Original article
Radiological study to evaluate the spreading of two volumes (10 vs. 20ml) of radiological contrast in the block of cutaneous branches of intercostal nerves in medial axillary line (BRILMA) in a porcine experimental model
Estudio radiológico para evaluar la difusión de dos volúmenes (10 vs. 20ml) de contraste radiopaco en el bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar (BRILMA) en un modelo experimental porcino
O. Varelaa,
, A. Melonea, R. López-Menchacaa, R. Sevillaa, D. Callejoa, S. López-Álvarezb, A. Román Fernándezc, S. Garcíaa, I. Mantillaa, M. Zaballosa,d
Corresponding author
a Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
c Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario Universitario Álvaro Cunqueiro, Vigo, Spain
d Universidad Complutense de Madrid, Madrid, Spain
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Varela, A. Melone, R. López-Menchaca, R. Sevilla, D. Callejo, S. López-Álvarez, A. Román Fernández, S. García, I. Mantilla, M. Zaballos" "autores" => array:10 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "Varela" "email" => array:1 [ 0 => "olallava@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" => "A." "apellidos" => "Melone" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "López-Menchaca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "R." 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"apellidos" => "Mantilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "M." "apellidos" => "Zaballos" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario Universitario Álvaro Cunqueiro, Vigo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio radiológico para evaluar la difusión de dos volúmenes (10 vs. 20<span class="elsevierStyleHsp" style=""></span>ml) de contraste radiopaco en el bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar (BRILMA) en un modelo experimental porcino" ] ] "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" => 1174 "Ancho" => 1583 "Tamanyo" => 192502 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound image of the lateral wall of the thorax in the porcine model. 5C and 6C: 5th and 6th ribs; M. Intercost: external intercostal muscles; M. Serr: serratus anterior muscle. <span class="elsevierStyleSup">*</span>Radiopaque contrast deposited between the fascia of the serratus anterior muscle and the fascia of the external intercostal muscle. The arrows indicate the direction of the needle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The introduction of ultrasound-guided anaesthesiology techniques coupled with the interest in finding good quality, fast-track anaesthetic–analgesic approaches in breast surgery have led to the development of new interfascial thoracic wall blocks.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> Various new techniques have been described in the literature: interpectoral blocks<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2–6</span></a> (Pecs I and Pecs II), the serratus-intercostal fascial plane block (BRILMA),<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">7–10</span></a> the blockade of the anterior cutaneous branches of the intercostal nerves (BRCA), the serratus plane block,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> the erector spinae plane block (ESP),<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> and the rhomboid intercostal block.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">These blocks require a short learning curve and are both safe and effective when used in the right surgical procedure. Despite the limited number of studies, they are considered an effective, long-lasting (750–840<span class="elsevierStyleHsp" style=""></span>min)<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> analgesic strategy for surgery involving the breast,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> axilla, anterior chest wall and ribs, and even the upper abdominal wall<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> and are being accepted as an alternative to epidural and paravertebral blocks.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9,15–17</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">However, the real spread of the local anaesthetic in the different interfascial spaces in the foregoing blocks has never been accurately quantified. Earlier studies have evaluated the effectiveness of the BRILMA block and the technique used; however, little has been done to measure the direction and spread of the local anaesthetic after injection.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to compare the spread of two volumes (10 and 20<span class="elsevierStyleHsp" style=""></span>ml) of radiopaque contrast after performing BRILMA block in the mid axillary line in a live pig model.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The research study was approved by the animal ethics committee of the Gregorio Marañón University Hospital (reference PROEX 260/16), and all current EU and national recommendations for the care of experimental animals were followed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was performed in 10 Large White pigs. All the animals were premedicated with 20<span class="elsevierStyleHsp" style=""></span>mg/kg ketamine (Ketolar, PFIZER GEP S.L.). Anaesthesia was induced with 5<span class="elsevierStyleHsp" style=""></span>mg/kg sodium thiopental (Tiobarbital Braun, B. Braun Medical S.A.) administered through an auricular vein catheter. Following this, the animal was intubated using a straight blade laryngoscope without the use of muscle relaxants. Animals were mechanically ventilated with 100% oxygen, and minute volume was adjusted to maintain a partial pressure of exhaled CO<span class="elsevierStyleInf">2</span> of around 35–40<span class="elsevierStyleHsp" style=""></span>mmHg (Heinen & Löwenstein Leon Anaesthesia Workstation, Direx SL, Germany). During the procedure, all animals were given 2 – 5<span class="elsevierStyleHsp" style=""></span>ml/kg/h 0.9% saline for fluid management. Anaesthesia was maintained with sevoflurane 2.6%, the equivalent of 1 MAC for the animal model used.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> Monitoring consisted of peripheral oxygen saturation (SpO<span class="elsevierStyleInf">2</span>), expired CO<span class="elsevierStyleInf">2</span> and electrocardiogram (LABSYSTEM, polygraph LABSYSTEM PRO 40 channels [BARD<span class="elsevierStyleSup">®</span> LS8900 Workstation]). A femoral artery catheter was placed under ultrasound guidance (Vivid S5 GE Healthcare, Wauwatosa, USA) to monitor blood pressure, haemodynamic status and to draw arterial blood for blood gas analyses.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Once the animal had been prepared for surgery, it was placed in the supine position and the ultrasound-guided BRILMA bilateral nerve block was performed using a linear transducer (6–12<span class="elsevierStyleHsp" style=""></span>mHz). An echogenic needle (22G-50<span class="elsevierStyleHsp" style=""></span>mm Stimuplex B. Braun<span class="elsevierStyleSup">®</span>) was inserted in plane at a distance of 1<span class="elsevierStyleHsp" style=""></span>cm from the transducer, along the midaxillary line, in a craniocaudal direction, at the level of the animal's first teat. The following structures were visualised at all times during the procedure: the pleura, the 4th and 5th ribs, the intercostal muscles, the serratus anterior muscle and the subcutaneous cellular tissue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Two different volumes of iopamiro<span class="elsevierStyleSup">®</span> 370<span class="elsevierStyleHsp" style=""></span>mg/ml radiopaque contrast agent (Bracco Imaging S.P.A.) were injected into the interfascial space between the serratus anterior muscle and the external intercostal muscle in each hemithorax to observe the spread of the agent: 10<span class="elsevierStyleHsp" style=""></span>ml contrast in the left hemithorax and 20<span class="elsevierStyleHsp" style=""></span>ml in the right. The blockade was always performed by the same operator; the agent was injected at a steady rate of 1<span class="elsevierStyleHsp" style=""></span>ml/s, which was timed by another researcher using a chronometer. The spread of contrast was quantified using fluoroscopy and recorded for subsequent analysis by three investigators independently. The agent was considered to have spread to one intercostal space if it was observed between the lower edge of the upper rib and the upper edge of the lower rib.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA). Values are represented as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation. The Spearman correlation test was used to evaluate the radiological volume/spread ratio. Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Sample size calculation</span><p id="par0050" class="elsevierStylePara elsevierViewall">Accepting an alpha risk of 0.05 and a beta risk of 0.2 for a two-tailed test, seven blocks were required in each hemithorax to detect a difference equal to or greater than 0.7 spaces between both hemithorax. To compensate for losses, this was increased to 10 blocks in each hemithorax.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Twenty blocks were performed, 10 in each hemithorax. In two animals, the quality of the image was too poor to correctly quantify the spread after administration of 10<span class="elsevierStyleHsp" style=""></span>ml contrast, so they were excluded from the statistical analysis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">All the animals remained haemodynamically stable with no ventilatory alterations throughout the procedure, and the injection of the contrast caused no remarkable changes.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the 18 cases included and evaluated, as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, we observed that administration of 10<span class="elsevierStyleHsp" style=""></span>ml was associated with an average spread of 2.28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.31 (95% CI: 2.01–2.54) intercostal spaces, and 20<span class="elsevierStyleHsp" style=""></span>ml was associated with a spread of 3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.25 (95% CI: 2.81–3.18) intercostal spaces. There was a statistically significant correlation between the injected volume and the spread of the contrast (Spearman's rank correlation coefficient of 0.81; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The main finding of this study is that the spread of radioopaque contrast during BRILMA block in the pig model used was proportional to the volume injected, albeit not in a 1:1 ratio. In other words, double the volume of contrast only increased the number of segments blocked by 31% (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The ratio of volume administered to extent of spread in interfascial blocks of the thoracic wall has rarely been evaluated in the literature. The extent of the interfascial blockade in both healthy volunteers and cadaver models has been evaluated in previous studies with different objectives.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Blanco et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> used nuclear magnetic resonance imaging (MRI) to compare the anatomical spread of local anaesthetic during superficial and deep serratus plane block. In their study, the authors injected 0.4<span class="elsevierStyleHsp" style=""></span>ml/kg levobupivacaine 0.125%<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0.1<span class="elsevierStyleHsp" style=""></span>ml/kg gadolinium in four healthy volunteers and observed that the spread was more posterior in the superficial block. In all four patients and in all planes, the area of paresthesia in the superficial block extended from T2 to T8–9, although this varied slightly in the anterior, lateral and posterior planes. In the deep block, the spread also extended from T2 in all patients and in all planes, although caudal spread was more restricted, especially when paraesthesia was evaluated in the anterior plane, where it only reached T5–T6. Note that considering the weight of the patients, the volume administered ranged from 19 to 29<span class="elsevierStyleHsp" style=""></span>ml. Bearing in mind the different models used—humans in the case of Blanco et al. and the porcine model used in our study—the differences in the spread of the injectate could be due, among other things, to the different volumes used. Likewise, the objectives differed: our aim was to evaluate the difference in spread between two volumes of injectate, while Blanco et al. analysed the metameric limit of spread of two different serratus plane blocks using the same volume of local anaesthetic.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Daga et al.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> evaluated the spread of 20<span class="elsevierStyleHsp" style=""></span>ml of saline solution, 8<span class="elsevierStyleHsp" style=""></span>ml of water and 2<span class="elsevierStyleHsp" style=""></span>ml of air in seven cadaver models receiving anterior serratus plane block. Using ultrasound, the authors observed less cephalad spread, only as far as T3 and T4, than Blanco et al. and suggested that this could be due to differences in the evaluation methods: actual dermatomal spread in a clinical setting may be greater than that visualised with ultrasound. Other factors that can justify the differences between these and our findings are the different volume injected, use of a cadaver model versus human volunteer, the injection technique, the rate of administration, and the needle used, among others. We used less volume that Daga et al. in both blocks, although other factors, such as the type of needle, the rate of administration, and the technique used were the same. The extent of spread was also more restricted, which is consistent with the lower volume administered. Other considerations, such as the composition of the liquid administered (saline vs. water soluble iodine contrast), could have influenced the differences observed.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Mayes et al.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> compared the spread of 20<span class="elsevierStyleHsp" style=""></span>ml of methylene blue (to evaluate the upper limit of spread) and 20<span class="elsevierStyleHsp" style=""></span>ml of latex in the contralateral hemithorax (to evaluate the lower limit of spread), respectively, after performing an anterior serratus plane block in six embalmed cadavers. They observed that lateral cutaneous branches of the intercostal nerves contained dye and latex in all cases, but the intercostal nerves contained methylene blue but not latex in three cases. However, as the authors did not describe the anatomical craniocaudal spread, we cannot compare their results with ours.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Alfaro de la Torre et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> evaluated the anatomical spread of 20<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic after performing an anterior intercostal serratus plane block in 34 patients and noted a metameric spread from T1 to T3. They performed MRI in five of these patients and observed axillary uptake in all cases. In the same study, the authors analysed axillary propagation of 20<span class="elsevierStyleHsp" style=""></span>ml of methylene blue after performing an anterior intercostal serratus block in nine embalmed cadavers. They performed anatomical dissection and observed the presence of methylene blue at the axillary level in all cases. Although this study differs from ours in terms of approach and experimental model, it coincides with our findings in terms of the metameric spread of 20<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic across three intercostal spaces.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In clinical practice, interfascial nerve blocks are associated with the administration of large volumes of local anaesthetic in order to achieve a “large bolus” in a plane where there is relatively little vascularisation. Clinical studies in thoracic interfascial nerve blocks generally use between 15 and 30<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">7,13,18–21</span></a> When performing local anaesthetic techniques, the aim is to achieve effective analgesia for the particular procedure while avoiding the toxicity associated with the administration of a large volume of anaesthetic. Therefore, studies such as ours contribute to our understanding of these relatively novel nerve blocks and clarify some uncertainties surrounding interfascial thoracic blocks.</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Limitations</span><p id="par0105" class="elsevierStylePara elsevierViewall">Although the anatomy of the chest wall of the pig is very similar to that of humans, care should be taken when extrapolating the results of a porcine model to clinical practice in humans. Another limitation concerns the nerve block technique used in our study, which consisted of a single puncture to inject the entire volume at the same point. In normal clinical practice in humans, the tip of the needle is usually re-positioned several times to ensure the spread of the local anaesthetics to the upper intercostal spaces.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> We cannot know whether re-positioning the needle would have resulted in a greater spread of the injectate. Finally, we cannot say with certainty that there are no relevant differences in spread of a volume of radiological contrast versus an identical volume of local anaesthetic. However, we believe that these differences, if they exist, would be minor, due to our use of a water-soluble contrast agent. Nevertheless, exactly the same solution was injected in both hemithoraces, so the differences in spread observed on both sides is due to the differences in volume and not the composition of the injectate.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Within the limits inherent to research using animal models, the results of our study show a statistically significant correlation, though not a 1:1 ratio, between the volume injected and the spread of the contrast. Doubling the volume only increased the number of blocked segments by 31%. Transferring these findings to clinical practice would have important repercussions, since it would allow anaesthesiologists to achieve the same results with smaller volumes of local anaesthetic, which would increase the safety of the technique by reducing the risk of toxicity.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">This study has been funded by a grant awarded by Carlos III Health Institute in 2015.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no potential conflicts of interest related to the contents of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1092837" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 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" => "xpalclavsec1035697" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1092838" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 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" => "xpalclavsec1035696" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Sample size calculation" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "sec0025" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-04" "fechaAceptado" => "2018-05-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035697" "palabras" => array:5 [ 0 => "Interfascial blocks of the thoracic wall" 1 => "Block of cutaneous branches of intercostal nerves in medial axillary line" 2 => "Extension of the local anaesthetic" 3 => "Blocks in breast surgery" 4 => "Regional anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1035696" "palabras" => array:5 [ 0 => "Bloqueos interfasciales torácicos" 1 => "Bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar" 2 => "Dispersión del anestésico local" 3 => "Bloqueos de mama" 4 => "Anestesia regional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Interfascial blocks of the thoracic wall are being developed as an alternative to central blocks in breast surgery. However, there are few studies that have evaluated the anatomical extension of the local anaesthetic. The objective of this study was to analyse, using fluoroscopy, the spreading of two volumes (10 vs. 20<span class="elsevierStyleHsp" style=""></span>ml) of radiological contrast in the serratus-intercostal plane block in an experimental pig model.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ten Large-White breed pigs were selected to have a bilateral ultrasound serratus-intercostal plane block performed, with the administering of 10 and 20<span class="elsevierStyleHsp" style=""></span>ml of iopamidol in the right and left hemithorax, respectively. The spreading of contrast was analysed by fluoroscopy. The Spearman test correlation was used to evaluate the relationship between the administered volume and radiological spreading. A value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 was considered significant.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty anaesthetic blocks were performed, being able to analyse 18 of them. The administration of 10<span class="elsevierStyleHsp" style=""></span>ml of contrast was associated with a mean spreading of 2.28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.31 (95% CI: 2.01–2.54) intercostal spaces, while the administration of 20<span class="elsevierStyleHsp" style=""></span>ml showed a spreading of 3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.25 (95% CI: 2.81–3.18) intercostal spaces. There was a significant correlation between the injected volume and the spreading of the contrast (Spearman correlation coefficient of 0.81; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0001).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The results showed a spreading of volume subject to the serratus-intercostal plane block, although not maintaining a 1:1 ratio. Doubling the volume increased the blocked segments by 31%. These findings, if corroborated in the clinical practice, would allow a more precise adjustment in the anaesthetic volume administered.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 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">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los bloqueos interfasciales de la pared torácica se están desarrollando como alternativa a los bloqueos centrales en la cirugía de mama. Sin embargo, existen escasos estudios que hayan evaluado la extensión anatómica del anestésico local. Nuestro objetivo fue analizar, mediante fluoroscopia, la difusión de dos volúmenes (10 vs. 20<span class="elsevierStyleHsp" style=""></span>ml) de contraste radiopaco (iopamidol) en el bloqueo del plano serrato-intercostal (BRILMA) en un modelo experimental porcino.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se seleccionaron 10 cerdos de la raza Large-White a los que se realizó un bloqueo BRILMA ecoguiado bilateral, administrando 10 y 20<span class="elsevierStyleHsp" style=""></span>ml de iopamidol en hemitórax izquierdo y derecho, respectivamente. La difusión del contraste se analizó por fluoroscopia. Se utilizó el test de correlación de Spearman para evaluar la relación entre el volumen administrado y la difusión radiológica. Se consideró significativo un valour de <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realizaron 20 bloqueos, pudiéndose analizar 18. La administración de 10<span class="elsevierStyleHsp" style=""></span>ml de contraste se asoció con una difusión media de 2,28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0,31 espacios (IC 95%: 2,01–2,54), mientras que la administración de 20<span class="elsevierStyleHsp" style=""></span>ml mostró una difusión de 3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0,25 espacios (IC 95%: 2,81–3,18). Hubo una correlación significativa entre el volumen inyectado y la difusión del contraste (coeficiente de correlación de Spearman de 0,81; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,0001).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados demuestran una difusión dependiente del volumen en el bloqueo BRILMA, aunque sin guardar una relación 1:1. Duplicar el volumen ha incrementado en un 31% los segmentos bloqueados. Estos hallazgos, si se corroboran en la práctica clínica, permitirían un ajuste más preciso en el volumen de anestésico administrado.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 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: Varela O, Melone A, López-Menchaca R, Sevilla R, Callejo D, López-Álvarez S, et al. Estudio radiológico para evaluar la difusión de dos volúmenes (10 vs. 20<span class="elsevierStyleHsp" style=""></span>ml) de contraste radiopaco en el bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar (BRILMA) en un modelo experimental porcino. Rev Esp Anestesiol Reanim. 2018;65:441–446.</p>" ] ] "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" => 1174 "Ancho" => 1583 "Tamanyo" => 192502 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound image of the lateral wall of the thorax in the porcine model. 5C and 6C: 5th and 6th ribs; M. Intercost: external intercostal muscles; M. Serr: serratus anterior muscle. <span class="elsevierStyleSup">*</span>Radiopaque contrast deposited between the fascia of the serratus anterior muscle and the fascia of the external intercostal muscle. The arrows indicate the direction of the needle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 638 "Ancho" => 1500 "Tamanyo" => 88726 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Radiological image of the administration of 10<span class="elsevierStyleHsp" style=""></span>ml (left hemithorax) and 20<span class="elsevierStyleHsp" style=""></span>ml (right hemithorax) of iodinated contrast. In the left hemithorax, the contrast has spread across two intercostal spaces. 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