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Serratus-intercostal interfascial block as an opioid-saving strategy in supra-umbilical open surgery
Bloqueo interfascial serrato-intercostal como estrategia ahorradora de opioides en cirugía supraumbilical abierta
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Estudio de reclasificación" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1649 "Ancho" => 2158 "Tamanyo" => 182647 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ROC curve for selected model (APACHE II<span class="elsevierStyleInf">CCP</span>) in multivariate logistic regression analysis (AROC 0.91; 95% CI 0.87–0.94; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001), and ROC curve for general APACHE II (AROC 0.62; 95% CI 0.54–0.70; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002). Scored area depicts the increase in AROC. AROC, area under receiver-operating characteristic curve; APACHE, Acute Physiology and Chronic Health Evaluation; APACHE II<span class="elsevierStyleInf">CCP</span>, APACHE II for critically ill patients with a solid tumor; CI, confidence interval; ROC, receiver-operating characteristic.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F.D. Martos-Benítez, I. Cordero-Escobar, A. Soto-García, I. Betancourt-Plaza, I. González-Martínez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "F.D." "apellidos" => "Martos-Benítez" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Cordero-Escobar" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Soto-García" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Betancourt-Plaza" ] 4 => array:2 [ "nombre" => "I." 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Fernández Martín, S. López Álvarez, M.A. Pérez Herrero" "autores" => array:3 [ 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" ] ] ] 2 => array:3 [ "nombre" => "M.A." "apellidos" => "Pérez Herrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Medina del Campo, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Abente y Lago, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo interfascial serrato-intercostal como estrategia ahorradora de opioides en cirugía supraumbilical abierta" ] ] "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" => 608 "Ancho" => 2500 "Tamanyo" => 107389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolution of postoperative pain. The bar chart shows the range of pain scores reported by most patients. Dispersal is shown by dots and lines, and the mean NRS scores in each group are shown by a cross.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Good postoperative pain management is one of the most important perioperative strategies to maximise recovery and reduce complications and mortality in abdominal surgery. In this context, laparoscopic techniques help reduce surgical stress in a large number of abdominal procedures, making them ideal for multimodal enhanced recovery programmes.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> However, technical problems or intra-operative complications sometime call for conversion from laparoscopic to open surgery. These unplanned incisions (subcostal incision, midline laparotomy) cause moderate to intense postoperative pain, and in these situations anaesthesiologists must find an effective technique that can give adequate pain relief without delaying functional recovery.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The anterior abdominal wall is mainly innervated by the last intercostal nerves,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> so a nerve blockade at this level should provide sufficient analgesia to prevent somatic pain. Previous studies have shown the effectiveness of blocking the cutaneous branches of the intercostal nerves in the mid-axillary line (BRILMA or serratus-intercostal fascial block) in non-reconstructive breast surgery.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Our group obtained satisfactory postoperative analgesia outcomes in patients undergoing open cholecystectomy with a modified BRILMA blockade, in which the local anaesthetic was deposited in the same interfascial plane but at the level of T7–T11 (modified BRILMA).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this study, we analyse whether the administration of local anaesthetic in the interfascial space between the anterior serratus and external intercostal muscle at the level of the eighth rib is an effective opioid-saving technique that provides good acute postoperative pain control and facilitates recovery in multimodal open abdominal surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This prospective observational study was approved by the hospital's research ethics committee (no. PI-16-354) and was conducted between August 2015 and October 2017. We studied patients scheduled for upper abdominal surgery with subcostal incision or supraumbilical midline laparotomy under general anaesthesia combined with modified BRILMA nerve block. All patients included in the study signed an informed consent for general and regional anaesthesia. Inclusion criteria were age ≥18 years, open upper abdominal surgery, and the ability to assess pain using a verbal numerical rating scales (NRS). The exclusion criteria were no informed consent for regional anaesthesia, allergy to local anaesthetics, or contraindication for regional anaesthesia on the basis of a coagulation study.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We collected demographic data (age, sex), comorbidity (ASA physical status), premedication, and intra-operative use of opioids. In the operating room, all patients were monitored with a five-lead electrocardiogram, non-invasive blood pressure, peripheral oxygen saturation, and depth of anaesthesia using a bispectral index monitor (BIS, A-200™ version 3.4, Aspect Medical System, Inc., Norwood, USA). Patients were premedicated with 0.03<span class="elsevierStyleHsp" style=""></span>mg/kg midazolam, and general anaesthesia was induced with fentanyl and propofol. Hypnosis was maintained with MAC I sevoflurane with a target BIS of between 40 and 60, and rocuronium was given for muscle relaxation. Four milligrams of ondansetron were administered 10<span class="elsevierStyleHsp" style=""></span>min before the end of surgery. Eight milligrams of preincisional dexamethasone were included in the multimodal analgesic protocol. Intra-operative fentanyl was administered on demand, taking as a reference the variations in the autonomic responses, to maintain an adequate depth of hypnosis (BIS value not higher than 60), giving 100<span class="elsevierStyleHsp" style=""></span>μg boluses of fentanyl when haemodynamic parameters increased more than 20% over baseline. In the postoperative period, 50<span class="elsevierStyleHsp" style=""></span>mg of dexketopropofen were given every 8<span class="elsevierStyleHsp" style=""></span>h and 1<span class="elsevierStyleHsp" style=""></span>g of paracetamol every 6<span class="elsevierStyleHsp" style=""></span>h. Analgesic rescue consisted of 2-mg boluses of intravenous morphine chloride when pain was rated higher than 3 on the NRS.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to intravenous analgesia, all study patients received ultrasound-guided (portable M-Turbo, Sonosite<span class="elsevierStyleSup">®</span>, Bothell, WA, USA) modified BRILMA nerve block using a high-frequency 6–15<span class="elsevierStyleHsp" style=""></span>Hz linear probe and an 80<span class="elsevierStyleHsp" style=""></span>mm Ultraplex<span class="elsevierStyleSup">®</span> 360 needle (B. Braun<span class="elsevierStyleSup">®</span>, Germany). With the patient in the supine position, the transducer was placed in the sagittal plane of the mid-axillary line to identify the fascial plane between the serratus anterior muscle and the external intercostal muscle. The needle was inserted in a caudal to cephalad direction at the level of the eighth rib, and 3<span class="elsevierStyleHsp" style=""></span>ml of levobupovacaine 0.25% was administered for each target dermatome (Annex available online). The timing of the nerve was determined by the procedure performed, thus when laparoscopic surgery was converted to open surgery, the blockade was performed at the end of the surgery, after anaesthetic education; in the case of abdominal wall surgery (eventroplasties), the blockade was performed bilaterally before surgery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main postoperative variable evaluated was the difference in at-rest and on-movement pain (cough, deep breathing, movement) on arrival at the post-anaesthesia recovery unit (PACU). Pain was rated on the NRS from 0 (no pain) to 10 (the worst pain imaginable) at 6, 12, 24, and 48 postoperative hours. The evaluation was performed by anaesthesiologists and nurses trained in the use of pain assessment scales. We also recorded the need for rescue analgesia (number of boluses and total intravenous morphine chloride), analgesia-induced adverse events (hypotension, nausea, vomiting, sedation) and complications related to the regional technique.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The statistical analysis was performed on SPSS<span class="elsevierStyleSup">®</span> for Windows, version 21. The Shapiro–Williams test was used to determine the normality of the data. Normally distributed variables were analysed using the Student's <span class="elsevierStyleItalic">t</span>-test for paired samples, and non-normally distributed variables were analysed using the Wilcoxon signed-rank test. The results are presented as measures of central tendency (mean) and dispersion (standard deviation). The level of statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fifty-two patients were included in the study. In 41 cases, laparoscopy was converted to open surgery, and the blockade was administered at the end of the procedure (33 cholecystectomies, 4 nephrectomies, and 4 gastrectomies), and 11 patients underwent abdominal wall repair (eventroplasty) and received bilateral blockade prior to the surgical incision. Patient demographics, ASA status, and type of surgical procedure are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Significant differences (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) in intra-operative opioid consumption (fentanyl) were observed between patients with pre-incision nerve block (110<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>g) vs. end-of-surgery block (400<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>g).</p><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the at-rest and dynamic postoperative pain scores for the different procedures. The graph shows a similar trend in NRS scores in patients who received unilateral block (cholecystectomies and nephrectomies), while in patients who received bilateral blockade (gastrectomies and eventroplasties), there was a tendency towards higher NRS scores for dynamic pain in patients undergoing gastrectomy, particularly at 24 postoperative hours.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Analysing the data by the type of surgery shows that most patients reported adequate pain control (NRS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>3). Patients undergoing eventroplasty and nephrectomy did not require any analgesic rescue, and pain on the NRS was rated at around 0 at 48 postoperative hours. In the cholecystectomy group, 94% reported an NRS score of <3. Two patients required rescue analgesia: 1 at 24<span class="elsevierStyleHsp" style=""></span>h (2<span class="elsevierStyleHsp" style=""></span>mg iv morphine) and the other at 48<span class="elsevierStyleHsp" style=""></span>h (several boluses of morphine: total dose of 6<span class="elsevierStyleHsp" style=""></span>mg). After this, pain was adequately controlled using the analgesia regimen. Patients undergoing gastrectomy reported higher pain scores: in the first 24<span class="elsevierStyleHsp" style=""></span>h, 50% (two of four) required rescue analgesia (2<span class="elsevierStyleHsp" style=""></span>mg bolus of morphine) and at 48<span class="elsevierStyleHsp" style=""></span>h, 75% reported high pain scores (NRS 5<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2) and required further rescue analgesia (8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mg morphine).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The most notable adverse effect was postoperative nausea and/or vomiting, which was observed in four patients. This complication was unrelated to the administration of morphine and was treated with ondansetron 4<span class="elsevierStyleHsp" style=""></span>mg. No cases of excessive sedation or analgesia-induced complications were observed.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The administration of local anaesthetic in the serratus-intercostal fascial space anaesthetises several intercostal nerves with a single shot. This has been shown to reduce the incidence of pulmonary complications and opioid requirements in breast surgery<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> and<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> open cholecystectomy.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Scientific evidence supports the use of multimodal analgesic strategies designed to speed up recovery and avoid complications, particularly in procedures such as midline laparotomy or subcostal incision, which cause moderate to intense pain.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Thoracic epidural remains the standard analgesic technique in open abdominal surgery, although it is not without its complications and limitations. However, since they were introduced into clinical practice, thoracic and abdominal fascial blocks have been part of this analgesic strategy and are a good alternative to epidural anaesthesia. In addition, recent studies have shown that in breast surgery, in which paravertebral block is the standard technique, BRILMA produces similar postoperative outcomes.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study shows that modified BRILMA could be a useful analgesic technique and a good opioid-saving alternative to thoracic epidural in a multimodal approach to supraumbilical open abdominal surgery.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Comparing our data with those of studies using other analgesic strategies,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7,8</span></a> we observed lower morphine consumption, to the extent that opioid doses in open surgery were comparable to those used in laparoscopic procedures. There are two possible explanations for this: the multimodal strategy used in the studies is not comparable; or fewer opioids are used in supraumbilical surgery because intercostal nerves T7–11, which are mainly responsible for the somatic innervation of the abdominal wall, are blocked.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The effectiveness of other interfascial blocks in abdominal surgery is controversial. One example is the transversus abdominis plane block. This technique has given good results in infraumbilical surgery, but the results obtained in supraumbilical surgery are conflicting,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9–12</span></a> a situation that has raised concerns about the maximum cephalad reach of this nerve block. New approaches aimed at achieving a higher level of blockade have been described, such as the subcostal (Hebbard et al.),<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> lumbar quadratus, or transversalis fascia<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> block, but results have been inconclusive.</p><p id="par0095" class="elsevierStylePara elsevierViewall">There are very important limitations to the conclusions that can be drawn from our study. First, it is an observational study. Second, it compares various surgical techniques without taking into account other factors that could influence postoperative pain (chronic pain, opioid use, duration of surgery). Third, the importance of the visceral component relative to the type of procedure was not taken into consideration. Finally, the sample size is small. For all these reasons, multicentre, randomised, standardised studies with a high statistical power are needed before this analgesic technique can be considered optimal in open supraumbilical surgery.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Our results confirm that considerable opioid savings are achieved in surgeries involving a subcostal incision. However, due to the small sample size and the results obtained, our results in midline laparotomy should be viewed with caution, because although pain management was adequate after eventroplasty, it was suboptimal after gastrectomy.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion, blockade of the intercostal nerves (T7–T11) in the serratus-intercostal space (modified BRILMA) could be a useful alternative to epidural analgesia in open supraumbilical abdominal surgery. Although the results in gastrectomy are suboptimal, we have shown that in the context of a multimodal strategy, this blockade allows significant opioid savings in hernia, nephrectomy, and cholecystectomy.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1092848" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1035703" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1092847" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1035704" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack371307" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-21" "fechaAceptado" => "2018-03-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035703" "palabras" => array:5 [ 0 => "Ultrasound-guided serratus-intercostal interfascial block" 1 => "Opioid" 2 => "Multimodal analgesia" 3 => "Post-operative pain" 4 => "Open supra-umbilical surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1035704" "palabras" => array:5 [ 0 => "Bloqueo interfascial serrato-intercostal ecoguiado" 1 => "Opioides" 2 => "Analgesia multimodal" 3 => "Dolor postoperatorio" 4 => "Cirugía abierta supraumbilical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The administration of local anaesthetic in the serratus-intercostal space provides adequate analgesia in non-reconstructive breast surgery. The aim of this study was to evaluate whether the blockage of the last intercostal nerves (T7–T11) can lead to opioid savings in supra-umbilical open surgery procedures.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was conducted on patients undergoing open supra-umbilical surgery under general anaesthesia and with a serratus-intercostal plane block [modified Blocking the bRanches of IntercostaL nerves in the Middle Axillary line (BRILMA)] as an associated analgesic strategy. Post-operative pain was assessed with the numerical verbal scale (NVS 0–10) on admission to the post-anaesthesia recovery unit, at 6, 12, 24, and 48<span class="elsevierStyleHsp" style=""></span>h post-intervention and by need for analgesic rescues with opioids (2<span class="elsevierStyleHsp" style=""></span>mg iv of morphine, if values higher than 3 in NVS). Adverse events related to the technique were also recorded. The statistical package used in the analysis of the data was SPSS<span class="elsevierStyleSup">®</span> for Windows.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study recruited 52 patients. Differences, with a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05, were found intra-operatively in the consumption of fentanyl: 400<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>μg versus 110<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>μg in patients who underwent pre-incisional blockade. In the first 24<span class="elsevierStyleHsp" style=""></span>h, only three cases (two gastrectomies and one cholecystectomy) required morphine (single bolus of 2<span class="elsevierStyleHsp" style=""></span>mg). Between 24 and 48<span class="elsevierStyleHsp" style=""></span>h, it was necessary to administer several morphine boluses (8<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mg) in four patients (three gastrectomies and one cholecystectomy). Four patients presented with nausea and/or vomiting and there were no complications related to the analgesic technique.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The intercostal nerves block (T7–T11) in the serratus-intercostal space may constitute an opioid-sparing analgesic strategy in open supra-umbilical surgery.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La administración de anestésico local en el espacio serrato-intercostal (BRILMA) proporciona analgesia adecuada en cirugía no reconstructiva de mama. Nuestro objetivo ha sido evaluar si el bloqueo de los últimos nervios intercostales (T7-T11) puede permitir un ahorro de opioides en procedimientos de cirugía abierta supraumbilical.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo de pacientes sometidos a cirugía supraumbilical abierta bajo anestesia general y bloqueo del plano serrato-intercostal (BRILMA modificado) como estrategia analgésica asociada. El dolor postoperatorio se valoró mediante la escala verbal numérica (EVN 0 a 10) al ingreso en la unidad de recuperación postanestésica, a las 6, 12, 24 y 48<span class="elsevierStyleHsp" style=""></span>h postintervención y mediante la necesidad de rescates analgésicos con opioides (2<span class="elsevierStyleHsp" style=""></span>mg iv de morfina si los valores eran superiores a 3 en EVN). También se registraron los eventos adversos relacionados con la técnica. El paquete estadístico aplicado fue SPSS® para Windows en el análisis de los datos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El estudio reclutó 52 pacientes. Intraoperatoriamente, con p <0,05, se han encontrado diferencias en el consumo de fentanilo: 400 ± 80<span class="elsevierStyleHsp" style=""></span>μg versus 110 ± 50<span class="elsevierStyleHsp" style=""></span>μg en pacientes a los que se realizó el bloqueo preincisional. En las primeras 24<span class="elsevierStyleHsp" style=""></span>h solo tres casos (dos gastrectomías y una colecistectomía) precisaron morfina (bolo único de 2<span class="elsevierStyleHsp" style=""></span>mg). Entre las 24<span class="elsevierStyleHsp" style=""></span>h y 48<span class="elsevierStyleHsp" style=""></span>h fue necesario administrar varios bolos de morfina (8 ± 2<span class="elsevierStyleHsp" style=""></span>mg) en cuatro pacientes (tres gastrectomías y una colecistectomía). Presentaron náuseas y/o vómitos cuatro pacientes y no hubo complicaciones relacionadas con la técnica analgésica.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El bloqueo de los nervios intercostales (T7-T11) en el espacio serrato-intercostal puede constituir una estrategia analgésica ahorradora de opioides en cirugía abierta supraumbilical.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Martín MT, López Álvarez S, Pérez Herrero MA. Bloqueo interfascial serrato-intercostal como estrategia ahorradora de opioides en cirugía supraumbilical abierta. Rev Esp Anestesiol Reanim. 2018;65:456–460.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0125" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 608 "Ancho" => 2500 "Tamanyo" => 107389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolution of postoperative pain. The bar chart shows the range of pain scores reported by most patients. Dispersal is shown by dots and lines, and the mean NRS scores in each group are shown by a cross.</p>" ] ] 1 => 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:1 [ "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex (man/woman)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23/29 \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="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.99 \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="elsevierStyleItalic">Physical status (ASA I/II/III/IV)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18/22/12/0 \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"><span class="elsevierStyleItalic">Type of procedure</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cholecystectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \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="elsevierStyleHsp" style=""></span>Nephrectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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"><span class="elsevierStyleHsp" style=""></span>Ventral hernia repair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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"><span class="elsevierStyleHsp" style=""></span>Gastrectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1868925.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">General data.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 216841 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Grupo de Trabajo. 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