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Campos, J. Azevedo, L. Mendes, H. Rebelo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Campos" "email" => array:1 [ 0 => "martagcampos@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Azevedo" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Mendes" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "Rebelo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo de nervios pectorales como técnica anestésica única para cirugía mamaria con biopsia de ganglio centinela" ] ] "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" => 637 "Ancho" => 755 "Tamanyo" => 69336 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of PECs block II. SM: Serratus muscle; pm: pectoralis minor muscle; PM: pectoralis major muscle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer is the most common cause of malignancy in women, and its incidence has increased significantly in the last decade.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Surgery is the treatment of choice for this type of cancer, and is usually performed under general anesthesia or, more recently, combined with conventional regional techniques.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite possible complications and inherent technical difficulties, thoracic epidural or paravertebral blocks (TPVB) were initially the standard choice.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Nowadays, PECs block is the new standard approach for effective anesthesia and multimodal postoperative analgesia in breast surgery. Several studies have already demonstrated its advantage as a combined analgesic technique, but few have reported its use as the sole anesthetic technique. This ultrasound guided block is technically simple, easy to perform, and is associated with fewer complications.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> For these reasons, it is fast becoming the method of choice for perioperative pain management in breast surgery, particularly in enhanced recovery after surgery (ERAS) care pathways.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a patient with multiple severe comorbidities (ASA IV) scheduled for tumorectomy and sentinel lymph node investigation, in whom ultrasound guided PECS II block was successfully used as the sole anesthetic technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 56-year-old female, BMI 31<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, ASA IV, diagnosed with an invasive lobular carcinoma, was admitted for elective tumorectomy of the left upper quadrant of the right breast and sentinel lymph node investigation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The preoperative assessment revealed hemidystonia diagnosed in childhood, secondary to cerebral peripartum anoxia, type 2 diabetes mellitus, arterial hypertension, history of stroke, smoking, and with evidence of non-stratified COPD. The patient had a history of acute myocardial infarction, with heart failure grade III of NHYA and severe global systolic disfunction.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the multiple comorbidities and the high anesthetic-surgical risk, the anesthetic plan consisted of ultrasound guided PECS II block as the sole anesthetic technique.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After standard ASA monitoring (noninvasive blood pressure, pulse oximetry and continuous eletrocardiogram), and premedication with 1<span class="elsevierStyleHsp" style=""></span>mg of intravenous midazolam, the patient was placed in the supine position with the left upper limb in abduction. Supplementary oxygen was provided by nasal prongs (3<span class="elsevierStyleHsp" style=""></span>l/min). Under strict aseptic conditions, the linear ultrasound probe was initially placed below the lateral third of the left clavicle and moved distally and laterally toward the anterior axillary line, until the 3rd and 4th ribs were identified. The puncture site was infiltrated with 2% lidocaine (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A 22G needle was inserted in-plane, and 20<span class="elsevierStyleHsp" style=""></span>ml of 0.375% ropivacaine was injected between the anterior serratus and minor pectoral muscles. The needle was then switched to the interphascial plane between the major and minor pectoralis muscles, and 10<span class="elsevierStyleHsp" style=""></span>ml of 0.375% ropivacaine was injected to block the medial and lateral pectoral nerves.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Fifteen minutes after performing the block, the sensory blockade was assessed using the cold test. The patient only reported mild discomfort when the upper-medial region of the nipple was approached, requiring additional infiltration with 5<span class="elsevierStyleHsp" style=""></span>ml of 2% lidocaine.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Hemodynamic stability was maintained during the entire procedure (63<span class="elsevierStyleHsp" style=""></span>min), and the patient was then admitted to the post-anesthesia care unit, where she remained for 3<span class="elsevierStyleHsp" style=""></span>h, with no additional need for analgesia or antiemetic drugs. She was discharged after 4 days, with no anesthetic or surgical complications.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Breast surgery is associated with severe acute postoperative pain and restricted upper limb mobility. In this context, PECs block has often been described as a simple and effective technique for providing perioperative analgesia in breast cancer surgery, as an alternative to conventional regional techniques such as thoracic epidural and TPVB.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> In addition to the risks of pneumothorax, spinal cord trauma and sympathetic block, TPVB frequently provides inadequate analgesia because it does not block the medial and lateral pectoral nerves as effectively as it does the long thoracic and thoracodorsal nerves.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Wahba et al. found that patients undergoing PECs block had lower postoperative pain scores in the first 12<span class="elsevierStyleHsp" style=""></span>h and lower morphine consumption in the first 24<span class="elsevierStyleHsp" style=""></span>h compared to paravertebral block. This ultrasound guided PECs block is technically simpler, faster, with less risk of complications and high success rates, making it an excellent alternative to conventional techniques in breast surgery.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Type I PECs block was initially described in 2011 as an inter-connective block of the lateral and medial pectoral nerves, performed between major and minor pectoral muscles for analgesia in breast surgery.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> Subsequently, type II PECs block was described for more extensive surgeries with axillary and intercostal nerve block, essential for procedures such as tumorectomy, sentinel lymph node investigation or some types of mastectomy. In this block, the local anesthetic is injected between the anterior serrated and minor pectoral muscles, in order to block the lateral branches of some intercostal nerves (T2–T4), thoracic and thoracodorsal nerve.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Descriptions of PECs block as the sole anesthetic technique are scarce. The case presented here shows that it may also be an option in high risk cardiac patients, in whom general anesthesia or other blocks and their side effects should be avoided. In addition to sensory blockade and postoperative pain control, this block may reduce the risk of pulmonary and cardiovascular complications and hasten hospital discharge.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,6</span></a> The reduction in opioid consumption reduces the risk of postoperative nausea and vomiting and opioid-induced tumor progression through several mechanisms.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">During surgery, the patient only reported mild discomfort when the superomedial region, close to the nipple, was surgically manipulated, requiring local infiltration with lidocaine. According to the literature, there may be a need for anesthetic supplementation in this area, since this block may not cover the anterior parasternal branches of the intercostal nerves on the medial side.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9–11</span></a> Hong et al. suggest combining the technique with pecto-intercostal fascial block, in which local anesthetic is injected into the inter-connective plane between the major pectoral and the external intercostal muscles, where the anterior cutaneous branch emerges from the lateral side of the sternum.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">We believe that in selected high-risk patients such as ours, PECs block as the sole anesthetic technique may be a safe and advantageous alternative, providing sensory blockade with hemodynamic stability and few side effects. Nonetheless, more studies and randomized controlled trial are needed to confirm this hypothesis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">We have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1103963" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1044202" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1103964" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1044201" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-03" "fechaAceptado" => "2018-05-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1044202" "palabras" => array:5 [ 0 => "Pectoral nerves" 1 => "PECs block" 2 => "Breast surgery" 3 => "Regional anesthesia" 4 => "Ultrasonography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1044201" "palabras" => array:5 [ 0 => "Nervios pectorales" 1 => "Bloqueo PEC" 2 => "Cirugía del cáncer de mama" 3 => "Anestesia regional" 4 => "Ecografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Breast cancer surgery is usually performed under general anesthesia or, more recently, combined with conventional regional techniques. Pectoral nerves (PECs) block appears as an analgesic alternative in these procedures, but few studies refer to it as a single anesthetic technique.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–3</span></a></p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this case report, we describe a 56-year-old female patient, BMI 31<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, ASA IV, admitted for elective tumorectomy of the left upper quadrant of the breast and sentinel node investigation. Given the multiple comorbidities and the high anesthetic and surgical risk, the anesthetic plan consisted in ultrasound guided PECs II block as a single anesthetic technique.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The authors report a successful anesthetic and pain management without complications in breast surgery. PECs block, as a single anesthetic technique, may be safe, advantageous and effective with hemodynamic stability and few side effects in high risk cardiac patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La cirugía del cáncer de mama generalmente se realiza bajo anestesia general o, más recientemente, combinada con técnicas regionales convencionales. El bloqueo de los nervios pectorales (PEC) aparece como una alternativa analgésica en estos procedimientos, pero pocos estudios la denominan una técnica anestésica única<span class="elsevierStyleSup">1–3</span>.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En este informe de caso, describimos a una paciente de 56 años de edad, con un índice de masa corporal de 31<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, ASA IV, ingresada por tumorectomía electiva del cuadrante superior izquierdo de la mama y biopsia del ganglio centinela. Dadas las múltiples comorbilidades y el alto riesgo anestésico y quirúrgico, el plan anestésico consistió en bloqueo PEC II ecoguiado, como única técnica anestésica.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los autores informan del manejo exitoso de la anestesia y el dolor sin complicaciones en la cirugía de mamas. El bloqueo de los PEC, como técnica anestésica única, puede ser seguro, ventajoso y efectivo, con estabilidad hemodinámica y pocos efectos secundarios en pacientes cardiacos de alto riesgo.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Campos M, Azevedo J, Mendes L, Rebelo H. Bloqueo de nervios pectorales como técnica anestésica única para cirugía mamaria con biopsia de ganglio centinela. Rev Esp Anestesiol Reanim. 2018;65:534–536.</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" => 637 "Ancho" => 755 "Tamanyo" => 69336 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of PECs block II. 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