Analgesic efficacy of modified pectoral block plus serratus plane block in breast augmentation surgery: A randomised, controlled, triple-blind clinical trial | Revista Española de Anestesiología y Reanimación (English Edition)

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"apellidos" => "Cubero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, QuironSalud Hospital Universitari General de Catalunya e Hypnos S.L.P., Sant Cugat del Vallès, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic de Barcelona, Departamento de Anatomía Humana, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología Intervencionista, Invenciones Tecnológicas en Medicina (INTEM), QuironSalud Hospital Universitari General de Catalunya, Sant Cugat del Vallès, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sección de Estadística, Facultad de Biología, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eficacia analgésica del bloqueo pectoral modificado más bloqueo del plano del serrato en mamoplastia subpectoral: ensayo clínico, controlado, aleatorizado, triple ciego" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2229 "Ancho" => 2084 "Tamanyo" => 180295 ] ] "descripcion" => array:1 [ "en" => "Box-plot showing verbal reporting scale (VRS) scores obtained at 3, 6 and 24 postoperative hours at rest and on passive and active movement of the extremity in each group. GC: control group; GPEC: treatment group." ] ] ] "textoCompleto" => "IntroductionCosmetic breast surgery is the most common plastic surgery procedure performed in the United States. The management of postoperative pain is a challenge for the surgical team. Treatment, which usually consists of intravenous or oral opioids, is sometimes ineffective, and it is also important to remember that opioids are not free of side effects, such as nausea and vomiting, which can lead to suture dehiscence and bruising.<a class="elsevierStyleCrossRef" href="#bib0215">1</a> In addition, manipulation of the pectoral muscle during retropectoral prosthesis insertion can cause painful muscle spasms. Alternative pain management methods based on afferent nerve blocks have recently been described in breast surgery, although their efficacy in retropectoral breast augmentation has not been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0220">2</a>The innervation of the breast is complex, being supplied by multiple nerve branches.<a class="elsevierStyleCrossRef" href="#bib0225">3</a> The deep fascia on which the mammary gland lies, a space known as the retromammary bursa or Chassaignac's bursa,<a class="elsevierStyleCrossRef" href="#bib0225">3</a> receives afferents from the lateral and medial pectoral nerves, which supply motor innervation to the pectoral muscles. These motor nerves supply sensory innervation to the aforementioned fascia.<a class="elsevierStyleCrossRefs" href="#bib0230">4,5</a> The cutaneous innervation of the breast is mainly derived from the lateral and anterior branches of the 2nd to 6th intercostal nerves. The 4th intercostal nerve, which innervates the nipple, is of particular interest.<a class="elsevierStyleCrossRefs" href="#bib0240">6–9</a> The anterior branch of the intercostal nerves gives bilateral innervation, that is, right-sided branches cross over the sternum to the left and vice versa. Finally, the upper quadrants of the breast are innervated by the supraclavicular nerves from the superficial cervical plexus.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>Recently, Blanco et al.<a class="elsevierStyleCrossRefs" href="#bib0265">11,12</a> described several ultrasound-guided interfascial blocks of the anterior chest wall that may be of interest in breast surgery. The most important of these are the PEC II<a class="elsevierStyleCrossRef" href="#bib0265">11</a> block and the serratus plane block.<a class="elsevierStyleCrossRef" href="#bib0270">12</a>The purpose of this study was to assess the analgesic efficacy of the modified pectoral and serratus plane blocks in retropectoral breast augmentation. This was determined by measuring the decrease in intraoperative haemodynamic variability or the absence of intraoperative movements, decrease in postoperative analgesic consumption, decrease or absence of postoperative pain measured using a verbal rating scale (VRS) at rest and after upper limb mobilisation in the immediate postoperative period, measured at 3, 6 and 24h, and the absence of the morphine-related side effects. Finally, we assessed subjective patient and surgeon satisfaction with the anaesthetic technique.Patients and methodThirty patients who underwent retropectoral breast augmentation were included in the study. The study was approved by the QuironSalud Clinical Research Ethics Committee of the General University Hospital of Catalonia (study code PEC-HGC-2013-01), and the corresponding informed consent was obtained from all participating patients.Inclusion criteria were: patients with ASA I to III, without previous breast pain, not receiving analgesic treatments, without neuromuscular diseases or coagulation disorders, undergoing breast enlargement using the infraaerolar approach, and who agreed to participate in the study. Exclusion criteria were: patients with known allergies to any of the medications administered, patients receiving opioid therapy, or patients in whom the infraaerolar surgical approach was changed to prepectoral prosthesis placement, or patients wishing to withdraw from the study.We performed a controlled, randomised, triple blind study. Patients were randomised on the day of inclusion in the study. Randomisation was performed by the secretary of the anaesthesiology department using the free online software Randomiser (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.randomizer.org/">http://www.randomizer.org</a>).<a class="elsevierStyleCrossRef" href="#bib0275">13</a> The randomised patient list was sent to the pharmacy service, where the drug syringes were prepared and delivered to the operating room for administration on the day of the procedure. The research anaesthetist was blinded to the contents of the syringe, and the pharmacy service was not involved in any other way with the patients or the research team until the end of the study. Therefore, the patients, the anaesthesiologist and the personnel responsible for postoperative care were blinded to the patient's study group. Fifteen patients underwent modified pectoral block plus serratus plane block with local anaesthetic (treatment group [GPEC]) and in 15 other patients the same procedure was performed using saline (control group [GC]), according to the randomisation protocol.All patients underwent standardised general anaesthesia and basic monitoring. The patients were placed in the supine position and operated on using the same surgical technique by 2 surgeons with more than 15 years of experience working together. All underwent breast augmentation using the infraaerolar approach. After monitoring was started (heart rate [HR], non-invasive blood pressure [NIBP], partial oxygen saturation [SpO2], end-tidal carbon dioxide [ETCO2] and bispectral index [BIS]), the patients received intravenous prophylactic multimodal analgesia with paracetamol 1g and metamizol 2g, and 4mg dexamethasone prophylaxis for postoperative nausea and vomiting. Following this, general anaesthesia was induced with intravenous fentanyl (1mg/kg) and propofol (2mg/kg). When BIS fell to below 60, an appropriately sized laryngeal mask airway (based on patient weight) was inserted. In all patients, anaesthesia was maintained with 50/50 air/oxygen mixture using sevoflurane as an anaesthetic agent, maintaining a minimum alveolar concentration (MAC) of 0.8.After disinfection of the thorax and axilla, an ultrasound-guided block was performed using a 6–12MHz linear high frequency probe (LA523® ESAOTE SpA®, Florence, Italy). Ultrasound was performed on both sides of the anterior thoracic wall to identify the pectoralis major and minor muscles and the thoracoacromial artery in the interfascial space, and the costal margin on both sides was counted. Once all the structures had been identified, the ultrasound probe was placed on the third costal margin and a 21G×90mm needle (Temena® UPC 90, RM Temena GmbH, Felesberg, Germany) was inserted in plane from lateral to medial until it contacted the third costal margin. The mixture prepared by pharmacy was infiltrated below the pectoralis minor muscle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and C) in order to block the medial pectoral nerve. The needle was then withdrawn to the edge of the pectoralis minor and inserted in the interfascial plane adjacent to the artery, where the mixture prepared by pharmacy was injected to block the lateral pectoral nerve, as described in our modified PEC II block<a class="elsevierStyleCrossRef" href="#bib0280">14</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B and D).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Following this, the serratus plane block was performed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) as described by Blanco et al.<a class="elsevierStyleCrossRef" href="#bib0270">12</a> The needle was withdrawn to the subcutaneous level and the transducer was placed in the axial plane at the subaxillary level of the thorax, advancing the needle in plane in the direction of the 4th and/or 5th costal margin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B) until it was located under the anterior serratus muscle, in contact with the costal margin. At this point, 20ml of the mixture prepared by pharmacy was injected, verifying separation of the muscle with respect to the costal margin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C) (lateral intercostal nerve block). The same procedure was performed on the contralateral breast.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The local anaesthetic administered was 0.25% bupivacaine plus 1:200,000 adrenaline (GPEC) or physiological saline (GC). The anaesthetic was prepared by the hospital's pharmacy service in a laminar flow cabinet. Surgeons made the first incision 20min after completion of the block on the first breast, always starting with the right breast.During surgery, vital signs (HR and NIBP) were monitored after induction and every 5min until completion of the intervention. The need for rocuronium for muscular relaxation was noted using the limb mobilisation-withdrawal test, and the need for rescue analgesia was noted when mobilisation-withdrawal was observed during painful surgical manoeuvres or when tachycardia/hypertension was observed (>20–25% increase over baseline values). Ondansetron 4mg was administered before education. After the surgery, the patient was transferred to the post-anaesthesia care unit (PACU). The duration of surgery was recorded (from the performance of nerve block until the end of surgery).In the PACU, vital signs and the need for rescue analgesia and i.v. morphine when the VRS score >3 were recorded on admission and every 15min until discharge to the ward. Post-nerve block pain at rest and on passive and active limb mobilisation was measured at 3 (in PACU), 6, and 24h (on the ward). Finally, the presence of nausea and/or vomiting was noted, together with total postoperative morphine consumption (0.05mg/kg) both in the PACU and on the ward.Pain was measured using the VRS (0 being no pain and 10 the worst pain imaginable). Nausea was measured on a categorical 4-point scale (no nausea=0, mild, occasional nausea [self-limiting]=1; moderate nausea=2; severe nausea [requiring treatment and/or with retching, no vomiting]=3). Satisfaction was measured on a 5-point Likert scale<a class="elsevierStyleCrossRef" href="#bib0285">15</a> (1=very satisfied, 2=satisfied; 3=indifferent 4=dissatisfied, and 5=very dissatisfied). Satisfaction was measured at discharge from the PACU and at 24h post intervention. The same satisfaction form was completed by the surgeons at the end of the intervention and at 24h. For the purpose of analysis, patients with satisfaction scores of 1 and 2 and those with scores of 3, 4 or 5 were grouped together.All data were uploaded to an electronic data collection form, which was analysed by a biostatistician blinded to the objectives and characteristics of the study.The sample size was calculated on the basis of the prevalence of moderate to severe postoperative pain reported by Baratta et al.,<a class="elsevierStyleCrossRef" href="#bib0290">16</a> together with our previous experience with these surgical procedures. We reviewed studies in anaesthetic management before the introduction of the nerve blocks used, which showed that rescue analgesia requirements in the PACU and on the ward were very high (>90% of patients) due to moderate to severe pain (VRS>5). The aim of these regional anaesthesia–analgesia techniques is to reduce the use of rescue drugs by at least half (in the treatment group, only 40% of patients should require rescue analgesia). In order to achieve a sample power of 80% (β error 20%) to detect differences in the percentage of patients requiring rescue analgesia in the postoperative period, assuming an α error of 5%, 13 patients per group would be needed to confirm our hypothesis. Assuming a post-randomisation exclusion rate of 15%, 30 patients were included in the study. Given the characteristics of the sample, the data were analysed by nonparametric statistical tests (Chi square or Fisher for qualitative variables and U Mann–Whitney and Wilcoxon for quantitative variables). Significance was set at p<0.05.ResultsThe groups were well-matched in terms of age, weight, height and ASA status, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Blood pressure and heart rate were more stable in the GPEC group compared to the GC group, although this difference was not statistically significant (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The haemodynamic parameters showed that in the GPEC group, these values remained unchanged or were below baseline levels, which shows that intraoperative analgesia was effective. In contrast, in the CG group they remained above baseline in the PACU due to the presence of pain.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>In the CG group, 6 patients (40%) required intraoperative rescue analgesia (fentanyl) and 5 required intraoperative rocuronium (33%). In the GPEC group, however, only 1 patient required intraoperative fentanyl (p=0.031) and rocuronium (p=0.068). The duration of surgery was similar in both groups (68±26 in GC vs. 59±13 in GPEC; p=0.252).During their stay in the PACU, CG patients presented significantly greater postoperative pain both at rest and on movement with respect to GPEC (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), although consumption of rescue analgesics did not differ significantly between groups, as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>VRS scores (at rest or on passive or active movement) at 3, 6 and 24 postoperative hours did not differ significantly between groups, as shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>One GPEC patient (7%) and 3 CG patients (20%) (p=0.283) required rescue analgesia on the ward (morphine). Consumption on the ward in the GPEC group was 0.2±0.8mg/24h, while in the GC group it was 0.6±1.2mg/24h (p=0.291). The appearance of side effects in the PACU or on the ward did not differ significantly between groups.Although differences in patient satisfaction in the PACU (quality of surgery) or at 24h (quality of analgesia) were not significant, the percentages were markedly higher in the GPEC group (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Surgeon satisfaction, also evaluated at the end of the surgery and at 24 postoperative hours, was significantly higher in the GPEC groups with respect to the CG group (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionOur study shows the effectiveness of the combination of pectoral muscle block and serratus plane block in intraoperative and immediate postoperative pain management of patients undergoing retropectoral breast augmentation surgery. Performance of these blocks provides greater haemodynamic stability, reduces intraoperative fentanyl and rocuronium requirements, gives greater pain relief in the immediate postoperative period, and is highly rated by surgeons.Inadequate management of postoperative pain in breast augmentation surgery prolongs the hospital stay and increases care costs. In this study, we observed a significant decrease in intraoperative opioid consumption, and a non-significant decrease in the postoperative period. The differences in postoperative morphine consumption were similar to those observed in other studies,<a class="elsevierStyleCrossRef" href="#bib0295">17</a> showing that the sample size was inadequate.Thoracic paravertebral block has been used successfully in breast cancer surgery,<a class="elsevierStyleCrossRefs" href="#bib0300">18,19</a> but not in breast augmentation surgery, in which anaesthesia has been reported to be incomplete because it does not reach the supraclavicular branches from the superficial cervical plexus and the pectoral nerves from the brachial plexus. The combination of paravertebral block with general anaesthesia gives good analgesia.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>Breast augmentation surgery has an added factor that contributes to the appearance of postoperative pain, namely, the dissection of the pectoralis major muscle and the insertion of the prosthesis in the interpectoral space. This causes painful muscle spasms in the postoperative period.<a class="elsevierStyleCrossRefs" href="#bib0220">2,17–19</a> These spasms have also been described in some types of mastectomies with retropectoral tissue expander placement.<a class="elsevierStyleCrossRef" href="#bib0310">20</a> Several strategies have been used to prevent this type of pain, including the use of intramuscular botulinum toxin, with very good results.<a class="elsevierStyleCrossRefs" href="#bib0310">20,21</a>Although the pectoral nerves have typically been considered motor nerves (iatrogenic section produces atrophy of the pectoral muscles), they possess sensory fibres from the aponeurotic tissues that supply sensory innervation to the periosteum of the ribs where they are inserted, and of the sternum and of the clavicle. They also supply sensory innervation to the deep fascial tissues of the mammary gland. The administration of a lateral pectoral nerve block (PEC1) is not sufficient for breast augmentation surgery for several reasons.The pectoral muscles are innervated by both nerves, which enter the thorax from different anatomical sites. The lateral pectoral nerve enters the thorax through the clavipectoral fascia, following the course of the thoracoacromial artery,<a class="elsevierStyleCrossRef" href="#bib0320">22</a> and the medial pectoral nerve enters the thorax after crossing the deep fascia of the pectoralis minor at the level of the third costal margin.<a class="elsevierStyleCrossRef" href="#bib0220">2</a> The medial pectoral nerve, through several perforating branches (M1, M2, M3 and ML),<a class="elsevierStyleCrossRef" href="#bib0320">22</a> mainly innervates the sternal and costal portions of the pectoralis major muscle.In a series of 26 cadaver dissections,<a class="elsevierStyleCrossRef" href="#bib0325">23</a> branches of the medial pectoral nerve were observed to traverse the pectoralis minor muscle and innervate the pectoralis major muscle in 65% of cases, and in the remaining 35%, the same branches passed around the lateral edge of the pectoralis minor to reach the pectoralis major muscle. This same structures was described by Macchi et al.<a class="elsevierStyleCrossRef" href="#bib0320">22</a> as the “A” and “B” patterns of branching of the medial pectoral nerve, which, according to the authors, is determined by size of the pectoralis minor muscle.Finally, the combined fibres of the pectoral nerves form the ansa pectoralis that, according to some authors, is present in 100% of the patients.<a class="elsevierStyleCrossRef" href="#bib0330">24</a> Based on this, we believe that the PEC I would be insufficient in a high percentage of patients, because the pectoral muscles receive both sensory and motor innervation from both pectoral nerves.<a class="elsevierStyleCrossRefs" href="#bib0220">2,3,5–7,19</a> Pectoral nerve block has been shown to be useful in patients with chronic pain,<a class="elsevierStyleCrossRef" href="#bib0335">25</a> and helps reduce the postoperative pain associated with the placement of the breast prosthesis.<a class="elsevierStyleCrossRefs" href="#bib0340">26–29</a>The breast is an organ with complex innervation derived from multiple branches, as described above. The pectoral nerves provide sensory innervation to the muscular and deep portion not only of the gland, but also of the chest wall, with some authors describing sensory innervation of the lateral chest wall. The lateral, medial and superior branches of the intercostal nerves, specifically, the 2nd to 6th intercostal branch, supply sensory innervation to the skin of the thoracic wall and/or the mammary gland. The lateral branches correspond to the communicating branches of the anterior division of the lateral cutaneous branch of the same nerve, with the exception of the 2nd lateral cutaneous branch, that gives origin to the intercostobrachial nerve.<a class="elsevierStyleCrossRefs" href="#bib0235">5,11</a> The lateral branch of the 4th margin is of particular interest, since in most cases it innervates the areola-nipple complex.<a class="elsevierStyleCrossRefs" href="#bib0240">6–10</a> The results of our study are consistent with previous studies<a class="elsevierStyleCrossRef" href="#bib0270">12</a> describing the use of the serratus plane block to anaesthetise all these lateral branches of the intercostal nerves for anaesthesia/analgesia in this type of surgery.In planning the study, we believed that contact with the rib would simplify the technique and ensure that the needle was located in the plane of cleavage, even though serratus plane block has been described as being more effective when performed superficial to the muscle. Although Blanco describes this in his original paper,<a class="elsevierStyleCrossRef" href="#bib0270">12</a> the study was performed in 4 healthy volunteers, and the discussion section of the paper emphasises the descriptive nature of the study and the need for clinical studies, such as ours, to validate this observation. The same author, in a subsequent letter to the editor,<a class="elsevierStyleCrossRef" href="#bib0360">30</a> states that injecting the anaesthetic below the serratus results gives a less distal and more anterior distribution in the chest wall, and is more effective in lower dermatomes. Obviously, the choice of block will depend on the analgesia required in each case, and we believe that the clinical effect we aimed for is achieved with more anterior analgesia. An anatomical study<a class="elsevierStyleCrossRef" href="#bib0365">31</a> demonstrated the spread of the anaesthetic when injected under the muscle, showing that it reaches the lateral cutaneous branches of the intercostal nerves.We assume that analgesia was incomplete in our patients, since the anaesthetic does not reach some parts of the breast, especially the 2 medial quadrants.<a class="elsevierStyleCrossRef" href="#bib0260">10</a> Blanco et al.<a class="elsevierStyleCrossRef" href="#bib0265">11</a> described the use of this block to perform oncological mastectomies with sedation. It is important to remember that breast augmentation surgery is associated not only with pectoral muscle spasm, but also with an additional pain factor, namely, the insertion of retropectoral prostheses. This entails the creation of a “pocket” to hold the prosthesis by detaching the muscle from the costal wall, which is painful. In addition, the anterior branches of the intercostals that innervate this area are not anaesthetised, and the innervation supplied by the small branches of the supraclavicular nerves coming from the superficial cervical plexus must also be taken into account.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>Neither the nerve block nor the drugs administered were associated with any complications in any of the study patients. This has been the case in all blocks performed by our team (with a significant number of cases). The use of ultrasound-guidance is an additional safety measure in thoracic wall nerve blocks.<a class="elsevierStyleCrossRef" href="#bib0260">10</a> In this regard, the modified technique used by our team allowed highly accurate visualisation of the needle, since it is inserted in-plane perpendicular to the sound waves from the transducer.<a class="elsevierStyleCrossRef" href="#bib0370">32</a>Although there were no statistically significant differences in patient satisfaction between the 2 groups, surgeon satisfaction differed significantly. Pain management is an integral part of anaesthesia care, and should be evaluated in order to determine patient satisfaction; as such, it is a measure of quality of care. Although patient satisfaction is assumed to be strictly related to the intensity of pain, this has not been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0375">33</a> Hanna et al.<a class="elsevierStyleCrossRef" href="#bib0380">34</a> showed that satisfaction was 4.86 times higher when postoperative pain was adequately controlled, and 9.92 times higher when the medical team took action to alleviate the pain. However, there is a general consensus in the literature that patient satisfaction is both a subjective measure and a multifactorial concept not associated exclusively with pain.<a class="elsevierStyleCrossRefs" href="#bib0385">35–38</a> Satisfaction is important for plastic surgeons, as it correlates with the patient's expectations in respect of their surgery; however, it is not easy to compare results because each patient has their own expectations, challenges and perception of a good result.<a class="elsevierStyleCrossRefs" href="#bib0405">39–42</a>This study has important limitations, some of which have already been mentioned in the opening paragraphs of the discussion section. Our expectations at the start of the study fell short in terms of the results observed. The sample was too small to detect more advantages than those reported, which are limited to the immediate postoperative period. Despite this limitation, the descriptive data support the efficacy of this technique beyond the immediate postoperative period, since they show better haemodynamic stability and decreased consumption of intraoperative fentanyl and rocuronium. Although no significant differences were observed at 24 postoperative hours, the satisfaction of the surgeons, who were blinded to patient groups, shows that the postoperative course was improved in patients receiving nerve block.Therefore, we conclude that the combination of the anterior thoracic wall blocks initially described by Blanco et al.<a class="elsevierStyleCrossRefs" href="#bib0260">10,12</a> are a safe and effective technique for multimodal analgesic management in the intraoperative and postoperative period after retropectoral prosthetic breast surgery. Further randomised studies with a larger number of patients are needed to corroborate our encouraging results.Conflicts of interestNo conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1145552" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1075736" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1145551" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1075737" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and method" ] 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" => "xack390384" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-06" "fechaAceptado" => "2018-08-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1075736" "palabras" => array:6 [ 0 => "Thoracic nerves" 1 => "Mammoplasty" 2 => "Postoperative pain" 3 => "Conduction anaesthesia" 4 => "Nerve block" 5 => "Reconstructive surgical procedures" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1075737" "palabras" => array:6 [ 0 => "Nervios torácicos" 1 => "Mamoplastia" 2 => "Dolor postoperatorio" 3 => "Anestesia de conducción" 4 => "Bloqueo nervioso" 5 => "Procedimientos quirúrgicos reconstructivos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionProsthetic breast surgery is a very common plastic surgery procedure, but its postoperative analgesic management is a challenge for the surgical team. The purpose of the present study is to validate the analgesic efficacy of pectoral block and serratus plane block in retropectoral mammoplasty. Patients and methodsA randomised, controlled, triple-blind, clinical trial was designed, and included 30 patients undergoing retropectoral augmentation mammoplasty. All of them had a modified PEC II block and a serratus plane block with a total volume of 40ml per breast. In 15 of them bupivacaine 0.25% (GPEC) was injected and in the other 15 patients saline was used (GC). Standardised management of anaesthesia and postoperative analgesia was performed. Intra-operative haemodynamic parameters required for postoperative analgesia, and a numeric verbal scale on arrival in the recovery unit were measured and at 3, 6, and 24h. The quality perceived by patients and surgeons was also measured. ResultsPost-operative pain was significantly better in GPEC (5.3±2.3 vs. 2.9±2.7; p=0.018). No significant differences were observed at 3, 6, and 24h. The surgeons rated the anaesthetic–analgesic quality as very good in 80% of the cases in GPEC versus 33% in CG (p=0.01). ConclusionsThe use of these blocks is a good perioperative analgesic strategy in the multimodal management of retropectoral augmentation mammoplasty." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa cirugía protésica de mama es un procedimiento de cirugía plástica muy común, cuyo manejo analgésico postoperatorio es un reto para el equipo quirúrgico. El propósito del presente estudio fue validar la eficacia analgésica del bloqueo de los nervios pectorales y plano del serrato en mamoplastia de aumento retropectoral. Pacientes y métodosSe diseñó un ensayo clínico, controlado, aleatorizado, triple ciego, que incluyó a 30 pacientes intervenidas mediante mamoplastia de aumento retropectoral. En ambos grupos se realizaron bloqueo pectoral modificado y bloqueo del plano serrato con un volumen total de 40ml por mama. En 15 de ellas se inyectó bupivacaína 0,25% con epinefrina (GPEC), y en las otras 15 se administró suero fisiológico (GC). Se hizo manejo estandarizado de la anestesia y la analgesia postoperatoria. Se midieron parámetros hemodinámicos intraoperatorios, necesidad de analgesia postoperatoria y la escala numérica verbal a su llegada a reanimación, a las 3, 6 y 24h, así como la calidad percibida por los pacientes y cirujanos. ResultadosEn el postoperatorio inmediato, se pudo percibir una disminución del dolor en las pacientes del GPEC (5,3±2,3 vs. 2,9±2,7; p=0,018). No se observaron diferencias significativas a las 3, 6 y 24h. Los cirujanos valoraron la calidad anestésico-analgésica como muy buena en el 80% de los casos en el GPEC frente al 33% en el GC (p=0,01). ConclusionesEl uso de estos bloqueos es una buena estrategia analgésica perioperatoria en el manejo multimodal en la mamoplastia de aumento retropectoral." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Schuitemaker R. JB, Sala-Blanch X, Sánchez Cohen AP, López-Pantaleon LA, Mayoral R. JT, Cubero M. Eficacia analgésica del bloqueo pectoral modificado más bloqueo del plano del serrato en mamoplastia subpectoral: ensayo clínico, controlado, aleatorizado, triple ciego. Rev Esp Anestesiol Reanim. 2019;66:62–71." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1726 "Ancho" => 2083 "Tamanyo" => 417898 ] ] "descripcion" => array:1 [ "en" => "PEC II block modified by the authors.<a class="elsevierStyleCrossRef" href="#bib0280">14</a> (A and B) Lateral-to-medial insertion of the needle in plane and position of the ultrasound probe. (C) Ultrasound image of the PEC II needle in plane contacting the 3rd costal margin (3°AC) in order to block the medial pectoral nerve at the site of its entrance in the chest wall (the path of the needle is marked with *, and the neurovascular bundle with a circle of red dashes). (D) Needle in plane in the interpectoral space, adjacent to the neurovascular bundle (thoracoacromial artery together with the lateral pectoral nerve, circle of yellow dashes); the path of the needle is marked with *. The hydro-dissection of the local anaesthetic can be seen in the lower portion of the pectoralis minor muscle (MPm). MPM: pectoralis major muscle." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1736 "Ancho" => 2083 "Tamanyo" => 342144 ] ] "descripcion" => array:1 [ "en" => "Serratus plane block. (A) Position of the needle before performing the block, parallel to the ultrasound probe in order to perform the technique in plane. (B) Final position of the needle. (C) Ultrasound images of the serratus plane block inferior to the serratus muscle (MSA). The latissimus dorsi (MDA) and the 3rd and 4th costal margins (3°AC and 4°AC) can be seen separated from the muscle by the local anaesthetic (the path of the needle is marked with *). Cefalic=cephalad." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1580 "Ancho" => 2084 "Tamanyo" => 167968 ] ] "descripcion" => array:1 [ "en" => "Intraperative blood pressure (BP) in the control group (CG) (dashes) and the treatment group (GPEC) (solid line). The data are expressed as mean systolic (TAs), mean (TAm) and diastolic (TAd) pressures. PACU: post-anaesthesia care unit." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1134 "Ancho" => 2169 "Tamanyo" => 98131 ] ] "descripcion" => array:1 [ "en" => "Box-plot showing verbal reporting scale (VRS) scores in the post-anaesthesia care unit (PACU) at rest and on passive and active movement of the extremity in each group (*p<0.05). GC: control group; GPEC: treatment group." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2229 "Ancho" => 2084 "Tamanyo" => 180295 ] ] "descripcion" => array:1 [ "en" => "Box-plot showing verbal reporting scale (VRS) scores obtained at 3, 6 and 24 postoperative hours at rest and on passive and active movement of the extremity in each group. GC: control group; GPEC: treatment group." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are expressed as mean±SD or number of patients (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GC (n=15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GPEC (n=15) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33±6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33±9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52±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">Height (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">163±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">163±5 \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">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20±2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20±1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA (I/II) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955076.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient demographics." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are expressed as mean±SD or number of patients (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GC (n=15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GPEC (n=15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VRS PACU at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.3±2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.9±2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.018 \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">VRS PACU on passive movement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.3±2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.3±2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \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">VRS PACU on active movement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.3±2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.2±2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.035 \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">No. of patients requiring morphine in PACU (% patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.085 \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">Milligrams (mg) of morphine consumed on the ward \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955075.png" ] ] ] ] "descripcion" => array:1 [ "en" => "VRS scores in PACU and consumption of morphine." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are expressed as mean±SD or number of patients (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GC (n=15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GPEC (n=15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient satisfaction on discharge from PACU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.232 \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">Patient satisfaction at 24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.121 \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">Surgeon satisfaction at end of surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.099 \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">Surgeon satisfaction at 24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955077.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Self-reported satisfaction of patients and surgeons in PACU and on the ward." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pain control following breast augmentation: a qualitative systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.S. 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Original article

Analgesic efficacy of modified pectoral block plus serratus plane block in breast augmentation surgery: A randomised, controlled, triple-blind clinical trial

Eficacia analgésica del bloqueo pectoral modificado más bloqueo del plano del serrato en mamoplastia subpectoral: ensayo clínico, controlado, aleatorizado, triple ciego

J.B. Schuitemaker R.a,

Corresponding author

juanbernardosr@iCloud.com

Corresponding author.

, X. Sala-Blanchb, A.P. Sánchez Cohenc, L.A. López-Pantaleona, J.T. Mayoral R.a, M. Cuberod

a Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, QuironSalud Hospital Universitari General de Catalunya e Hypnos S.L.P., Sant Cugat del Vallès, Barcelona, Spain

b Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic de Barcelona, Departamento de Anatomía Humana, Universitat de Barcelona, Barcelona, Spain

c Servicio de Radiología Intervencionista, Invenciones Tecnológicas en Medicina (INTEM), QuironSalud Hospital Universitari General de Catalunya, Sant Cugat del Vallès, Barcelona, Spain

d Sección de Estadística, Facultad de Biología, Universitat de Barcelona, Barcelona, Spain

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        "titulo" => "Eficacia analg&#233;sica del bloqueo pectoral modificado m&#225;s bloqueo del plano del serrato en mamoplastia subpectoral&#58; ensayo cl&#237;nico&#44; controlado&#44; aleatorizado&#44; triple ciego"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing verbal reporting scale &#40;VRS&#41; scores obtained at 3&#44; 6 and 24 postoperative hours at rest and on passive and active movement of the extremity in each group&#46; GC&#58; control group&#59; GPEC&#58; treatment group&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cosmetic breast surgery is the most common plastic surgery procedure performed in the United States&#46; The management of postoperative pain is a challenge for the surgical team&#46; Treatment&#44; which usually consists of intravenous or oral opioids&#44; is sometimes ineffective&#44; and it is also important to remember that opioids are not free of side effects&#44; such as nausea and vomiting&#44; which can lead to suture dehiscence and bruising&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> In addition&#44; manipulation of the pectoral muscle during retropectoral prosthesis insertion can cause painful muscle spasms&#46; Alternative pain management methods based on afferent nerve blocks have recently been described in breast surgery&#44; although their efficacy in retropectoral breast augmentation has not been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The innervation of the breast is complex&#44; being supplied by multiple nerve branches&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a> The deep fascia on which the mammary gland lies&#44; a space known as the retromammary bursa or Chassaignac&#39;s bursa&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a> receives afferents from the lateral and medial pectoral nerves&#44; which supply motor innervation to the pectoral muscles&#46; These motor nerves supply sensory innervation to the aforementioned fascia&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;5</span></a> The cutaneous innervation of the breast is mainly derived from the lateral and anterior branches of the 2nd to 6th intercostal nerves&#46; The 4th intercostal nerve&#44; which innervates the nipple&#44; is of particular interest&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#8211;9</span></a> The anterior branch of the intercostal nerves gives bilateral innervation&#44; that is&#44; right-sided branches cross over the sternum to the left and vice versa&#46; Finally&#44; the upper quadrants of the breast are innervated by the supraclavicular nerves from the superficial cervical plexus&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently&#44; Blanco et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;12</span></a> described several ultrasound-guided interfascial blocks of the anterior chest wall that may be of interest in breast surgery&#46; The most important of these are the PEC II<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> block and the serratus plane block&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The purpose of this study was to assess the analgesic efficacy of the modified pectoral and serratus plane blocks in retropectoral breast augmentation&#46; This was determined by measuring the decrease in intraoperative haemodynamic variability or the absence of intraoperative movements&#44; decrease in postoperative analgesic consumption&#44; decrease or absence of postoperative pain measured using a verbal rating scale &#40;VRS&#41; at rest and after upper limb mobilisation in the immediate postoperative period&#44; measured at 3&#44; 6 and 24<span class="elsevierStyleHsp" style=""></span>h&#44; and the absence of the morphine-related side effects&#46; Finally&#44; we assessed subjective patient and surgeon satisfaction with the anaesthetic technique&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">Thirty patients who underwent retropectoral breast augmentation were included in the study&#46; The study was approved by the QuironSalud Clinical Research Ethics Committee of the General University Hospital of Catalonia &#40;study code PEC-HGC-2013-01&#41;&#44; and the corresponding informed consent was obtained from all participating patients&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inclusion criteria were&#58; patients with ASA I to III&#44; without previous breast pain&#44; not receiving analgesic treatments&#44; without neuromuscular diseases or coagulation disorders&#44; undergoing breast enlargement using the infraaerolar approach&#44; and who agreed to participate in the study&#46; Exclusion criteria were&#58; patients with known allergies to any of the medications administered&#44; patients receiving opioid therapy&#44; or patients in whom the infraaerolar surgical approach was changed to prepectoral prosthesis placement&#44; or patients wishing to withdraw from the study&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We performed a controlled&#44; randomised&#44; triple blind study&#46; Patients were randomised on the day of inclusion in the study&#46; Randomisation was performed by the secretary of the anaesthesiology department using the free online software Randomiser &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.randomizer.org/">http&#58;&#47;&#47;www&#46;randomizer&#46;org</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a> The randomised patient list was sent to the pharmacy service&#44; where the drug syringes were prepared and delivered to the operating room for administration on the day of the procedure&#46; The research anaesthetist was blinded to the contents of the syringe&#44; and the pharmacy service was not involved in any other way with the patients or the research team until the end of the study&#46; Therefore&#44; the patients&#44; the anaesthesiologist and the personnel responsible for postoperative care were blinded to the patient&#39;s study group&#46; Fifteen patients underwent modified pectoral block plus serratus plane block with local anaesthetic &#40;treatment group &#91;GPEC&#93;&#41; and in 15 other patients the same procedure was performed using saline &#40;control group &#91;GC&#93;&#41;&#44; according to the randomisation protocol&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All patients underwent standardised general anaesthesia and basic monitoring&#46; The patients were placed in the supine position and operated on using the same surgical technique by 2 surgeons with more than 15 years of experience working together&#46; All underwent breast augmentation using the infraaerolar approach&#46; After monitoring was started &#40;heart rate &#91;HR&#93;&#44; non-invasive blood pressure &#91;NIBP&#93;&#44; partial oxygen saturation &#91;SpO<span class="elsevierStyleInf">2</span>&#93;&#44; end-tidal carbon dioxide &#91;ETCO<span class="elsevierStyleInf">2</span>&#93; and bispectral index &#91;BIS&#93;&#41;&#44; the patients received intravenous prophylactic multimodal analgesia with paracetamol 1<span class="elsevierStyleHsp" style=""></span>g and metamizol 2<span class="elsevierStyleHsp" style=""></span>g&#44; and 4<span class="elsevierStyleHsp" style=""></span>mg dexamethasone prophylaxis for postoperative nausea and vomiting&#46; Following this&#44; general anaesthesia was induced with intravenous fentanyl &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; and propofol &#40;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46; When BIS fell to below 60&#44; an appropriately sized laryngeal mask airway &#40;based on patient weight&#41; was inserted&#46; In all patients&#44; anaesthesia was maintained with 50&#47;50 air&#47;oxygen mixture using sevoflurane as an anaesthetic agent&#44; maintaining a minimum alveolar concentration &#40;MAC&#41; of 0&#46;8&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">After disinfection of the thorax and axilla&#44; an ultrasound-guided block was performed using a 6&#8211;12<span class="elsevierStyleHsp" style=""></span>MHz linear high frequency probe &#40;LA523<span class="elsevierStyleSup">&#174;</span> ESAOTE SpA<span class="elsevierStyleSup">&#174;</span>&#44; Florence&#44; Italy&#41;&#46; Ultrasound was performed on both sides of the anterior thoracic wall to identify the pectoralis major and minor muscles and the thoracoacromial artery in the interfascial space&#44; and the costal margin on both sides was counted&#46; Once all the structures had been identified&#44; the ultrasound probe was placed on the third costal margin and a 21<span class="elsevierStyleHsp" style=""></span>G<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mm needle &#40;Temena<span class="elsevierStyleSup">&#174;</span> UPC 90&#44; RM Temena GmbH&#44; Felesberg&#44; Germany&#41; was inserted in plane from lateral to medial until it contacted the third costal margin&#46; The mixture prepared by pharmacy was infiltrated below the pectoralis minor muscle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and C&#41; in order to block the medial pectoral nerve&#46; The needle was then withdrawn to the edge of the pectoralis minor and inserted in the interfascial plane adjacent to the artery&#44; where the mixture prepared by pharmacy was injected to block the lateral pectoral nerve&#44; as described in our modified PEC II block<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B and D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Following this&#44; the serratus plane block was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; as described by Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> The needle was withdrawn to the subcutaneous level and the transducer was placed in the axial plane at the subaxillary level of the thorax&#44; advancing the needle in plane in the direction of the 4th and&#47;or 5th costal margin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41; until it was located under the anterior serratus muscle&#44; in contact with the costal margin&#46; At this point&#44; 20<span class="elsevierStyleHsp" style=""></span>ml of the mixture prepared by pharmacy was injected&#44; verifying separation of the muscle with respect to the costal margin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41; &#40;lateral intercostal nerve block&#41;&#46; The same procedure was performed on the contralateral breast&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The local anaesthetic administered was 0&#46;25&#37; bupivacaine plus 1&#58;200&#44;000 adrenaline &#40;GPEC&#41; or physiological saline &#40;GC&#41;&#46; The anaesthetic was prepared by the hospital&#39;s pharmacy service in a laminar flow cabinet&#46; Surgeons made the first incision 20<span class="elsevierStyleHsp" style=""></span>min after completion of the block on the first breast&#44; always starting with the right breast&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">During surgery&#44; vital signs &#40;HR and NIBP&#41; were monitored after induction and every 5<span class="elsevierStyleHsp" style=""></span>min until completion of the intervention&#46; The need for rocuronium for muscular relaxation was noted using the limb mobilisation-withdrawal test&#44; and the need for rescue analgesia was noted when mobilisation-withdrawal was observed during painful surgical manoeuvres or when tachycardia&#47;hypertension was observed &#40;&#62;20&#8211;25&#37; increase over baseline values&#41;&#46; Ondansetron 4<span class="elsevierStyleHsp" style=""></span>mg was administered before education&#46; After the surgery&#44; the patient was transferred to the post-anaesthesia care unit &#40;PACU&#41;&#46; The duration of surgery was recorded &#40;from the performance of nerve block until the end of surgery&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the PACU&#44; vital signs and the need for rescue analgesia and i&#46;v&#46; morphine when the VRS score &#62;3 were recorded on admission and every 15<span class="elsevierStyleHsp" style=""></span>min until discharge to the ward&#46; Post-nerve block pain at rest and on passive and active limb mobilisation was measured at 3 &#40;in PACU&#41;&#44; 6&#44; and 24<span class="elsevierStyleHsp" style=""></span>h &#40;on the ward&#41;&#46; Finally&#44; the presence of nausea and&#47;or vomiting was noted&#44; together with total postoperative morphine consumption &#40;0&#46;05<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; both in the PACU and on the ward&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Pain was measured using the VRS &#40;0 being no pain and 10 the worst pain imaginable&#41;&#46; Nausea was measured on a categorical 4-point scale &#40;no nausea<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44; mild&#44; occasional nausea &#91;self-limiting&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#59; moderate nausea<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; severe nausea &#91;requiring treatment and&#47;or with retching&#44; no vomiting&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46; Satisfaction was measured on a 5-point Likert scale<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a> &#40;1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very satisfied&#44; 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>satisfied&#59; 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>indifferent 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>dissatisfied&#44; and 5<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>very dissatisfied&#41;&#46; Satisfaction was measured at discharge from the PACU and at 24<span class="elsevierStyleHsp" style=""></span>h post intervention&#46; The same satisfaction form was completed by the surgeons at the end of the intervention and at 24<span class="elsevierStyleHsp" style=""></span>h&#46; For the purpose of analysis&#44; patients with satisfaction scores of 1 and 2 and those with scores of 3&#44; 4 or 5 were grouped together&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All data were uploaded to an electronic data collection form&#44; which was analysed by a biostatistician blinded to the objectives and characteristics of the study&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The sample size was calculated on the basis of the prevalence of moderate to severe postoperative pain reported by Baratta et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> together with our previous experience with these surgical procedures&#46; We reviewed studies in anaesthetic management before the introduction of the nerve blocks used&#44; which showed that rescue analgesia requirements in the PACU and on the ward were very high &#40;&#62;90&#37; of patients&#41; due to moderate to severe pain &#40;VRS<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span><span class="elsevierStyleHsp" style=""></span>5&#41;&#46; The aim of these regional anaesthesia&#8211;analgesia techniques is to reduce the use of rescue drugs by at least half &#40;in the treatment group&#44; only 40&#37; of patients should require rescue analgesia&#41;&#46; In order to achieve a sample power of 80&#37; &#40;&#946; error 20&#37;&#41; to detect differences in the percentage of patients requiring rescue analgesia in the postoperative period&#44; assuming an &#945; error of 5&#37;&#44; 13 patients per group would be needed to confirm our hypothesis&#46; Assuming a post-randomisation exclusion rate of 15&#37;&#44; 30 patients were included in the study&#46; Given the characteristics of the sample&#44; the data were analysed by nonparametric statistical tests &#40;Chi square or Fisher for qualitative variables and <span class="elsevierStyleItalic">U</span> Mann&#8211;Whitney and Wilcoxon for quantitative variables&#41;&#46; Significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">The groups were well-matched in terms of age&#44; weight&#44; height and ASA status&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Blood pressure and heart rate were more stable in the GPEC group compared to the GC group&#44; although this difference was not statistically significant &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The haemodynamic parameters showed that in the GPEC group&#44; these values remained unchanged or were below baseline levels&#44; which shows that intraoperative analgesia was effective&#46; In contrast&#44; in the CG group they remained above baseline in the PACU due to the presence of pain&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In the CG group&#44; 6 patients &#40;40&#37;&#41; required intraoperative rescue analgesia &#40;fentanyl&#41; and 5 required intraoperative rocuronium &#40;33&#37;&#41;&#46; In the GPEC group&#44; however&#44; only 1 patient required intraoperative fentanyl &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;031&#41; and rocuronium &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;068&#41;&#46; The duration of surgery was similar in both groups &#40;68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26 in GC vs&#46; 59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 in GPEC&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;252&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">During their stay in the PACU&#44; CG patients presented significantly greater postoperative pain both at rest and on movement with respect to GPEC &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; although consumption of rescue analgesics did not differ significantly between groups&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">VRS scores &#40;at rest or on passive or active movement&#41; at 3&#44; 6 and 24 postoperative hours did not differ significantly between groups&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">One GPEC patient &#40;7&#37;&#41; and 3 CG patients &#40;20&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;283&#41; required rescue analgesia on the ward &#40;morphine&#41;&#46; Consumption on the ward in the GPEC group was 0&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; while in the GC group it was 0&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;291&#41;&#46; The appearance of side effects in the PACU or on the ward did not differ significantly between groups&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Although differences in patient satisfaction in the PACU &#40;quality of surgery&#41; or at 24<span class="elsevierStyleHsp" style=""></span>h &#40;quality of analgesia&#41; were not significant&#44; the percentages were markedly higher in the GPEC group &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Surgeon satisfaction&#44; also evaluated at the end of the surgery and at 24 postoperative hours&#44; was significantly higher in the GPEC groups with respect to the CG group &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Our study shows the effectiveness of the combination of pectoral muscle block and serratus plane block in intraoperative and immediate postoperative pain management of patients undergoing retropectoral breast augmentation surgery&#46; Performance of these blocks provides greater haemodynamic stability&#44; reduces intraoperative fentanyl and rocuronium requirements&#44; gives greater pain relief in the immediate postoperative period&#44; and is highly rated by surgeons&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Inadequate management of postoperative pain in breast augmentation surgery prolongs the hospital stay and increases care costs&#46; In this study&#44; we observed a significant decrease in intraoperative opioid consumption&#44; and a non-significant decrease in the postoperative period&#46; The differences in postoperative morphine consumption were similar to those observed in other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a> showing that the sample size was inadequate&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Thoracic paravertebral block has been used successfully in breast cancer surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;19</span></a> but not in breast augmentation surgery&#44; in which anaesthesia has been reported to be incomplete because it does not reach the supraclavicular branches from the superficial cervical plexus and the pectoral nerves from the brachial plexus&#46; The combination of paravertebral block with general anaesthesia gives good analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Breast augmentation surgery has an added factor that contributes to the appearance of postoperative pain&#44; namely&#44; the dissection of the pectoralis major muscle and the insertion of the prosthesis in the interpectoral space&#46; This causes painful muscle spasms in the postoperative period&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;17&#8211;19</span></a> These spasms have also been described in some types of mastectomies with retropectoral tissue expander placement&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> Several strategies have been used to prevent this type of pain&#44; including the use of intramuscular botulinum toxin&#44; with very good results&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Although the pectoral nerves have typically been considered motor nerves &#40;iatrogenic section produces atrophy of the pectoral muscles&#41;&#44; they possess sensory fibres from the aponeurotic tissues that supply sensory innervation to the periosteum of the ribs where they are inserted&#44; and of the sternum and of the clavicle&#46; They also supply sensory innervation to the deep fascial tissues of the mammary gland&#46; The administration of a lateral pectoral nerve block &#40;PEC1&#41; is not sufficient for breast augmentation surgery for several reasons&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The pectoral muscles are innervated by both nerves&#44; which enter the thorax from different anatomical sites&#46; The lateral pectoral nerve enters the thorax through the clavipectoral fascia&#44; following the course of the thoracoacromial artery&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a> and the medial pectoral nerve enters the thorax after crossing the deep fascia of the pectoralis minor at the level of the third costal margin&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a> The medial pectoral nerve&#44; through several perforating branches &#40;M1&#44; M2&#44; M3 and ML&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a> mainly innervates the sternal and costal portions of the pectoralis major muscle&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In a series of 26 cadaver dissections&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a> branches of the medial pectoral nerve were observed to traverse the pectoralis minor muscle and innervate the pectoralis major muscle in 65&#37; of cases&#44; and in the remaining 35&#37;&#44; the same branches passed around the lateral edge of the pectoralis minor to reach the pectoralis major muscle&#46; This same structures was described by Macchi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a> as the &#8220;A&#8221; and &#8220;B&#8221; patterns of branching of the medial pectoral nerve&#44; which&#44; according to the authors&#44; is determined by size of the pectoralis minor muscle&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Finally&#44; the combined fibres of the pectoral nerves form the ansa pectoralis that&#44; according to some authors&#44; is present in 100&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> Based on this&#44; we believe that the PEC I would be insufficient in a high percentage of patients&#44; because the pectoral muscles receive both sensory and motor innervation from both pectoral nerves&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;3&#44;5&#8211;7&#44;19</span></a> Pectoral nerve block has been shown to be useful in patients with chronic pain&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">25</span></a> and helps reduce the postoperative pain associated with the placement of the breast prosthesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">26&#8211;29</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The breast is an organ with complex innervation derived from multiple branches&#44; as described above&#46; The pectoral nerves provide sensory innervation to the muscular and deep portion not only of the gland&#44; but also of the chest wall&#44; with some authors describing sensory innervation of the lateral chest wall&#46; The lateral&#44; medial and superior branches of the intercostal nerves&#44; specifically&#44; the 2nd to 6th intercostal branch&#44; supply sensory innervation to the skin of the thoracic wall and&#47;or the mammary gland&#46; The lateral branches correspond to the communicating branches of the anterior division of the lateral cutaneous branch of the same nerve&#44; with the exception of the 2nd lateral cutaneous branch&#44; that gives origin to the intercostobrachial nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">5&#44;11</span></a> The lateral branch of the 4th margin is of particular interest&#44; since in most cases it innervates the areola-nipple complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#8211;10</span></a> The results of our study are consistent with previous studies<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> describing the use of the serratus plane block to anaesthetise all these lateral branches of the intercostal nerves for anaesthesia&#47;analgesia in this type of surgery&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In planning the study&#44; we believed that contact with the rib would simplify the technique and ensure that the needle was located in the plane of cleavage&#44; even though serratus plane block has been described as being more effective when performed superficial to the muscle&#46; Although Blanco describes this in his original paper&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> the study was performed in 4 healthy volunteers&#44; and the discussion section of the paper emphasises the descriptive nature of the study and the need for clinical studies&#44; such as ours&#44; to validate this observation&#46; The same author&#44; in a subsequent letter to the editor&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a> states that injecting the anaesthetic below the serratus results gives a less distal and more anterior distribution in the chest wall&#44; and is more effective in lower dermatomes&#46; Obviously&#44; the choice of block will depend on the analgesia required in each case&#44; and we believe that the clinical effect we aimed for is achieved with more anterior analgesia&#46; An anatomical study<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a> demonstrated the spread of the anaesthetic when injected under the muscle&#44; showing that it reaches the lateral cutaneous branches of the intercostal nerves&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We assume that analgesia was incomplete in our patients&#44; since the anaesthetic does not reach some parts of the breast&#44; especially the 2 medial quadrants&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a> Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> described the use of this block to perform oncological mastectomies with sedation&#46; It is important to remember that breast augmentation surgery is associated not only with pectoral muscle spasm&#44; but also with an additional pain factor&#44; namely&#44; the insertion of retropectoral prostheses&#46; This entails the creation of a &#8220;pocket&#8221; to hold the prosthesis by detaching the muscle from the costal wall&#44; which is painful&#46; In addition&#44; the anterior branches of the intercostals that innervate this area are not anaesthetised&#44; and the innervation supplied by the small branches of the supraclavicular nerves coming from the superficial cervical plexus must also be taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Neither the nerve block nor the drugs administered were associated with any complications in any of the study patients&#46; This has been the case in all blocks performed by our team &#40;with a significant number of cases&#41;&#46; The use of ultrasound-guidance is an additional safety measure in thoracic wall nerve blocks&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a> In this regard&#44; the modified technique used by our team allowed highly accurate visualisation of the needle&#44; since it is inserted in-plane perpendicular to the sound waves from the transducer&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Although there were no statistically significant differences in patient satisfaction between the 2 groups&#44; surgeon satisfaction differed significantly&#46; Pain management is an integral part of anaesthesia care&#44; and should be evaluated in order to determine patient satisfaction&#59; as such&#44; it is a measure of quality of care&#46; Although patient satisfaction is assumed to be strictly related to the intensity of pain&#44; this has not been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> Hanna et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a> showed that satisfaction was 4&#46;86 times higher when postoperative pain was adequately controlled&#44; and 9&#46;92 times higher when the medical team took action to alleviate the pain&#46; However&#44; there is a general consensus in the literature that patient satisfaction is both a subjective measure and a multifactorial concept not associated exclusively with pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">35&#8211;38</span></a> Satisfaction is important for plastic surgeons&#44; as it correlates with the patient&#39;s expectations in respect of their surgery&#59; however&#44; it is not easy to compare results because each patient has their own expectations&#44; challenges and perception of a good result&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">39&#8211;42</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">This study has important limitations&#44; some of which have already been mentioned in the opening paragraphs of the discussion section&#46; Our expectations at the start of the study fell short in terms of the results observed&#46; The sample was too small to detect more advantages than those reported&#44; which are limited to the immediate postoperative period&#46; Despite this limitation&#44; the descriptive data support the efficacy of this technique beyond the immediate postoperative period&#44; since they show better haemodynamic stability and decreased consumption of intraoperative fentanyl and rocuronium&#46; Although no significant differences were observed at 24 postoperative hours&#44; the satisfaction of the surgeons&#44; who were blinded to patient groups&#44; shows that the postoperative course was improved in patients receiving nerve block&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Therefore&#44; we conclude that the combination of the anterior thoracic wall blocks initially described by Blanco et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;12</span></a> are a safe and effective technique for multimodal analgesic management in the intraoperative and postoperative period after retropectoral prosthetic breast surgery&#46; Further randomised studies with a larger number of patients are needed to corroborate our encouraging results&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">No conflict of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2017-02-06"
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          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Thoracic nerves"
            1 => "Mammoplasty"
            2 => "Postoperative pain"
            3 => "Conduction anaesthesia"
            4 => "Nerve block"
            5 => "Reconstructive surgical procedures"
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          "palabras" => array:6 [
            0 => "Nervios tor&#225;cicos"
            1 => "Mamoplastia"
            2 => "Dolor postoperatorio"
            3 => "Anestesia de conducci&#243;n"
            4 => "Bloqueo nervioso"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prosthetic breast surgery is a very common plastic surgery procedure&#44; but its postoperative analgesic management is a challenge for the surgical team&#46; The purpose of the present study is to validate the analgesic efficacy of pectoral block and serratus plane block in retropectoral mammoplasty&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A randomised&#44; controlled&#44; triple-blind&#44; clinical trial was designed&#44; and included 30 patients undergoing retropectoral augmentation mammoplasty&#46; All of them had a modified PEC II block and a serratus plane block with a total volume of 40<span class="elsevierStyleHsp" style=""></span>ml per breast&#46; In 15 of them bupivacaine 0&#46;25&#37; &#40;GPEC&#41; was injected and in the other 15 patients saline was used &#40;GC&#41;&#46; Standardised management of anaesthesia and postoperative analgesia was performed&#46; Intra-operative haemodynamic parameters required for postoperative analgesia&#44; and a numeric verbal scale on arrival in the recovery unit were measured and at 3&#44; 6&#44; and 24<span class="elsevierStyleHsp" style=""></span>h&#46; The quality perceived by patients and surgeons was also measured&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Post-operative pain was significantly better in GPEC &#40;5&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;3 vs&#46; 2&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#41;&#46; No significant differences were observed at 3&#44; 6&#44; and 24<span class="elsevierStyleHsp" style=""></span>h&#46; The surgeons rated the anaesthetic&#8211;analgesic quality as very good in 80&#37; of the cases in GPEC versus 33&#37; in CG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of these blocks is a good perioperative analgesic strategy in the multimodal management of retropectoral augmentation mammoplasty&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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          2 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a prot&#233;sica de mama es un procedimiento de cirug&#237;a pl&#225;stica muy com&#250;n&#44; cuyo manejo analg&#233;sico postoperatorio es un reto para el equipo quir&#250;rgico&#46; El prop&#243;sito del presente estudio fue validar la eficacia analg&#233;sica del bloqueo de los nervios pectorales y plano del serrato en mamoplastia de aumento retropectoral&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se dise&#241;&#243; un ensayo cl&#237;nico&#44; controlado&#44; aleatorizado&#44; triple ciego&#44; que incluy&#243; a 30 pacientes intervenidas mediante mamoplastia de aumento retropectoral&#46; En ambos grupos se realizaron bloqueo pectoral modificado y bloqueo del plano serrato con un volumen total de 40<span class="elsevierStyleHsp" style=""></span>ml por mama&#46; En 15 de ellas se inyect&#243; bupivaca&#237;na 0&#44;25&#37; con epinefrina &#40;GPEC&#41;&#44; y en las otras 15 se administr&#243; suero fisiol&#243;gico &#40;GC&#41;&#46; Se hizo manejo estandarizado de la anestesia y la analgesia postoperatoria&#46; Se midieron par&#225;metros hemodin&#225;micos intraoperatorios&#44; necesidad de analgesia postoperatoria y la escala num&#233;rica verbal a su llegada a reanimaci&#243;n&#44; a las 3&#44; 6 y 24<span class="elsevierStyleHsp" style=""></span>h&#44; as&#237; como la calidad percibida por los pacientes y cirujanos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En el postoperatorio inmediato&#44; se pudo percibir una disminuci&#243;n del dolor en las pacientes del GPEC &#40;5&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;3 vs&#46; 2&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;7&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#46; No se observaron diferencias significativas a las 3&#44; 6 y 24<span class="elsevierStyleHsp" style=""></span>h&#46; Los cirujanos valoraron la calidad anest&#233;sico-analg&#233;sica como muy buena en el 80&#37; de los casos en el GPEC frente al 33&#37; en el GC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso de estos bloqueos es una buena estrategia analg&#233;sica perioperatoria en el manejo multimodal en la mamoplastia de aumento retropectoral&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Schuitemaker R&#46; JB&#44; Sala-Blanch X&#44; S&#225;nchez Cohen AP&#44; L&#243;pez-Pantaleon LA&#44; Mayoral R&#46; JT&#44; Cubero M&#46; Eficacia analg&#233;sica del bloqueo pectoral modificado m&#225;s bloqueo del plano del serrato en mamoplastia subpectoral&#58; ensayo cl&#237;nico&#44; controlado&#44; aleatorizado&#44; triple ciego&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;62&#8211;71&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PEC II block modified by the authors&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a> &#40;A and B&#41; Lateral-to-medial insertion of the needle in plane and position of the ultrasound probe&#46; &#40;C&#41; Ultrasound image of the PEC II needle in plane contacting the 3rd costal margin &#40;3&#176;AC&#41; in order to block the medial pectoral nerve at the site of its entrance in the chest wall &#40;the path of the needle is marked with &#42;&#44; and the neurovascular bundle with a circle of red dashes&#41;&#46; &#40;D&#41; Needle in plane in the interpectoral space&#44; adjacent to the neurovascular bundle &#40;thoracoacromial artery together with the lateral pectoral nerve&#44; circle of yellow dashes&#41;&#59; the path of the needle is marked with &#42;&#46; The hydro-dissection of the local anaesthetic can be seen in the lower portion of the pectoralis minor muscle &#40;MPm&#41;&#46; MPM&#58; pectoralis major muscle&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Serratus plane block&#46; &#40;A&#41; Position of the needle before performing the block&#44; parallel to the ultrasound probe in order to perform the technique in plane&#46; &#40;B&#41; Final position of the needle&#46; &#40;C&#41; Ultrasound images of the serratus plane block inferior to the serratus muscle &#40;MSA&#41;&#46; The latissimus dorsi &#40;MDA&#41; and the 3rd and 4th costal margins &#40;3&#176;AC and 4&#176;AC&#41; can be seen separated from the muscle by the local anaesthetic &#40;the path of the needle is marked with &#42;&#41;&#46; Cefalic<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cephalad&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1580
            "Ancho" => 2084
            "Tamanyo" => 167968
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Intraperative blood pressure &#40;BP&#41; in the control group &#40;CG&#41; &#40;dashes&#41; and the treatment group &#40;GPEC&#41; &#40;solid line&#41;&#46; The data are expressed as mean systolic &#40;TAs&#41;&#44; mean &#40;TAm&#41; and diastolic &#40;TAd&#41; pressures&#46; PACU&#58; post-anaesthesia care unit&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1134
            "Ancho" => 2169
            "Tamanyo" => 98131
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing verbal reporting scale &#40;VRS&#41; scores in the post-anaesthesia care unit &#40;PACU&#41; at rest and on passive and active movement of the extremity in each group &#40;&#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; GC&#58; control group&#59; GPEC&#58; treatment group&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 2229
            "Ancho" => 2084
            "Tamanyo" => 180295
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing verbal reporting scale &#40;VRS&#41; scores obtained at 3&#44; 6 and 24 postoperative hours at rest and on passive and active movement of the extremity in each group&#46; GC&#58; control group&#59; GPEC&#58; treatment group&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Values are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or number of patients &#40;&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GC &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GPEC &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">163<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">163<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA &#40;I&#47;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1955076.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patient demographics&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Values are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or number of patients &#40;&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GC &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GPEC &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VRS PACU at rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VRS PACU on passive movement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VRS PACU on active movement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#46; of patients requiring morphine in PACU &#40;&#37; patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;085&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Milligrams &#40;mg&#41; of morphine consumed on the ward&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1955075.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">VRS scores in PACU and consumption of morphine&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Values are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or number of patients &#40;&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GC &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GPEC &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient satisfaction on discharge from PACU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;232&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient satisfaction at 24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgeon satisfaction at end of surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;099&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgeon satisfaction at 24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1955077.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Self-reported satisfaction of patients and surgeons in PACU and on the ward&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:42 [
            0 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pain control following breast augmentation&#58; a qualitative systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46;S&#46; Stanley"
                            1 => "I&#46;C&#46; Hoppe"
                            2 => "F&#46;S&#46; Ciminello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/1090820X12457014"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aesthet Surg J"
                        "fecha" => "2012"
                        "volumen" => "32"
                        "paginaInicial" => "964"
                        "paginaFinal" => "972"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22914699"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surgical anatomy of the pectoral nerves and the pectoral musculature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Porzionato"
                            1 => "V&#46; Macchi"
                            2 => "C&#46; Stecco"
                            3 => "M&#46; Loukas"
                            4 => "R&#46; Shane Tubbs"
                            5 => "R&#46; de Caro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ca.21301"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Anat"
                        "fecha" => "2012"
                        "volumen" => "25"
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