency for Medicines and Health Products (<a id="intr0015" class="elsevierStyleInterRef" href="https://www.aemps.gob.es/">https://www.aemps.gob.es</a>), written informed consent was obtained from all study subjects. We included all women aged between 18 and 75 years, ASA I-III, scheduled for non-reconstructive breast and axillary surgery (quadrantectomys or mastectomies with sentinel node resection and axillary dissection) in our hospital from January to September 2016. Exclusion criteria were: sensitivity to local anaesthetics, coagulation disorders, contraindication for CPEC, and refusal to participate.On arrival in the operating room, continuous monitoring with electrocardiography, non-invasive blood pressure and pulse oximetry was started in all cases. Following this, a peripheral venous catheter (Abocath18G®) was placed and BIS level-guided general anaesthesia was induced with propofol, fentanyl 150μg and cisatracurium 0.05mg/kg−1. An I-gel® laryngeal mask airway appropriate to the patient's weight was inserted and connected to a ventilator, and i.v. perfusion of BIS level-guided propofol was started. Following this, each patient was assigned to one of the study groups using the block randomisation technique that ensured that each study treatment would be administered a certain number of times in a certain number of patients.All the data were collected and all procedures performed by 4 anaesthesiologists from our hospital, all experts in regional anaesthesia and ultrasound, and members of a locoregional anaesthesia in breast surgery working group.In group 1 (continuous interpectoral block [CPEC]), following general anaesthesia induction a PEC nerve block was performed as described by Blanco et al.<a class="elsevierStyleCrossRef" href="#bib0225">11</a> The patient was placed in the supine position with the ipsilateral arm next to the body and the head turned to the contralateral side. After the usual skin prep, a 12L linear ultrasound probe (Sonosite S series™ FUJIFILM SonoSite S.L.) was placed under the lateral third of the clavicle, transverse to the axis of the body at the level of the second intercostal space (<a class="elsevierStyleCrossRef" href="#sec0035">Appendix A</a>: supplementary material on line). Both pectoral muscles and their respective fascias were identified in the ultrasound window, and Doppler was used to identify the acromothoracic artery, which is located medial to the lateral pectoral nerve in the interfascial space between the pectoral fascia and the clavipectoral fascia, that is, between the muscles. Following this, an 18G×80mm Tuhoy needle was inserted in plane in a medial to lateral direction at an angle of 45° until it reached the artery. After a negative aspiration, test 0.5% ropivacaine was administered in increments of 5ml, with continuous aspirations, for a total dose of 30ml. After the spread of the anaesthetic was observed in the interfascial space, a 20G×100mm catheter was placed in the space. If heart rate and blood pressure (BP) increased more than 15% during the surgical incision, 1μg/kg1−1 i.v. fentanyl was administered, repeating the dose as required. At the end of surgery, 2g metamizol with 50mg dexketoprofen and 4mg ondansetron were administered intravenously. After transfer to the post-anaesthesia care unit (PACU), patient-controlled analgesia (PCA) with 0.2% ropivacaine at 5ml/h−1 with a patient-controlled bolus dose of 5ml/30min was delivered through the interpectoral catheter for 24h. Additional analgesia with 2g metamizole every 8h was also prescribed, with 5mg subcutaneous morphine chloride as rescue analgesia.In group 2, (intravenous [i.v.] analgesia), after anaesthesia induction 1μg/kg−1 i.v. fentanyl was administered if heart rate and BP increase by more than 15% during the surgical incision repeating the dose if necessary. At the end of surgery, 2g metamizol with 50mg dexketoprofen and 4mg ondansetron were administered intravenously, followed by PCA with 4% metamizol, 0.1% tramadol and 0.08% ondansetron at 2ml/h−1 with a patient-controlled bolus dose of 2ml/20min. The same rescue analgesic used in group 1 was also prescribed.The main variables collected were pain at rest and on movement, evaluated on a simple verbal numerical scale (VNS) from 0 to 10; the rescue analgesia required, recorded as yes or no; patient-controlled boluses requested and administered, and undesirable effects at 12 and 24h after PACU discharge.Other variables collected were the degree of patient satisfaction (scored as: 1, very good; 2, good; 3, indifferent; 4, bad, and 5, very bad), willingness to repeat the technique (valued as: 1, yes; 2, no, and 3, indifferent), the type of surgical intervention, the duration of surgery (min), the total dose of intraoperative i.v. fentanyl administered, and the presence of pain interfering with sleep during the first postoperative night, recorded as yes or no. We also collected CPEC-related variables, such as the difficulty of the technique (valued as: 1, easy [1–2 attempts]; 2, difficult [3 attempts], and 4, very difficult [>4 attempts]); the time (min) from puncture until injection of the total dose of local anaesthetic, and the time (min) from completion of the blockade to the start of surgery, defined as the start of the surgical incision.Statistical analysis was performed with IBM SPSS 22.0 for Windows (SPSS®, Chicago, USA). Numerical variables were described as mean and standard deviation or median and 25 and 75 percentile, and qualitative variables were expressed as frequency and percentage. Independent samples were compared using the Student's t test; the Mann–Whitney U test was used to compare the means of numerical variables, and the chi-square or Fisher's exact test was used to compare qualitative variables. Significance was set at p<0.05.ResultsIn total, 137 patients were included: 81 in group 1 (59.12%) and 56 in group 2 (40.87%). Nine patients were excluded due to incorrect follow-up and treatment (4 from group 1 and 5 from group 2). Patient demographics were similar in both groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> show surgical data and those related to the nerve block technique, respectively.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>No significant differences in postoperative pain at rest and on movement were observed between groups at all data collection time points (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>), or in patient-controlled boluses requested and administered (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). Significant differences were observed in intraoperative fentanyl doses required (150μg [P25 150-P75 300] in group 1 and 293.75μg [P25 300-P75 300] in group 2) (p<0.05) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). No significant differences were observed in the need for rescue analgesia in the PACU, which was 10% lower in group 1 (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), and pain interference with sleep, which was 8% greater in group 2 (9 patients, 18.8%) compared to group 1 (8 patients, 10.8%). Side effects in the PACU were only observed in group 2, and scant, mild side effects were observed in both groups at 12 and 24h (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). Patient satisfaction in both groups was either good or very good (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>) and most would be willing to repeat the analgesic technique (group 1: 91.5%; group 2: 63.8%).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>DiscussionAlthough both techniques provide adequate analgesia after breast surgery with few side effects and a high degree of patient satisfaction, the CPEC group required significantly less intraoperative fentanyl. Patients in this group also required less rescue analgesia in the PACU, and fewer were awakened by pain in the first 24 postoperative hours.In their first description of the technique, Blanco et al.<a class="elsevierStyleCrossRef" href="#bib0230">12</a> reported good postoperative analgesia with the PEC I block in over 50 patients undergoing breast surgery, and good results in more than 100 patients in whom a catheter was placed at the site of the blockade.<a class="elsevierStyleCrossRef" href="#bib0235">13</a> Following the preliminary descriptions and case series, it became clear that clinical trials and further studies were needed to provide sufficient scientific evidence to warrant this nerve block becoming standard practice in breast surgery; this is what we set out to provide with our study. In an observational study comparing the thoracic paravertebral block with the PEC block plus sedation, patients in the PEC group required less sedation and reported better postoperative analgesia.<a class="elsevierStyleCrossRef" href="#bib0240">14</a>The paravertebral block for regional anaesthesia in breast surgery had been widely used and described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0220">10,15</a> Recently, the PEC block was devised in order to avoid some of the more serious nerve block-related complications, such as epidural or even spinal spread of anaesthetic. The PEC block, moreover, is a purely sensory and motor block with no associated sympathetic blockade. Although the acromothoracic artery can be injured during the technique, sufficient training and ultrasound guidance all but rule out this complication. Performing the PEC blocks under ultrasound guidance is currently supported by grade A evidence.<a class="elsevierStyleCrossRef" href="#bib0250">16</a> So far, no complications have been reported when using this approach, and small studies have shown its clinical utility, although more research is needed to confirm these findings.<a class="elsevierStyleCrossRefs" href="#bib0220">10,12</a> A recent case report described the intraoperative placement of the interpectoral catheter by surgeons as a useful alternative for anaesthesiologists with little experience in ultrasound techniques.<a class="elsevierStyleCrossRef" href="#bib0255">17</a>Management of acute postoperative pain as a means of preventing the development of chronic pain after surgery is a common strategy. Studies have reported that perioperative preventive analgesia using regional techniques, such as paravertebral block in breast surgery, helps prevent surgery-induced central and peripheral sensitisation that contributes to chronic pain. A recent Cochrane review concluded that this blockade reduces the risk of persistent postoperative pain at 6 months after surgery in 1 in 4–5 women.<a class="elsevierStyleCrossRef" href="#bib0260">18</a> A study comparing general anaesthesia with or without preincisional paravertebral block in extended radical mastectomy concluded that pain was similar in both groups after surgery, but differed 5 months after the procedure.<a class="elsevierStyleCrossRef" href="#bib0265">19</a> In another study comparing single injection or continuous infusion paravertebral block with general anaesthesia, the authors observed that postoperative pain and analgesic consumption were reduced in patients undergoing breast cancer surgery. Moreover, the prevalence and severity of chronic postoperative pain were also reduced,<a class="elsevierStyleCrossRef" href="#bib0270">20</a> although a subsequent study found no significant difference in the incidence or relative risk of chronic pain at 3 and 6 months after surgery when paravertebral block is used in conjunction with general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0275">21</a> The effect of CPEC on chronic pain after breast surgery has not so far been evaluated in the literature, but we believe it could be a useful preventive analgesic technique that merits investigation.<a class="elsevierStyleCrossRef" href="#bib0220">10</a>Another important finding in our study was the significant difference in intraoperative fentanyl requirements between groups: 150μg (P25 150-P75 300) in group 1, and 293.75μg (P25 300-P75 300) in group 1, (p<0.05). In the interpectoral block, an initial 30ml bolus of anaesthetic injected between the fascia is sufficient to allow the drug to spread in the axillary compartment. We used the same dose in our patients, and this would explain the difference in intraoperative analgesia requirements between groups, but not the difference in postoperative requirements, because perfusion of anaesthetic at 5ml/h−1 is insufficient to reach the axillary space. In addition, reducing the intraoperative fentanyl dose could have some influence on the recurrence of breast cancer, although the impact of regional anaesthesia on recurrence is controversial.<a class="elsevierStyleCrossRefs" href="#bib0280">22,23</a> A recent retrospective study tested the hypothesis that the use of paravertebral block during breast cancer surgery would prolong recurrence-free survival and overall survival in women with breast cancer (average of 5.8–6 years, respectively). Like us, the authors observed significantly higher fentanyl consumption in patients that did not receive the blockade (402.23±343.8μg vs 122.8±77.85μg), but found no evidence to show that regional anaesthesia prolongs recurrence-free survival (1.60 [0.81–3.16], p=0.172) or overall survival (1.28 [0.55–3.01]) in this type of cancer.<a class="elsevierStyleCrossRef" href="#bib0290">24</a> In another retrospective study, the authors also concluded that regional anaesthesia does not influence overall survival, disease-free survival, or local recurrence.<a class="elsevierStyleCrossRef" href="#bib0295">25</a>The use of regional anaesthesia in breast surgery has been described for decades. Hoffman and Elliot,<a class="elsevierStyleCrossRef" href="#bib0300">26</a> in 1987, suggested blocking the pectoral nerves to reduce chronic postoperative pain and muscle expansion after mastectomy. According to these authors, in 62% of women the medial pectoral nerve travels inferiorly to the pectoralis minor muscle and courses through the 2 layers of the clavipectoral fascia to innervate the lower third of the pectoralis major muscle. In the other 38% of patients, the medial pectoral nerve exits around the lateral aspect of the pectoralis minor muscle. The puncture site was initially determined to be approximately 2.81+0.33cm below the medial third of the clavicle, and 8.12+1.09cm lateral to the midsternal line, in the fascial space that lies deep to the pectoralis minor muscle. Later, in a cadaver study, the authors found that the ultrasound-guided injection of 10ml of solution in cadavers was sufficient to reach the lateral and medial pectoral branches without spreading proximal to the cords of the brachial plexus.<a class="elsevierStyleCrossRef" href="#bib0305">27</a> That same year, Blanco et al. described the technique they dubbed the PEC, or PEC I block – an interfascial block in which the anaesthetic is administered in the plane between the pectoralis major and minor muscles to facilitate spread to the lateral pectoral nerve that always lies adjacent to the pectoral branch of the thoracoacromial artery between these structures. This nerve block provides anaesthesia and/or analgesia to the upper and anterior region of the thoracic wall.<a class="elsevierStyleCrossRef" href="#bib0225">11</a>More recently, the modified PEC or PEC II block was described, in which a second more lateral puncture was performed to deliver 20ml of local anaesthetic above the serratus anterior muscle, in the plane between this muscle and the pectoralis minor between the third and fourth rib. This facilitates the spread of the anaesthetic to the axilla and blocks the long thoracic nerve and the lateral branches of the intercostal nerves that is needed for axillary lymphadenectomy or wider resections.<a class="elsevierStyleCrossRef" href="#bib0310">28</a> The same authors later described another variation that they called the serratus plane block, in which the anaesthetic is injected superficial to the anterior serratus muscle to facilitate intercostal spread. The spread of the anaesthetic was confirmed using nuclear magnetic resonance imaging, and was found to correlate with the sensory examination.<a class="elsevierStyleCrossRef" href="#bib0315">29</a> Wahba and Kamal<a class="elsevierStyleCrossRef" href="#bib0320">30</a> compared ultrasound-guided PEC I combined with PEC II with paravertebral block at the level of T4 in women undergoing extended radical mastectomy. They found that the PEC block group presented lower intraoperative opioid requirements and better control of postoperative pain. The block also provided better axillary coverage and less postoperative nausea.Pérez et al.<a class="elsevierStyleCrossRef" href="#bib0325">31</a> described a different approach to PEC II, which required less systemic analgesic and gave greater patient satisfaction after major and minor breast surgery. They placed the ultrasound probe below the distal third of the clavicle and inserted the needle in plan from medial to lateral, staying as far as possible from structures such as the pleura and blood vessels. The authors considered this to be a safer approach. Another technique described involves blocking the intercostal branches in the mid-axillary line. These authors observed that this easy to perform blockade provided adequate intraoperative and postoperative analgesia in breast and axillary reconstructive surgery with a single puncture and low-dose local anaesthetic.<a class="elsevierStyleCrossRefs" href="#bib0330">32,33</a> Recently, another group described a single-shot combination PEC I and PEC II (COMBIPECS) technique that is time-saving and equally effective.<a class="elsevierStyleCrossRef" href="#bib0340">34</a>ConclusionsIn our study, the PEC block combined with general anaesthesia provided good intraoperative analgesia, although it was not superior to i.v. analgesia in the postoperative period. The technique is associated with few side effects, and could be a useful tool for the control of perioperative pain in breast cancer surgery.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1018413" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec976784" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1018414" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec976785" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-06" "fechaAceptado" => "2017-11-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec976784" "palabras" => array:4 [ 0 => "Ultrasound" 1 => "Pectoral nerves" 2 => "Regional anaesthesia" 3 => "Breast surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec976785" "palabras" => array:4 [ 0 => "Ultrasonidos" 1 => "Nervios pectorales" 2 => "Anestesia regional" 3 => "Cirugía de mama" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo compare the analgesic efficacy of continuous interpectoral block (CIPB) compared to intravenous analgesia (IV) after breast surgery. Material and methodA prospective, comparative and randomised study of women aged from 18 to 75years, ASAI-III, operated for breast cancer. In group1 (CIPB) after general anaesthetic, an ultrasound-guided interpectoral catheter was placed and 30ml of 0.5% ropivacaine was administered through it. In the event of an increase in heart rate and blood pressure >15% after the surgical incision, intravenous fentanyl 1μgkg−1 was administered, repeating the dose as necessary. In the postoperative period, perfusion of ropivacaine 0.2% 5mlh−1; with PCA bolus 5ml/30min was administered through the catheter for 24h and rescue analgesia prescribed with 5mg subcutaneous morphine chloride. In group2 (IV), after induction of general anaesthesia, intravenous fentanyl was administered in the same way as in the other group. The patients received metamizole 2g with dexketoprofen 50mg and ondansetron 4mg postoperatively followed by perfusion of metamizole 4%, tramadol 0.2% and ondansetron 0.08% 2mlh−1; with PCA bolus 2ml/20min for 24h. The same rescue analgesia was prescribed. The principal variables recorded were pain at rest and during movement, according to a simple verbal scale (VAS 0–10) and the rescue analgesia required on discharge from recovery, at 12 and at 24h. Results137 patients were included: 81 in group1 (59.12%) and 56 in group2 (40.87%). No significant differences were observed in the analgesia between either group, but differences were observed in the dose of intraoperative fentanyl (p<.05). Differences that were not significant were observed in the rescue analgesia required on recovery (10% fewer on group1). ConclusionsBoth techniques provided effective postoperative analgesia, but the CIPB group required significantly less intraoperative fentanyl." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoComparar la eficacia analgésica del bloqueo interpectoral continuo (BIPC) frente a la analgesia intravenosa (i.v.) tras cirugía de mama. Material y métodoEstudio prospectivo, comparativo y aleatorizado sobre mujeres de 18-75años, ASAI-III, intervenidas de cirugía oncológica de mama. En el grupo1 (BIPC), tras la inducción de anestesia general se colocó un catéter interpectoral ecoguiado y se administró ropivacaína 0,5% 30ml a su través. Tras la incisión quirúrgica, si la frecuencia cardiaca y la presión arterial se incrementaron >15% se administró fentanilo i.v., 1μg·kg−1, repitiendo la dosis en caso necesario. En el postoperatorio se inició perfusión de ropivacaína 0,2% 5ml·h−1; con bolo PCA 5ml/30min por el catéter durante 24h, y se prescribió analgesia de rescate con cloruro mórfico 5mg subcutáneo. En el grupo2 (i.v.), tras la inducción de anestesia general se administró fentanilo i.v. en caso necesario de la misma forma que en el otro grupo. En el postoperatorio se administró metamizol 2g con dexketoprofeno 50mg y ondansetrón 4mg seguido de perfusión de metamizol 4%, tramadol 0,2% y ondansetrón 0,08% 2ml·h−1; con bolo PCA 2ml/20min durante 24h. Se prescribió el mismo rescate analgésico. Las variables principales registradas fueron dolor en reposo y durante el movimiento, según una escala verbal simple (EVA 0-1), y la analgesia de rescate precisada al alta de reanimación, a las 12 y a las 24h. ResultadosSe incluyeron 137 pacientes: 81 en el grupo1 (59,12%) y 56 en el grupo2 (40,87%). No se observaron diferencias significativas en analgesia entre grupos, pero sí en la dosis de fentanilo intraoperatorio (p<0,05). Se observaron diferencias no significativas en la analgesia de rescate requerida en reanimación (10% menor en el grupo1). ConclusionesAmbas técnicas proporcionaron analgesia postoperatoria eficaz, pero el grupo BIPC precisó significativamente menos fentanilo intraoperatorio." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ortiz de la Tabla González R, Gómez Reja P, Moreno Rey D, Pérez Naranjo C, Sánchez Martín I, Echevarría Moreno M. Utilidad del bloqueo interpectoral continuo como técnica analgésica en cirugía oncológica de mama. Rev Esp Anestesiol Reanim. 2018;65:188–195." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:12 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 834 "Ancho" => 1225 "Tamanyo" => 44196 ] ] "descripcion" => array:1 [ "en" => "Pain at rest on the numerical verbal scale (0–10) at all data collection time points. No statistically significant differences (p>0.05)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 833 "Ancho" => 1240 "Tamanyo" => 39890 ] ] "descripcion" => array:1 [ "en" => "Pain on movement on the numerical verbal scale (0–10) at all data collection time points. No statistically significant differences (p>0.05)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 841 "Ancho" => 1247 "Tamanyo" => 38885 ] ] "descripcion" => array:1 [ "en" => "Patient-controlled boluses requested at all data collection time points in both groups. No statistically significant differences (p>0.05)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 826 "Ancho" => 1245 "Tamanyo" => 36448 ] ] "descripcion" => array:1 [ "en" => "Patient-controlled boluses administered at all data collection time points in both groups. No statistically significant differences (p>0.05)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1182 "Ancho" => 1504 "Tamanyo" => 42756 ] ] "descripcion" => array:1 [ "en" => "Box plot of intraoperative fentanyl requirements in both groups. Intraoperative fentanyl dose requirements are described as median and 25 and 75 percentile, and were 150g (150–300) in group 1 and 293.75g (300–300) in the group 2 (p<0.05)." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No.: number of patients.Numerical variables are described as mean and standard deviation. Qualitative variables are described as percentage.No statistically significant differences (p>0.05)." "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Group 1 (CPEC) No.=81 \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">Group 2 (i.v.) No.=56 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Age (years)</td><td class="td" title="table-entry " align="char" valign="top">57.10±13.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.55±12.67 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Weight (kg)</td><td class="td" title="table-entry " align="char" valign="top">70.91±13.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.50±13.19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Height (cm)</td><td class="td" title="table-entry " align="char" valign="top">159.15±6.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160.22±6.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">ASA</td><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (17.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (14.3%) \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">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (63.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (71.4%) \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">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (19.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727243.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics by group." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No.: number of patients.Numerical variables are described as mean and standard deviation. Qualitative variables are described as percentage." "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Group 1 (CPEC) No.=81 \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">Group 2 (i.v.) No.=56 \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">Simple mastectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (9.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8.9%) \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">Lumpectomy with sentinel node resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (14.3%) \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">Quadrantectomy with sentinel node resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (13.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (10.7%) \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">Mastectomy with sentinel node resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8.9%) \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">Lumpectomy with axillary lymphadenectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (7.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5.4%) \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">Quadrantectomy with axillary lymphadenectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (4.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (10.7%) \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">Mastectomy with axillary lymphadenectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (40.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (33.9%) \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">Mastectomy with sentinel node resection and tissue expander \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (11.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.1%) \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">Duration of surgery (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109.04±28.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101.51±28.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727238.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Type of surgery, by group." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No.: number of patients.Numerical variables are described as mean and standard deviation. Qualitative variables are described as percentage. Time to block: time (min) from puncture to completion of local anaesthetic infusion. Time to incision: time (min) from completion of block first surgical incision." "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">Nerve block technique (No.=81) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">1. Easy (1–2 attempts) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (87.7%) \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">2. Difficult (3 attempts) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (11%) \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">3. Very difficult (4 attempts) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4%) \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">Time to block (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.58±3.06 \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">Time to incision (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.58±4.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727241.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Continuous interpectoral block technique (CPEC group)." ] ] 8 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No.: number of patients.Need for rescue analgesia: Yes/No. Qualitative variables are described as percentage.No statistically significant differences (p>0.05)." "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Group 1 (CPEC) No.=81 \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">Group 2 (i.v.) No.=56 \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">PACU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (20.4%) \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">12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5.7%) \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">24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (9.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (10.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727239.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Need for rescue analgesia in both groups at all data collection time points." ] ] 9 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No.: number of patients.Qualitative variables are described as percentage.No statistically significant differences (p>0.05)." "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">PACU \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">12h \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">24h \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">Group 1 (CPEC) No.=81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 nausea-vomiting (2.5%) 1 paresthesia of the thumb (1.3%) 1 displacement of catheter (1.3%) 2 catheter occlusions (2.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 paresthesia of the thumb (2.7%) 2 paresthesia of the fingers (2.7%) 1 paresthesia of the axillar/forearm (1.4%) \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">Group 2 (i.v.) No.=56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 nausea-vomiting (3.7%) 2 dizziness (3.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 nausea-vomiting (9.3%) 2 dizziness (3.7%) 1 displacement of peripheral line (1.9%) 1 sedation (1.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 nausea-vomiting (8.2%) 2 dizziness (3.7%) 1 displacement of peripheral line (1.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727240.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Side effects in both groups at all data collection time points." ] ] 10 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No.: number of patients.Qualitative variables are described as percentage.No statistically significant differences (p>0.05)." "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Group 1 (CPEC) No.=81 \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">Group 2 (i.v.) No.=56 \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">1. Satisfied \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (58.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (47.9%) \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">2. Very satisfied \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (37.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (25%) \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">3. Indifferent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (23.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727242.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Degree of patient satisfaction in both groups." ] ] 11 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 85938 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breast cancer statistics, 2013" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. 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The usefulness of interpectoral block as an analgesic technique in breast cancer surgery

Utilidad del bloqueo interpectoral continuo como técnica analgésica en cirugía oncológica de mama

R. Ortiz de la Tabla González

Corresponding author

raquelortizdelat@gmail.com

Corresponding author.

, P. Gómez Reja, D. Moreno Rey, C. Pérez Naranjo, I. Sánchez Martín, M. Echevarría Moreno

UGCBQ Área Sur de Sevilla, Sevilla, Spain

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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pain on movement on the numerical verbal scale &#40;0&#8211;10&#41; at all data collection time points&#46; No statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer is the most common type of cancer among women&#46; In the United States&#44; 1 in 8 women will develop breast cancer at some time during their life&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> In Spain&#44; it affects 50&#46;9 women&#47;100&#44;000 inhabitants&#44; and around 26&#44;000 new cases are diagnosed each year&#46; Breast cancer currently accounts for almost 30&#37; of female tumours in Spain&#44; and incidence is expected to increase by 1&#8211;2&#37; annually&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">After breast cancer surgery&#44; 40&#37; of women will present severe acute postoperative pain&#44; and at 6 months 50&#37; will develop chronic pain that will affect their quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> In recent years&#44; regional anaesthesia has been used in breast cancer surgery to improve the speed and quality of their recovery&#46; These techniques have a number of beneficial effects&#58; they provide effective relief of acute perioperative pain and avoid central sensitisation and opioid-induced hyperalgesia&#44; which are considered risk factors for the onset of chronic pain<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a>&#59; and they also reduce the volume of general anaesthetics and opioids required&#44; particularly morphine&#44; thus attenuating the opioid-induced immunosuppression that some studies have linked to local recurrence and&#47;or tumour metastasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The use of ultrasound has been a key factor in the development of this type of regional anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> The standard technique has always been the paravertebral block&#44; which has been shown to provide better analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> One study has even shown this nerve block to reduce recurrence of breast cancer&#44; although these finding should be interpreted with caution&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> However&#44; in the last few years&#44; ultrasound-guided interfascial thoracic wall blocks have been described and are now used in clinical practice&#46; One such approach is the pectoral nerve block or interpectoral block &#40;PEC&#41;&#44; which has been described as a safer&#44; less invasive technique with fewer complications&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of our study was to compare the efficacy and side effects of continuous interpectoral block &#40;CPEC&#41; versus conventional intravenous &#40;i&#46;v&#46;&#41; analgesia after breast cancer surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a prospective&#44; comparative&#44; randomised study of women undergoing breast cancer&#46; The study was approved by the local Institutional Review Board and complies with the ethical standards of the Helsinki declaration of 1975&#44; revised in 2000 &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.wma.net/s/policy/17-c_s.html">http&#58;&#47;&#47;www&#46;wma&#46;net&#47;s&#47;policy&#47;17-c&#95;s&#46;html</a>&#41;&#44; with the new Royal Decree 1090&#47;2015 of December 4&#44; replacing Royal Decree 223&#47;2004&#44; regulating clinical trials with medicinal products&#44; ethics committees for investigation with medicinal products and the Spanish Clinical Studies Registry&#44; and approved by the Spanish Agency for Medicines and Health Products &#40;<a id="intr0015" class="elsevierStyleInterRef" href="https://www.aemps.gob.es/">https&#58;&#47;&#47;www&#46;aemps&#46;gob&#46;es</a>&#41;&#44; written informed consent was obtained from all study subjects&#46; We included all women aged between 18 and 75 years&#44; ASA <span class="elsevierStyleSmallCaps">I</span>-<span class="elsevierStyleSmallCaps">III&#44;</span> scheduled for non-reconstructive breast and axillary surgery &#40;quadrantectomys or mastectomies with sentinel node resection and axillary dissection&#41; in our hospital from January to September 2016&#46; Exclusion criteria were&#58; sensitivity to local anaesthetics&#44; coagulation disorders&#44; contraindication for CPEC&#44; and refusal to participate&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On arrival in the operating room&#44; continuous monitoring with electrocardiography&#44; non-invasive blood pressure and pulse oximetry was started in all cases&#46; Following this&#44; a peripheral venous catheter &#40;Abocath18G<span class="elsevierStyleSup">&#174;</span>&#41; was placed and BIS level-guided general anaesthesia was induced with propofol&#44; fentanyl 150<span class="elsevierStyleHsp" style=""></span>&#956;g and cisatracurium 0&#46;05<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<span class="elsevierStyleSup">&#8722;1</span>&#46; An I-gel<span class="elsevierStyleSup">&#174;</span> laryngeal mask airway appropriate to the patient&#39;s weight was inserted and connected to a ventilator&#44; and i&#46;v&#46; perfusion of BIS level-guided propofol was started&#46; Following this&#44; each patient was assigned to one of the study groups using the block randomisation technique that ensured that each study treatment would be administered a certain number of times in a certain number of patients&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All the data were collected and all procedures performed by 4 anaesthesiologists from our hospital&#44; all experts in regional anaesthesia and ultrasound&#44; and members of a locoregional anaesthesia in breast surgery working group&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In group 1 &#40;continuous interpectoral block &#91;CPEC&#93;&#41;&#44; following general anaesthesia induction a PEC nerve block was performed as described by Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a> The patient was placed in the supine position with the ipsilateral arm next to the body and the head turned to the contralateral side&#46; After the usual skin prep&#44; a 12<span class="elsevierStyleHsp" style=""></span>L linear ultrasound probe &#40;Sonosite S series&#8482; FUJIFILM SonoSite S&#46;L&#46;&#41; was placed under the lateral third of the clavicle&#44; transverse to the axis of the body at the level of the second intercostal space &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Appendix A</a>&#58; supplementary material on line&#41;&#46; Both pectoral muscles and their respective fascias were identified in the ultrasound window&#44; and Doppler was used to identify the acromothoracic artery&#44; which is located medial to the lateral pectoral nerve in the interfascial space between the pectoral fascia and the clavipectoral fascia&#44; that is&#44; between the muscles&#46; Following this&#44; an 18G<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mm Tuhoy needle was inserted in plane in a medial to lateral direction at an angle of 45&#176; until it reached the artery&#46; After a negative aspiration&#44; test 0&#46;5&#37; ropivacaine was administered in increments of 5<span class="elsevierStyleHsp" style=""></span>ml&#44; with continuous aspirations&#44; for a total dose of 30<span class="elsevierStyleHsp" style=""></span>ml&#46; After the spread of the anaesthetic was observed in the interfascial space&#44; a 20G<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mm catheter was placed in the space&#46; If heart rate and blood pressure &#40;BP&#41; increased more than 15&#37; during the surgical incision&#44; 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg1<span class="elsevierStyleSup">&#8722;1</span> i&#46;v&#46; fentanyl was administered&#44; repeating the dose as required&#46; At the end of surgery&#44; 2<span class="elsevierStyleHsp" style=""></span>g metamizol with 50<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron were administered intravenously&#46; After transfer to the post-anaesthesia care unit &#40;PACU&#41;&#44; patient-controlled analgesia &#40;PCA&#41; with 0&#46;2&#37; ropivacaine at 5<span class="elsevierStyleHsp" style=""></span>ml&#47;h<span class="elsevierStyleSup">&#8722;1</span> with a patient-controlled bolus dose of 5<span class="elsevierStyleHsp" style=""></span>ml&#47;30<span class="elsevierStyleHsp" style=""></span>min was delivered through the interpectoral catheter for 24<span class="elsevierStyleHsp" style=""></span>h&#46; Additional analgesia with 2<span class="elsevierStyleHsp" style=""></span>g metamizole every 8<span class="elsevierStyleHsp" style=""></span>h was also prescribed&#44; with 5<span class="elsevierStyleHsp" style=""></span>mg subcutaneous morphine chloride as rescue analgesia&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In group 2&#44; &#40;intravenous &#91;i&#46;v&#46;&#93; analgesia&#41;&#44; after anaesthesia induction 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg<span class="elsevierStyleSup">&#8722;1</span> i&#46;v&#46; fentanyl was administered if heart rate and BP increase by more than 15&#37; during the surgical incision repeating the dose if necessary&#46; At the end of surgery&#44; 2<span class="elsevierStyleHsp" style=""></span>g metamizol with 50<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron were administered intravenously&#44; followed by PCA with 4&#37; metamizol&#44; 0&#46;1&#37; tramadol and 0&#46;08&#37; ondansetron at 2<span class="elsevierStyleHsp" style=""></span>ml&#47;h<span class="elsevierStyleSup">&#8722;1</span> with a patient-controlled bolus dose of 2<span class="elsevierStyleHsp" style=""></span>ml&#47;20<span class="elsevierStyleHsp" style=""></span>min&#46; The same rescue analgesic used in group 1 was also prescribed&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The main variables collected were pain at rest and on movement&#44; evaluated on a simple verbal numerical scale &#40;VNS&#41; from 0 to 10&#59; the rescue analgesia required&#44; recorded as yes or no&#59; patient-controlled boluses requested and administered&#44; and undesirable effects at 12 and 24<span class="elsevierStyleHsp" style=""></span>h after PACU discharge&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Other variables collected were the degree of patient satisfaction &#40;scored as&#58; 1&#44; very good&#59; 2&#44; good&#59; 3&#44; indifferent&#59; 4&#44; bad&#44; and 5&#44; very bad&#41;&#44; willingness to repeat the technique &#40;valued as&#58; 1&#44; yes&#59; 2&#44; no&#44; and 3&#44; indifferent&#41;&#44; the type of surgical intervention&#44; the duration of surgery &#40;min&#41;&#44; the total dose of intraoperative i&#46;v&#46; fentanyl administered&#44; and the presence of pain interfering with sleep during the first postoperative night&#44; recorded as yes or no&#46; We also collected CPEC-related variables&#44; such as the difficulty of the technique &#40;valued as&#58; 1&#44; easy &#91;1&#8211;2 attempts&#93;&#59; 2&#44; difficult &#91;3 attempts&#93;&#44; and 4&#44; very difficult &#91;&#62;4 attempts&#93;&#41;&#59; the time &#40;min&#41; from puncture until injection of the total dose of local anaesthetic&#44; and the time &#40;min&#41; from completion of the blockade to the start of surgery&#44; defined as the start of the surgical incision&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with IBM SPSS 22&#46;0 for Windows &#40;SPSS<span class="elsevierStyleSup">&#174;</span>&#44; Chicago&#44; USA&#41;&#46; Numerical variables were described as mean and standard deviation or median and 25 and 75 percentile&#44; and qualitative variables were expressed as frequency and percentage&#46; Independent samples were compared using the Student&#39;s <span class="elsevierStyleItalic">t</span> test&#59; the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used to compare the means of numerical variables&#44; and the chi-square or Fisher&#39;s exact test was used to compare qualitative variables&#46; Significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">In total&#44; 137 patients were included&#58; 81 in group 1 &#40;59&#46;12&#37;&#41; and 56 in group 2 &#40;40&#46;87&#37;&#41;&#46; Nine patients were excluded due to incorrect follow-up and treatment &#40;4 from group 1 and 5 from group 2&#41;&#46; Patient demographics were similar in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> show surgical data and those related to the nerve block technique&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">No significant differences in postoperative pain at rest and on movement were observed between groups at all data collection time points &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#44; or in patient-controlled boluses requested and administered &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; Significant differences were observed in intraoperative fentanyl doses required &#40;150<span class="elsevierStyleHsp" style=""></span>&#956;g &#91;P<span class="elsevierStyleInf">25</span> 150-P<span class="elsevierStyleInf">75</span> 300&#93; in group 1 and 293&#46;75<span class="elsevierStyleHsp" style=""></span>&#956;g &#91;P<span class="elsevierStyleInf">25</span> 300-P<span class="elsevierStyleInf">75</span> 300&#93; in group 2&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; No significant differences were observed in the need for rescue analgesia in the PACU&#44; which was 10&#37; lower in group 1 &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; and pain interference with sleep&#44; which was 8&#37; greater in group 2 &#40;9 patients&#44; 18&#46;8&#37;&#41; compared to group 1 &#40;8 patients&#44; 10&#46;8&#37;&#41;&#46; Side effects in the PACU were only observed in group 2&#44; and scant&#44; mild side effects were observed in both groups at 12 and 24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; Patient satisfaction in both groups was either good or very good &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41; and most would be willing to repeat the analgesic technique &#40;group 1&#58; 91&#46;5&#37;&#59; group 2&#58; 63&#46;8&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Although both techniques provide adequate analgesia after breast surgery with few side effects and a high degree of patient satisfaction&#44; the CPEC group required significantly less intraoperative fentanyl&#46; Patients in this group also required less rescue analgesia in the PACU&#44; and fewer were awakened by pain in the first 24 postoperative hours&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In their first description of the technique&#44; Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> reported good postoperative analgesia with the PEC <span class="elsevierStyleSmallCaps">I</span> block in over 50 patients undergoing breast surgery&#44; and good results in more than 100 patients in whom a catheter was placed at the site of the blockade&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a> Following the preliminary descriptions and case series&#44; it became clear that clinical trials and further studies were needed to provide sufficient scientific evidence to warrant this nerve block becoming standard practice in breast surgery&#59; this is what we set out to provide with our study&#46; In an observational study comparing the thoracic paravertebral block with the PEC block plus sedation&#44; patients in the PEC group required less sedation and reported better postoperative analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The paravertebral block for regional anaesthesia in breast surgery had been widely used and described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10&#44;15</span></a> Recently&#44; the PEC block was devised in order to avoid some of the more serious nerve block-related complications&#44; such as epidural or even spinal spread of anaesthetic&#46; The PEC block&#44; moreover&#44; is a purely sensory and motor block with no associated sympathetic blockade&#46; Although the acromothoracic artery can be injured during the technique&#44; sufficient training and ultrasound guidance all but rule out this complication&#46; Performing the PEC blocks under ultrasound guidance is currently supported by grade A evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a> So far&#44; no complications have been reported when using this approach&#44; and small studies have shown its clinical utility&#44; although more research is needed to confirm these findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10&#44;12</span></a> A recent case report described the intraoperative placement of the interpectoral catheter by surgeons as a useful alternative for anaesthesiologists with little experience in ultrasound techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Management of acute postoperative pain as a means of preventing the development of chronic pain after surgery is a common strategy&#46; Studies have reported that perioperative preventive analgesia using regional techniques&#44; such as paravertebral block in breast surgery&#44; helps prevent surgery-induced central and peripheral sensitisation that contributes to chronic pain&#46; A recent Cochrane review concluded that this blockade reduces the risk of persistent postoperative pain at 6 months after surgery in 1 in 4&#8211;5 women&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">18</span></a> A study comparing general anaesthesia with or without preincisional paravertebral block in extended radical mastectomy concluded that pain was similar in both groups after surgery&#44; but differed 5 months after the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> In another study comparing single injection or continuous infusion paravertebral block with general anaesthesia&#44; the authors observed that postoperative pain and analgesic consumption were reduced in patients undergoing breast cancer surgery&#46; Moreover&#44; the prevalence and severity of chronic postoperative pain were also reduced&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> although a subsequent study found no significant difference in the incidence or relative risk of chronic pain at 3 and 6 months after surgery when paravertebral block is used in conjunction with general anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> The effect of CPEC on chronic pain after breast surgery has not so far been evaluated in the literature&#44; but we believe it could be a useful preventive analgesic technique that merits investigation&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">10</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Another important finding in our study was the significant difference in intraoperative fentanyl requirements between groups&#58; 150<span class="elsevierStyleHsp" style=""></span>&#956;g &#40;P<span class="elsevierStyleInf">25</span> 150-P<span class="elsevierStyleInf">75</span> 300&#41; in group 1&#44; and 293&#46;75<span class="elsevierStyleHsp" style=""></span>&#956;g &#40;P<span class="elsevierStyleInf">25</span> 300-P<span class="elsevierStyleInf">75</span> 300&#41; in group 1&#44; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; In the interpectoral block&#44; an initial 30<span class="elsevierStyleHsp" style=""></span>ml bolus of anaesthetic injected between the fascia is sufficient to allow the drug to spread in the axillary compartment&#46; We used the same dose in our patients&#44; and this would explain the difference in intraoperative analgesia requirements between groups&#44; but not the difference in postoperative requirements&#44; because perfusion of anaesthetic at 5<span class="elsevierStyleHsp" style=""></span>ml&#47;h<span class="elsevierStyleSup">&#8722;1</span> is insufficient to reach the axillary space&#46; In addition&#44; reducing the intraoperative fentanyl dose could have some influence on the recurrence of breast cancer&#44; although the impact of regional anaesthesia on recurrence is controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">22&#44;23</span></a> A recent retrospective study tested the hypothesis that the use of paravertebral block during breast cancer surgery would prolong recurrence-free survival and overall survival in women with breast cancer &#40;average of 5&#46;8&#8211;6 years&#44; respectively&#41;&#46; Like us&#44; the authors observed significantly higher fentanyl consumption in patients that did not receive the blockade &#40;402&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>343&#46;8<span class="elsevierStyleHsp" style=""></span>&#956;g vs 122&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>77&#46;85<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; but found no evidence to show that regional anaesthesia prolongs recurrence-free survival &#40;1&#46;60 &#91;0&#46;81&#8211;3&#46;16&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;172&#41; or overall survival &#40;1&#46;28 &#91;0&#46;55&#8211;3&#46;01&#93;&#41; in this type of cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a> In another retrospective study&#44; the authors also concluded that regional anaesthesia does not influence overall survival&#44; disease-free survival&#44; or local recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">25</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The use of regional anaesthesia in breast surgery has been described for decades&#46; Hoffman and Elliot&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a> in 1987&#44; suggested blocking the pectoral nerves to reduce chronic postoperative pain and muscle expansion after mastectomy&#46; According to these authors&#44; in 62&#37; of women the medial pectoral nerve travels inferiorly to the pectoralis minor muscle and courses through the 2 layers of the clavipectoral fascia to innervate the lower third of the pectoralis major muscle&#46; In the other 38&#37; of patients&#44; the medial pectoral nerve exits around the lateral aspect of the pectoralis minor muscle&#46; The puncture site was initially determined to be approximately 2&#46;81<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;33<span class="elsevierStyleHsp" style=""></span>cm below the medial third of the clavicle&#44; and 8&#46;12<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1&#46;09<span class="elsevierStyleHsp" style=""></span>cm lateral to the midsternal line&#44; in the fascial space that lies deep to the pectoralis minor muscle&#46; Later&#44; in a cadaver study&#44; the authors found that the ultrasound-guided injection of 10<span class="elsevierStyleHsp" style=""></span>ml of solution in cadavers was sufficient to reach the lateral and medial pectoral branches without spreading proximal to the cords of the brachial plexus&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a> That same year&#44; Blanco et al&#46; described the technique they dubbed the PEC&#44; or PEC <span class="elsevierStyleSmallCaps">I</span> block &#8211; an interfascial block in which the anaesthetic is administered in the plane between the pectoralis major and minor muscles to facilitate spread to the lateral pectoral nerve that always lies adjacent to the pectoral branch of the thoracoacromial artery between these structures&#46; This nerve block provides anaesthesia and&#47;or analgesia to the upper and anterior region of the thoracic wall&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">More recently&#44; the modified PEC or PEC <span class="elsevierStyleSmallCaps">II</span> block was described&#44; in which a second more lateral puncture was performed to deliver 20<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic above the serratus anterior muscle&#44; in the plane between this muscle and the pectoralis minor between the third and fourth rib&#46; This facilitates the spread of the anaesthetic to the axilla and blocks the long thoracic nerve and the lateral branches of the intercostal nerves that is needed for axillary lymphadenectomy or wider resections&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> The same authors later described another variation that they called the serratus plane block&#44; in which the anaesthetic is injected superficial to the anterior serratus muscle to facilitate intercostal spread&#46; The spread of the anaesthetic was confirmed using nuclear magnetic resonance imaging&#44; and was found to correlate with the sensory examination&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> Wahba and Kamal<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">30</span></a> compared ultrasound-guided PEC <span class="elsevierStyleSmallCaps">I</span> combined with PEC <span class="elsevierStyleSmallCaps">II</span> with paravertebral block at the level of T4 in women undergoing extended radical mastectomy&#46; They found that the PEC block group presented lower intraoperative opioid requirements and better control of postoperative pain&#46; The block also provided better axillary coverage and less postoperative nausea&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">P&#233;rez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> described a different approach to PEC <span class="elsevierStyleSmallCaps">II&#44;</span> which required less systemic analgesic and gave greater patient satisfaction after major and minor breast surgery&#46; They placed the ultrasound probe below the distal third of the clavicle and inserted the needle in plan from medial to lateral&#44; staying as far as possible from structures such as the pleura and blood vessels&#46; The authors considered this to be a safer approach&#46; Another technique described involves blocking the intercostal branches in the mid-axillary line&#46; These authors observed that this easy to perform blockade provided adequate intraoperative and postoperative analgesia in breast and axillary reconstructive surgery with a single puncture and low-dose local anaesthetic&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">32&#44;33</span></a> Recently&#44; another group described a single-shot combination PEC <span class="elsevierStyleSmallCaps">I</span> and PEC <span class="elsevierStyleSmallCaps">II</span> &#40;COMBIPECS&#41; technique that is time-saving and equally effective&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">In our study&#44; the PEC block combined with general anaesthesia provided good intraoperative analgesia&#44; although it was not superior to i&#46;v&#46; analgesia in the postoperative period&#46; The technique is associated with few side effects&#44; and could be a useful tool for the control of perioperative pain in breast cancer surgery&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare the analgesic efficacy of continuous interpectoral block &#40;CIPB&#41; compared to intravenous analgesia &#40;<span class="elsevierStyleSmallCaps">IV</span>&#41; after breast surgery&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; comparative and randomised study of women aged from 18 to 75<span class="elsevierStyleHsp" style=""></span>years&#44; ASA<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">I</span>-<span class="elsevierStyleSmallCaps">III</span>&#44; operated for breast cancer&#46; In group<span class="elsevierStyleHsp" style=""></span>1 &#40;CIPB&#41; after general anaesthetic&#44; an ultrasound-guided interpectoral catheter was placed and 30<span class="elsevierStyleHsp" style=""></span>ml of 0&#46;5&#37; ropivacaine was administered through it&#46; In the event of an increase in heart rate and blood pressure &#62;15&#37; after the surgical incision&#44; intravenous fentanyl 1<span class="elsevierStyleHsp" style=""></span>&#956;g<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">&#8722;1</span> was administered&#44; repeating the dose as necessary&#46; In the postoperative period&#44; perfusion of ropivacaine 0&#46;2&#37; 5<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">&#8722;1</span>&#59; with PCA bolus 5<span class="elsevierStyleHsp" style=""></span>ml&#47;30<span class="elsevierStyleHsp" style=""></span>min was administered through the catheter for 24<span class="elsevierStyleHsp" style=""></span>h and rescue analgesia prescribed with 5<span class="elsevierStyleHsp" style=""></span>mg subcutaneous morphine chloride&#46; In group<span class="elsevierStyleHsp" style=""></span>2 &#40;<span class="elsevierStyleSmallCaps">IV</span>&#41;&#44; after induction of general anaesthesia&#44; intravenous fentanyl was administered in the same way as in the other group&#46; The patients received metamizole 2<span class="elsevierStyleHsp" style=""></span>g with dexketoprofen 50<span class="elsevierStyleHsp" style=""></span>mg and ondansetron 4<span class="elsevierStyleHsp" style=""></span>mg postoperatively followed by perfusion of metamizole 4&#37;&#44; tramadol 0&#46;2&#37; and ondansetron 0&#46;08&#37; 2<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">&#8722;1</span>&#59; with PCA bolus 2<span class="elsevierStyleHsp" style=""></span>ml&#47;20<span class="elsevierStyleHsp" style=""></span>min for 24<span class="elsevierStyleHsp" style=""></span>h&#46; The same rescue analgesia was prescribed&#46; The principal variables recorded were pain at rest and during movement&#44; according to a simple verbal scale &#40;VAS 0&#8211;10&#41; and the rescue analgesia required on discharge from recovery&#44; at 12 and at 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">137 patients were included&#58; 81 in group<span class="elsevierStyleHsp" style=""></span>1 &#40;59&#46;12&#37;&#41; and 56 in group<span class="elsevierStyleHsp" style=""></span>2 &#40;40&#46;87&#37;&#41;&#46; No significant differences were observed in the analgesia between either group&#44; but differences were observed in the dose of intraoperative fentanyl &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; Differences that were not significant were observed in the rescue analgesia required on recovery &#40;10&#37; fewer on group<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Both techniques provided effective postoperative analgesia&#44; but the CIPB group required significantly less intraoperative fentanyl&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparar la eficacia analg&#233;sica del bloqueo interpectoral continuo &#40;BIPC&#41; frente a la analgesia intravenosa &#40;i&#46;v&#46;&#41; tras cirug&#237;a de mama&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; comparativo y aleatorizado sobre mujeres de 18-75<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; ASA<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">I</span>-<span class="elsevierStyleSmallCaps">III</span>&#44; intervenidas de cirug&#237;a oncol&#243;gica de mama&#46; En el grupo<span class="elsevierStyleHsp" style=""></span>1 &#40;BIPC&#41;&#44; tras la inducci&#243;n de anestesia general se coloc&#243; un cat&#233;ter interpectoral ecoguiado y se administr&#243; ropivaca&#237;na 0&#44;5&#37; 30<span class="elsevierStyleHsp" style=""></span>ml a su trav&#233;s&#46; Tras la incisi&#243;n quir&#250;rgica&#44; si la frecuencia cardiaca y la presi&#243;n arterial se incrementaron &#62;<span class="elsevierStyleHsp" style=""></span>15&#37; se administr&#243; fentanilo i&#46;v&#46;&#44; 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#44; repitiendo la dosis en caso necesario&#46; En el postoperatorio se inici&#243; perfusi&#243;n de ropivaca&#237;na 0&#44;2&#37; 5<span class="elsevierStyleHsp" style=""></span>ml&#183;h<span class="elsevierStyleSup">&#8722;1</span>&#59; con bolo PCA 5<span class="elsevierStyleHsp" style=""></span>ml&#47;30<span class="elsevierStyleHsp" style=""></span>min por el cat&#233;ter durante 24<span class="elsevierStyleHsp" style=""></span>h&#44; y se prescribi&#243; analgesia de rescate con cloruro m&#243;rfico 5<span class="elsevierStyleHsp" style=""></span>mg subcut&#225;neo&#46; En el grupo<span class="elsevierStyleHsp" style=""></span>2 &#40;i&#46;v&#46;&#41;&#44; tras la inducci&#243;n de anestesia general se administr&#243; fentanilo i&#46;v&#46; en caso necesario de la misma forma que en el otro grupo&#46; En el postoperatorio se administr&#243; metamizol 2<span class="elsevierStyleHsp" style=""></span>g con dexketoprofeno 50<span class="elsevierStyleHsp" style=""></span>mg y ondansetr&#243;n 4<span class="elsevierStyleHsp" style=""></span>mg seguido de perfusi&#243;n de metamizol 4&#37;&#44; tramadol 0&#44;2&#37; y ondansetr&#243;n 0&#44;08&#37; 2<span class="elsevierStyleHsp" style=""></span>ml&#183;h<span class="elsevierStyleSup">&#8722;1</span>&#59; con bolo PCA 2<span class="elsevierStyleHsp" style=""></span>ml&#47;20<span class="elsevierStyleHsp" style=""></span>min durante 24<span class="elsevierStyleHsp" style=""></span>h&#46; Se prescribi&#243; el mismo rescate analg&#233;sico&#46; Las variables principales registradas fueron dolor en reposo y durante el movimiento&#44; seg&#250;n una escala verbal simple &#40;EVA 0-1&#41;&#44; y la analgesia de rescate precisada al alta de reanimaci&#243;n&#44; a las 12 y a las 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 137 pacientes&#58; 81 en el grupo<span class="elsevierStyleHsp" style=""></span>1 &#40;59&#44;12&#37;&#41; y 56 en el grupo<span class="elsevierStyleHsp" style=""></span>2 &#40;40&#44;87&#37;&#41;&#46; No se observaron diferencias significativas en analgesia entre grupos&#44; pero s&#237; en la dosis de fentanilo intraoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Se observaron diferencias no significativas en la analgesia de rescate requerida en reanimaci&#243;n &#40;10&#37; menor en el grupo<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ambas t&#233;cnicas proporcionaron analgesia postoperatoria eficaz&#44; pero el grupo BIPC precis&#243; significativamente menos fentanilo intraoperatorio&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ortiz de la Tabla Gonz&#225;lez R&#44; G&#243;mez Reja P&#44; Moreno Rey D&#44; P&#233;rez Naranjo C&#44; S&#225;nchez Mart&#237;n I&#44; Echevarr&#237;a Moreno M&#46; Utilidad del bloqueo interpectoral continuo como t&#233;cnica analg&#233;sica en cirug&#237;a oncol&#243;gica de mama&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;188&#8211;195&#46;</p>"
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            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pain at rest on the numerical verbal scale &#40;0&#8211;10&#41; at all data collection time points&#46; No statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pain on movement on the numerical verbal scale &#40;0&#8211;10&#41; at all data collection time points&#46; No statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient-controlled boluses administered at all data collection time points in both groups&#46; No statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
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        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Box plot of intraoperative fentanyl requirements in both groups&#46; Intraoperative fentanyl dose requirements are described as median and 25 and 75 percentile&#44; and were 150<span class="elsevierStyleHsp" style=""></span>g &#40;150&#8211;300&#41; in group 1 and 293&#46;75<span class="elsevierStyleHsp" style=""></span>g &#40;300&#8211;300&#41; in the group 2 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
        ]
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      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
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          0 => array:3 [
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">No&#46;&#58; number of patients&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Numerical variables are described as mean and standard deviation&#46; Qualitative variables are described as percentage&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">No statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
          "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="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\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">Group 1 &#40;CPEC&#41;<br>No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&nbsp;\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">Group 2 &#40;i&#46;v&#46;&#41;<br>No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&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" title="table-entry  " colspan="2" align="left" valign="top">Age &#40;years&#41;</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top">Weight &#40;kg&#41;</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top">Height &#40;cm&#41;</td><td class="td" title="table-entry  " align="char" valign="top">159&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">160&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">ASA</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSmallCaps">I</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;17&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleSmallCaps">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;63&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;71&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;19&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1727243.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics by group&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">No&#46;&#58; number of patients&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Numerical variables are described as mean and standard deviation&#46; Qualitative variables are described as percentage&#46;</p>"
          "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="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\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">Group 1 &#40;CPEC&#41;<br>No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&nbsp;\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">Group 2 &#40;i&#46;v&#46;&#41;<br>No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&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">Simple mastectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;9&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;8&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lumpectomy with sentinel node resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;6&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Quadrantectomy with sentinel node resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;13&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;10&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mastectomy with sentinel node resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;6&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;8&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lumpectomy with axillary lymphadenectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;7&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;5&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Quadrantectomy with axillary lymphadenectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;4&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;10&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mastectomy with axillary lymphadenectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;40&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;33&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mastectomy with sentinel node resection and tissue expander&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;11&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of surgery &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">109&#46;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&#46;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Type of surgery&#44; by group&#46;</p>"
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      7 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">No&#46;&#58; number of patients&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Numerical variables are described as mean and standard deviation&#46; Qualitative variables are described as percentage&#46; Time to block&#58; time &#40;min&#41; from puncture to completion of local anaesthetic infusion&#46; Time to incision&#58; time &#40;min&#41; from completion of block first surgical incision&#46;</p>"
          "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">Nerve block technique &#40;No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&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">1&#46; Easy &#40;1&#8211;2 attempts&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64 &#40;87&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Difficult &#40;3 attempts&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Very difficult &#40;4 attempts&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to block &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;06&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">Time to incision &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Continuous interpectoral block technique &#40;CPEC group&#41;&#46;</p>"
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      8 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at4"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">No&#46;&#58; number of patients&#46;</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Need for rescue analgesia&#58; Yes&#47;No&#46; Qualitative variables are described as percentage&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">No statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
          "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="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\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">Group 1 &#40;CPEC&#41;<br>No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&nbsp;\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">Group 2 &#40;i&#46;v&#46;&#41;<br>No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&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">PACU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;20&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;6&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;5&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
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