Letter to the Director
BRILMA and PEC blocks: Simpler and more adequate options in radical breast surgery
Bloqueos BRILMA y PEC: opciones más sencillas y adecuadas en cirugía radical de mama
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Fernández Martín, S. López Álvarez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M.T." "apellidos" => "Fernández Martín" "email" => array:1 [ 0 => "Maitefm70@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "López Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Medina del Campo, Medina del Campo, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Abente y Lago, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueos BRILMA y PEC: opciones más sencillas y adecuadas en cirugía radical de mama" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 721 "Ancho" => 2000 "Tamanyo" => 123414 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Approach and ultrasound image of the BRILMA blockade.C4, 4th rib; AML, mid-axillary line; pl, pleura; sc, subcutaneous cellular tissue; serr, serratus muscle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the case study submitted by M. Veiga et al. titled “Erector spinae plane block for radical mastectomy: A new indication?”.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> We would like to congratulate the authors on their description of the erector spinae plane (ESP) block as an analgesic technique in radical breast surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The ESP is a fascial block performed in the deep plane of the posterior thoracic wall.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> We agree with the authors that acting on the dorsal and ventral rami of the spinal nerves produces a sensory blockade caused by the local anaesthetic spreading in a caudal and cranial direction and into the paravertebral space. The anaesthetic enters this space through existing openings in the wall of the anterior fascia, which facilitates the spread of the anaesthetic.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We are aware of its analgesic efficacy, but we question when it should form part of our anaesthetic–analgesic strategy in breast cancer surgery. Firstly, we doubt that intercostal nerve block will provide sufficient analgesia for radical mastectomy: although the chest wall is innervated by the first intercostal nerves (T2–T6), the deep muscles are innervated by the pectoral nerves, which have their origin in the lateral and medial fascicles of the brachial plexus.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Even so, we agree that the ESP block is an opioid-saving multimodal analgesia strategy. Secondly, we would draw attention to the difficulty and possible complications of ESP. In our opinion, this block requires extensive training in regional anaesthesia, and although the complications are probably similar to other nerve blocks, it is difficult to predict its extension due to the spread of the anaesthetic in the paravertebral space. Finally, with respect to patient comfort, this technique has the disadvantage of being performed in an awake patient placed in the prone or lateral decubitus position. Being a deep block, it can be painful to perform, and many of the female patients have high levels of anxiety as a result of their oncological process.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The ESP block is a recent technique that raises questions that need to be explored in clinical studies. In breast surgery, we routinely use different, easy-to-perform nerve blocks with proven analgesic efficacy<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> and few complications. They require a short learning curve and are performed on the anaesthetised patient in the supine position. Based on our experience, we believe a simpler option for the case described by the authors, and one that would probably provide better analgesia is the serratus-intercostal fascial block at the level of the fourth rib (BRILMA) associated with an interpectoral block (PEC). Both are superficial blocks that are performed with a high-frequency linear transducer, after anaesthesia induction, with the patient in the supine position (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Martín MT, López Álvarez S. Bloqueos BRILMA y PEC: opciones más sencillas y adecuadas en cirugía radical de mama. Rev Esp Anestesiol Reanim. 2018;65:478–479.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 721 "Ancho" => 2000 "Tamanyo" => 123414 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Approach and ultrasound image of the BRILMA blockade.C4, 4th rib; AML, mid-axillary line; pl, pleura; sc, subcutaneous cellular tissue; serr, serratus muscle.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bloqueo en el plano del músculo erector de la columna para mastectomía radical: ¿una nueva indicación?" 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Parras Maldonado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2012.07.003" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2012" "volumen" => "59" "paginaInicial" => "470" "paginaFinal" => "475" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22939099" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000008/v1_201810100615/S2341192918301318/v1_201810100615/en/main.assets" "Apartado" => array:4 [ "identificador" => "70434" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000008/v1_201810100615/S2341192918301318/v1_201810100615/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301318?idApp=UINPBA00004N" ]
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