Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery | Revista Española de Anestesiología y Reanimación (English Edition)

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González-García, A. González-Bada, J.M. López-Ramos, M.A. Echevarria-Correas, M.B.G. Muñecas-Herreras, L. Aguilera-Celorrio" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "González-García" "email" => array:1 [ 0 => "joseba.gonzalez.garcia@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "González-Bada" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "López-Ramos" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Echevarria-Correas" ] 4 => array:2 [ "nombre" => "M.B.G." "apellidos" => "Muñecas-Herreras" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Aguilera-Celorrio" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesia y Reanimación, Hospital Universitario Basurto, Bilbao, Vizcaya, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 812 "Ancho" => 1520 "Tamanyo" => 67745 ] ] "descripcion" => array:1 [ "en" => "Evolution of NRS scores over time." ] ] ] "textoCompleto" => "IntroductionIn Spain, as in other countries, breast cancer has the highest incidence and mortality rate of all cancers in women, and as such constitutes a major public health problem. Both the number of cases and the incidence rate, currently at around 1–2% per year, continue to increase gradually both in Spain and worldwide. This is probably due, on the one hand, to population ageing, on the other hand, to early diagnosis.<a class="elsevierStyleCrossRef" href="#bib0120">1</a>Non-reconstructive breast surgery has increased dramatically in recent years with the implementation of different surgical techniques. New techniques that avoid large incisions, which are associated with moderate to severe postoperative pain, are now available. Postoperative pain is responsible for worsening respiratory function, cardiovascular events, endocrine and metabolic disorders, and psychological problems such as distress, fear and even depression, and the anxiety that this causes increases pain. Although postoperative pain levels are less severe, pain continues to be a factor, particularly in the early postoperative period.Thoracic paravertebral block is currently considered the gold standard regional technique in thoracic interventions; however, it is not routinely performed in many hospitals.<a class="elsevierStyleCrossRefs" href="#bib0125">2,3</a> This may be due to the fact that it is not entirely free from complications, some of which are potentially serious, and the technique itself has a steep learning curve. This why many hospitals still choose traditional opioid-based analgesia for postoperative pain management in breast surgery.The introduction of ultrasound as a working tool led to the development of new thoracic interfascial blocks<a class="elsevierStyleCrossRefs" href="#bib0135">4–7</a> as an alternative to paravertebral block. These blocks are simpler, easier to learn, present fewer complications, and can be performed in patients undergoing general anaesthesia. The study and understanding of mammary and axillary innervation soon led to confusion about the best block for each type of surgery. In this context, the intercostal nerve block in the midaxillary line (BRILMA)<a class="elsevierStyleCrossRefs" href="#bib0155">8,9</a> was described as the best nerve block for non-reconstructive breast surgery, because it is the intercostal and not the pectoral nerves are involved in this type of surgery. The aim of this block is to deposit the local anaesthetic in the plane between the medial aspect of the serratus anterior muscle and the external intercostal muscle (serratus-intercostal space) in order to block innervation of the skin of the anterolateral chest wall.This block should always be performed under ultrasound vision in order to avoid complications, correctly locate the interfascial space, and observe the spread of local anaesthetic in real time. It is a fairly easy technique that can be performed safely after sedation or general anaesthesia, and provides adequate analgesic control with few complications.<a class="elsevierStyleCrossRefs" href="#bib0155">8,10</a>BRILMA is indicated in lumpectomy, quadrantectomy, sentinel lymph node biopsy, mastectomy with or without axillary emptying, mastopexy, subglandular breast augmentation, mammography and marker placement, chronic pain after breast surgery, analgesia for chest tube drainage and rib fractures.We hypothesised that BRILMA performed in the immediate postoperative period of non-reconstructive breast surgery would give optimal analgesia while reducing the risk of opiate-related side effects and shortening hospital stay.The main aim of our study was to evaluate whether BRILMA associated with a multimodal analgesia regimen is an opioid-saving strategy that also improves postoperative pain management and patient safety after non-reconstructive ambulatory breast surgery. The secondary objectives included evaluation of nerve block-related complications, drug-related adverse events, and patient satisfaction with the anaesthetic technique used.Material and methodsWe performed a prospective, randomized study in patients undergoing outpatient non-reconstructive breast surgery at the Basurto University Hospital from May 2015 to July 2016. Inclusion criteria were: age over 18 years, American Society of Anaesthesiologist (ASA) status I–III, scheduled for outpatient quadrantectomy or lumpectomy. Exclusion criteria were: allergy to any of the study drugs, chronic opioid use, inability to understand the evaluation scales or cognitive impairment, and refusal to participate in the study. Patients were recruited from the surgery schedule released 2 weeks prior to the date of the intervention. Once the aim and implications of the study had been explained to the patients, they were informed of the type of study planned and their rights regarding their voluntary participation. When the patient had agreed to take part and signed the informed consent form, he or she was randomized to one of the 2 study groups.Sample sizeFor an alpha error of 5% (95% confidence interval and an accuracy of 3%), and estimating losses of 15%, a total of 80 study patients were needed, although the final sample size could be smaller depending on of the inclusion/exclusion criteria.Patient selection and randomisationThe patients who agreed to take part of the study were randomized to the ultrasound-guided BRILMA group (Group 1) or the standard analgesia group (Group 0). Patients were randomized according to a computer-generated sequence created on the statistical programme SAS. Only the principal investigator was aware of the randomisation sequence.Surgical technique and treatmentSurgery was performed following the standard protocol. The same anaesthesia regimen was used in all patients, total intravenous anaesthesia (TIVA) with propofol plus fentanyl (2 mcg/kg). Dosage depended on the corresponding anaesthetic-analgesic requirements. If heart rate and mean blood pressure increased by more than 15% over baseline at the time of surgical incision, intravenous fentanyl 1 mcg/kg was administered, repeating the dose at 30–45min intervals as required. After anaesthesia induction, 8-mg dexamethasone was administered. Following this, the corresponding analgesic protocol was administered depending on the patient's group.Group 1 (G1): using an M-Turbo® ultrasound system (Sonosite, Bothell, WA, USA), “BRILMA” was performed at the end of surgery, prior to extubation, on the mid-axillary line ipsilateral to the lesion, inserting a 22G 55mm needle (Locoplex®, Vygon, Ecouen, France). The transducer was placed in the mid-axillary line at the level of the sixth intercostal space, parallel to the axis of the body in a coronal plane; the needle was inserted in plane with respect to the transducer. Ropivacaine 0.475% 15ml (5ml per intercostal space) was injected between the external intercostal muscles and the serratus anterior muscle, confirming the spread of local anaesthetic (LA) from the sixth to the fifth, fourth, third and second intercostal spaces, and advancing the needle to ensure correct LA spread at these levels. Prior to this, 30min before the end of surgery, 50mg of dexketoprofen, 1g paracetamol and 4mg of ondansetron were administered. If the patient continued to present nausea and/or vomiting, they were given a rescue dose of 0.625mg of droperidol.Group 0 (G0): 30min before the end of surgery, 50mg dexketoprofen, 1g paracetamol and 4mg ondansetron were administered. If the patient continued to present nausea and/or vomiting, they were given a rescue dose of 0.625mg of droperidol.The postoperative analgesia regimen used in the Major Outpatient Surgery (MOS) unit was 1g intravenous paracetamol every 6h, 50mg intravenous dexketoprofen every 8h, and 50mg intravenous tramadol for rescue analgesia. The MOS post-discharge analgesia regimen was 600mg oral ibuprofen q8h, 1g paracetamol q6h and 575mg oral metamizol for rescue analgesia. This treatment was continued in the home for 48h.Patient characteristicsAll patients were followed up for the first 24h. Demographic variables were collected (age, sex, body mass index, ASA physical status, intraoperative fentanyl, type and length of incision, and duration of surgery) and the main study variable, pain rated on a verbal numerical rating scale (NRS) was collected at 30min, 2 and 6h in the MOS, and at 24h via phone call to the patient's home. The NRS scores ranged from 0 (no pain) to 10 (worse pain imaginable), and tramadol was administered for rescue analgesia in the MOS when the NRS was greater than 5.We also reviewed the appearance of surgery-related adverse effects: surgical wound infection or haematoma; and LA-related toxicity.Two days after discharge home, patients were contacted by phone to complete a global satisfaction survey on the analgesic treatment received and their quality of sleep during treatment. Patients were asked to rate satisfaction and sleep quality as: unsatisfactory, neither unsatisfactory nor satisfactory, satisfactory, and excellent. Finally, at 1, 3 and 6 months, patients were again contacted by phone and asked whether they were still experiencing pain, whether they had any other surgical wound symptoms, and whether they required rescue analgesia.Statistical analysisStudy data from both the overall sample and from each study group were initially analysed using descriptive statistics: means and standard deviations were found for continuous variables, and frequencies and percentages for qualitative variables. For this purpose, the nonparametric Wilcoxon test for independent samples was used (for continuous variables) and the chi-square test (for categorical variables). Study variables were NRS score and opioid consumption. NRS was additionally divided into 3 different groups (≤3, 4–6, ≥7). The mean and standard deviation of each measurement and treatment group were determined for both variables. The differences in means between both groups were compared at each measurement point using the nonparametric Wilcoxon test for independent samples. The chi-square test was used to compare the percentages of the different NRS scores between the 2 groups (control group and treatment group). The evolution of NRS score and consumption of tramadol in both study groups were analysed and compared over time Finally, the presence of various complications associated with: (1) insertion of the needle used to perform the block, or the administration of LA (toxicity, haematoma, infection); (2) the consumption of tramadol (nausea, vomiting, itching and paralytic ileus) were compared between groups. Fisher's exact test was used to determine the correlation between complications and treatment groups. Statistical analyses were performed on the statistical package SAS System (v9.2). The significance level was set at p<0.05.ResultsA total of 75 patients were included in the study, 38 in the interfascial block group (G1) and 37 in the standard analgesia group (G0). No patients were excluded after recruitment and prior to randomisation. In addition, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, groups were well-matched in terms of sociodemographic variables, preoperative baseline status, and surgical variables.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Patients receiving BRILMA block, as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, reported less overall pain in the immediate postoperative period, measured by the NRS, compared to patients receiving standard analgesia. Significant differences were observed in overall scores, and scores at 30min, 2h, 6h and 24h respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>With regard to use of tramadol as rescue analgesia for acute postoperative pain (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), significant differences were found between both groups throughout the treatment period, both in partial (30min, 2, 6 and 24h) and overall consumption. At the end of the study, mean total consumption was 10.5mg in the BRILMA group compared with 34.3mg tramadol in the control group (p=0.0001) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The appearance of tramadol-related adverse effects did not differ significantly between groups, although more patients in the standard analgesia group presented nausea and vomiting.No BRILMA-related complications or LA-related toxicity were observed. No other complications or adverse effects were observed in any patients during the study period.Overall, overall satisfaction scores were higher and quality of sleep was better in G1. It is also interesting to note that all patients in G1 would be willing to receive the same analgesic treatment in the future, compared with 5 G0 patients that would not.Finally, one month after the surgical intervention, persistence of surgical wound pain was greater in G0. This difference was statistically significant, and patients required minor analgesics for pain relief. At 3 months, despite the prevalence of persistent surgical wound pain in G0, differences between groups were not statistically significant. At 6 months, no patients in either G1 or G0 reported persistent surgical wound pain (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionBRILMA was developed after extensive study of the anatomy of the anterolateral region of the thorax, a review of regional anaesthesia techniques reported in breast surgery, and the application of ultrasound anatomical imaging skills to identify thoracic structures. This knowledge was applied to a pilot cadaver study in which the spread of methylene blue dye was observed in the serratus-intercostal fascial plane after performance of BRILMA block. One of the advantage of this new ultrasound-guided technique guided is that a single injection site is sufficient to reach the anterior and lateral cutaneous branches of the intercostal nerves of the different metameric levels involved in non-reconstructive breast and axillary surgery (from the second to the sixth intercostal nerves).We have found that performing BRILMA as a complement to conventional analgesia in non-reconstructive breast surgery considerably lowers pain scores, which reduces the need for rescue analgesia and results in important tramadol savings in the postoperative period. Our results are consistent with those reported by Dieguez García et al.,<a class="elsevierStyleCrossRef" href="#bib0165">10</a> and confirm our working hypothesis that BRILMA produces optimal analgesia in non-reconstructive breast surgery.<a class="elsevierStyleCrossRef" href="#bib0170">11</a>The spread of the LA into the fascial space effectively blocks the lateral and anterior cutaneous branches of the intercostal nerves. The nerve branches are blocked at their point of bifurcation or, as previously described in a pilot cadaver study in which this approach was used to infiltrate methylene blue in 12 hemithoraxes of 6 cadavers, by the spread of LA from the external to the innermost intercostal muscles where it contacts the anterior cutaneous branches of the intercostal nerves on their course towards the parasternal line before they emerge at the level of the skin to innervate the corresponding cutaneous region.<a class="elsevierStyleCrossRefs" href="#bib0175">12–14</a> The results of cadaver studies describe the spread of the dye in the interfascial spaces. However, such studies cannot reflect the dynamic factors found in in vivo experiments, such the effect of respiratory activity on the spread of the LA. Furthermore, in cadaver studies, dissection is performed at room temperature, and it is unclear whether this factor can influence the spread of methylene blue.The results support the safety of the technique; however, the trajectory and tip of the needle must be observed at all times to reduce the risk of complications derived from incorrect placement. It is important to avoid injecting the LA in the intercostal muscles, since this would generate an intercostal nerve block, which would expand the intercostal space and cause the parietal pleura to descend, thus preventing the spread of LA to the superior costal levels.<a class="elsevierStyleCrossRefs" href="#bib0190">15–17</a> Similarly, if the LA is infiltrated in the serratus anterior muscle, it will cause it to bulge and prevent spread of the LA, limiting the block to the nerve fibres in the vicinity of the injection site.<a class="elsevierStyleCrossRefs" href="#bib0205">18,19</a>BRILMA is an uncomplicated, technically simple procedure that is easily reproduced and has a short learning curve for anaesthesiologists who are highly skilled in regional ultrasound-guided anaesthesia. It has a short latency and blocks all cutaneous sensory innervation of the breast region with a single entry site. The combination of ultrasound guidance and low-dose LA increase the safety margin of this technique, and allow it to be used in awake patients, or in patients under conscious sedation or general anaesthesia.Other interfascial blocks have also been described for non-reconstructive breast surgery, such as the interpectoral block, in which LA is infiltrated between the pectoralis major and minor muscles. However, recent studies<a class="elsevierStyleCrossRefs" href="#bib0215">20,21</a> have shown that the use of this nerve block in this type of surgery does not reduce opioid requirements when compared to conventional analgesia. However, like our findings, these reports must be analysed with caution due to their single-centre design and small sample size.For this reason, our small sample size, despite its homogeneity, is an important limitation of our study, and further studies with a larger sample of heterogeneous patients will be required to increase statistical power and external validity. In addition, this was a simple, randomized, prospective study, which provides limited scientific evidence, and new comparative studies and randomized clinical trials are called for.ConclusionsThere are currently many different strategies for the management of postoperative pain using ultrasound-guided regional nerve blocks. The emergence of level A scientific evidence for regional techniques<a class="elsevierStyleCrossRefs" href="#bib0130">3,22,23</a> as a coadjuvant to general anaesthesia in breast surgery now compels anaesthesiologists to learn the different techniques and update their anatomical knowledge. This approach improves management of acute postoperative pain, reduces the incidence of chronic pain, improves postsurgical rehabilitation, and reduces pulmonary and cardiovascular complications.In conclusion, our results show that ultrasound-guided BRILMA block is an effective alternative to conventional opioid-based analgesia in non-reconstructive breast surgery. It effectively reduces both postoperative pain levels and opioid consumption. It is a simple, easily repeated technique with a short learning curve that can be used in daily practice in this type of surgery for effective pain control with few, very minor, potential complications.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1160503" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1086802" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1160502" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1086801" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Sample size" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Patient selection and randomisation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical technique and treatment" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Patient characteristics" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-07-31" "fechaAceptado" => "2018-11-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1086802" "palabras" => array:6 [ 0 => "Nerve block" 1 => "Intercostal nerves" 2 => "Regional anaesthesia" 3 => "Breast-conserving surgery" 4 => "Opioids" 5 => "Ultrasound" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1086801" "palabras" => array:6 [ 0 => "Bloqueo nervioso" 1 => "Nervios intercostales" 2 => "Anestesia regional" 3 => "Cirugía conservadora de mama" 4 => "Opioides" 5 => "Ultrasonografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThe objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostals nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast. Material and methodsA prospective, randomized and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol. ResultsStatistically significant differences were observed in the consumption of tramadol during the study period (10.5mg in the BRILMA group, compared to 34.3 in the control group, p=.0001). There were also differences in the pain assessment, with lower values found in the BRILMA group. ConclusionsIn non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoNuestro objetivo es evaluar si la realización de un bloqueo interfascial, el bloqueo de las ramas cutáneas de los nervios intercostales en la línea axilar media (BRILMA) asociado a una pauta analgésica multimodal mejora la analgesia postoperatoria y permite ahorrar opioides tras cirugía no reconstructiva de mama. Material y métodosRealizamos un estudio aleatorizado y prospectivo simple, donde los pacientes fueron sometidos a cirugía no reconstructiva de mama. Los pacientes fueron asignados aleatoriamente al grupo de realización del bloqueo, o al grupo de analgesia postoperatoria estándar (paracetamol y dexketoprofeno). Las variables principales analizadas fueron la intensidad del dolor evaluada mediante la escala numérica verbal y las necesidades de rescate analgésico con tramadol. ResultadosSe observaron diferencias estadísticamente significativas en el consumo de tramadol durante el periodo de estudio (10,5mg en el grupo BRILMA, frente a los 34, 3 en el grupo control, p=0,0001). Asimismo también hubo diferencias en la evaluación del dolor con valores más bajos en el grupo BRILMA. ConclusionesEn cirugía no reconstructiva de mama la realización de un bloqueo BRILMA permite obtener unas puntuaciones de dolor más bajas, lo que implica menor necesidad de rescate y un importante ahorro de tramadol en el periodo." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: González-García J, González-Bada A, López-Ramos JM, Echevarria-Correas MA, Muñecas-Herreras MBG, Aguilera-Celorrio L. Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama. Rev Esp Anestesiol Reanim. 2019;66:137–143." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: www.elsevier.es/redar." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 812 "Ancho" => 1520 "Tamanyo" => 67745 ] ] "descripcion" => array:1 [ "en" => "Evolution of NRS scores over time." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 790 "Ancho" => 1496 "Tamanyo" => 68794 ] ] "descripcion" => array:1 [ "en" => "Evolution of tramadol consumption over time." ] ] 2 => 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" => "Results are shown as absolute frequency (percentage) except * which is shown as mean (SD).ASA: American Society of Anesthesiologists; G0: group without BRILMA; G1: group with BRILMA; NS: not significant." "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="" 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">G0 \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">G1 \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">Total \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 value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Demographic data</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 \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">Age (years)* \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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 (m)* \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Preoperative baseline status</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">ASA</td><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48 \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">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Clinical variables</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Incision length (cm)*</td><td class="td" title="table-entry " align="left" valign="top">8.69±1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.30±2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.98±1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Surgery duration (min)*</td><td class="td" title="table-entry " align="left" valign="top">66.40±5.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.20±6.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.8±5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Fentanyl (mcg)*</td><td class="td" title="table-entry " align="left" valign="top">245.61±5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">251.11±6.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">249.21±5.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981125.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient demographics, preoperative baseline status, and surgical variables." ] ] 3 => 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" => "Results are shown as mean (SD).NRS: numerical rating scale; G0: group without BRILMA; G1: group with BRILMA" "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">G0 \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">G1 \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 value \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">30min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2±1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">2h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \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">6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.20±5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3±0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \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">24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2±0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \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">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.40±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6±0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981129.png" ] ] ] ] "descripcion" => array:1 [ "en" => "NRS pain scores by groups." ] ] 4 => 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" => "Tramadol consumption shown in milligrams. Results are shown as mean (SD).G0: Group without BRILMA; G1: group with BRILMA" "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">G0 \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">G1 \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 value \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">30min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.7±33.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.6±16.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.03 \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">2h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.31±6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5±3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \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">6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.5±9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \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">24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.8±7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \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">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.31±7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.5±4.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981130.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Need for rescue tramadol." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Results are shown as absolute frequency (percentage).Non-opioid drugs: paracetamol, ibuprofen, metamizole; G0: group without BRILMA; G1: group with BRILMA; NS: not significant." "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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time \t\t\t\t\t\t\n \t\t\t\t</th><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="" 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">G0 \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">G1 \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">Total \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 value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">1 month</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Pain persists</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.00</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \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><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">0.01</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Every day \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><td class="td" title="table-entry " align="char" valign="top">0 \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><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥2 times per week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \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><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">3 months</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Pain persists</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \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><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Every day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥2 times per week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \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><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">6 months</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Pain persists</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981127.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pain at 1, 3 and 6 months after surgery." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Evolución del cáncer de mama. 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Original article

Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery

Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama

J. González-García

Corresponding author

joseba.gonzalez.garcia@hotmail.com

Corresponding author.

, A. González-Bada, J.M. López-Ramos, M.A. Echevarria-Correas, M.B.G. Muñecas-Herreras, L. Aguilera-Celorrio

Servicio de Anestesia y Reanimación, Hospital Universitario Basurto, Bilbao, Vizcaya, Spain

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        "titulo" => "Estudio prospectivo&#44; aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cut&#225;neas laterales de los nervios intercostales frente a analgesia convencional en cirug&#237;a no reconstructiva de mama"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolution of NRS scores over time&#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">In Spain&#44; as in other countries&#44; breast cancer has the highest incidence and mortality rate of all cancers in women&#44; and as such constitutes a major public health problem&#46; Both the number of cases and the incidence rate&#44; currently at around 1&#8211;2&#37; per year&#44; continue to increase gradually both in Spain and worldwide&#46; This is probably due&#44; on the one hand&#44; to population ageing&#44; on the other hand&#44; to early diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Non-reconstructive breast surgery has increased dramatically in recent years with the implementation of different surgical techniques&#46; New techniques that avoid large incisions&#44; which are associated with moderate to severe postoperative pain&#44; are now available&#46; Postoperative pain is responsible for worsening respiratory function&#44; cardiovascular events&#44; endocrine and metabolic disorders&#44; and psychological problems such as distress&#44; fear and even depression&#44; and the anxiety that this causes increases pain&#46; Although postoperative pain levels are less severe&#44; pain continues to be a factor&#44; particularly in the early postoperative period&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Thoracic paravertebral block is currently considered the gold standard regional technique in thoracic interventions&#59; however&#44; it is not routinely performed in many hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;3</span></a> This may be due to the fact that it is not entirely free from complications&#44; some of which are potentially serious&#44; and the technique itself has a steep learning curve&#46; This why many hospitals still choose traditional opioid-based analgesia for postoperative pain management in breast surgery&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The introduction of ultrasound as a working tool led to the development of new thoracic interfascial blocks<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#8211;7</span></a> as an alternative to paravertebral block&#46; These blocks are simpler&#44; easier to learn&#44; present fewer complications&#44; and can be performed in patients undergoing general anaesthesia&#46; The study and understanding of mammary and axillary innervation soon led to confusion about the best block for each type of surgery&#46; In this context&#44; the intercostal nerve block in the midaxillary line &#40;BRILMA&#41;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;9</span></a> was described as the best nerve block for non-reconstructive breast surgery&#44; because it is the intercostal and not the pectoral nerves are involved in this type of surgery&#46; The aim of this block is to deposit the local anaesthetic in the plane between the medial aspect of the serratus anterior muscle and the external intercostal muscle &#40;serratus-intercostal space&#41; in order to block innervation of the skin of the anterolateral chest wall&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This block should always be performed under ultrasound vision in order to avoid complications&#44; correctly locate the interfascial space&#44; and observe the spread of local anaesthetic in real time&#46; It is a fairly easy technique that can be performed safely after sedation or general anaesthesia&#44; and provides adequate analgesic control with few complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">BRILMA is indicated in lumpectomy&#44; quadrantectomy&#44; sentinel lymph node biopsy&#44; mastectomy with or without axillary emptying&#44; mastopexy&#44; subglandular breast augmentation&#44; mammography and marker placement&#44; chronic pain after breast surgery&#44; analgesia for chest tube drainage and rib fractures&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We hypothesised that BRILMA performed in the immediate postoperative period of non-reconstructive breast surgery would give optimal analgesia while reducing the risk of opiate-related side effects and shortening hospital stay&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The main aim of our study was to evaluate whether BRILMA associated with a multimodal analgesia regimen is an opioid-saving strategy that also improves postoperative pain management and patient safety after non-reconstructive ambulatory breast surgery&#46; The secondary objectives included evaluation of nerve block-related complications&#44; drug-related adverse events&#44; and patient satisfaction with the anaesthetic technique used&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">We performed a prospective&#44; randomized study in patients undergoing outpatient non-reconstructive breast surgery at the Basurto University Hospital from May 2015 to July 2016&#46; Inclusion criteria were&#58; age over 18 years&#44; American Society of Anaesthesiologist &#40;ASA&#41; status I&#8211;III&#44; scheduled for outpatient quadrantectomy or lumpectomy&#46; Exclusion criteria were&#58; allergy to any of the study drugs&#44; chronic opioid use&#44; inability to understand the evaluation scales or cognitive impairment&#44; and refusal to participate in the study&#46; Patients were recruited from the surgery schedule released 2 weeks prior to the date of the intervention&#46; Once the aim and implications of the study had been explained to the patients&#44; they were informed of the type of study planned and their rights regarding their voluntary participation&#46; When the patient had agreed to take part and signed the informed consent form&#44; he or she was randomized to one of the 2 study groups&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Sample size</span><p id="par0050" class="elsevierStylePara elsevierViewall">For an alpha error of 5&#37; &#40;95&#37; confidence interval and an accuracy of 3&#37;&#41;&#44; and estimating losses of 15&#37;&#44; a total of 80 study patients were needed&#44; although the final sample size could be smaller depending on of the inclusion&#47;exclusion criteria&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient selection and randomisation</span><p id="par0055" class="elsevierStylePara elsevierViewall">The patients who agreed to take part of the study were randomized to the ultrasound-guided BRILMA group &#40;Group 1&#41; or the standard analgesia group &#40;Group 0&#41;&#46; Patients were randomized according to a computer-generated sequence created on the statistical programme SAS&#46; Only the principal investigator was aware of the randomisation sequence&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique and treatment</span><p id="par0060" class="elsevierStylePara elsevierViewall">Surgery was performed following the standard protocol&#46; The same anaesthesia regimen was used in all patients&#44; total intravenous anaesthesia &#40;TIVA&#41; with propofol plus fentanyl &#40;2 mcg&#47;kg&#41;&#46; Dosage depended on the corresponding anaesthetic-analgesic requirements&#46; If heart rate and mean blood pressure increased by more than 15&#37; over baseline at the time of surgical incision&#44; intravenous fentanyl 1 mcg&#47;kg was administered&#44; repeating the dose at 30&#8211;45<span class="elsevierStyleHsp" style=""></span>min intervals as required&#46; After anaesthesia induction&#44; 8-mg dexamethasone was administered&#46; Following this&#44; the corresponding analgesic protocol was administered depending on the patient&#39;s group&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 1 &#40;G1&#41;</span>&#58; using an M-Turbo<span class="elsevierStyleSup">&#174;</span> ultrasound system &#40;Sonosite&#44; Bothell&#44; WA&#44; USA&#41;&#44; &#8220;BRILMA&#8221; was performed at the end of surgery&#44; prior to extubation&#44; on the mid-axillary line ipsilateral to the lesion&#44; inserting a 22<span class="elsevierStyleHsp" style=""></span>G 55<span class="elsevierStyleHsp" style=""></span>mm needle &#40;Locoplex<span class="elsevierStyleSup">&#174;</span>&#44; Vygon&#44; Ecouen&#44; France&#41;&#46; The transducer was placed in the mid-axillary line at the level of the sixth intercostal space&#44; parallel to the axis of the body in a coronal plane&#59; the needle was inserted in plane with respect to the transducer&#46; Ropivacaine 0&#46;475&#37; 15<span class="elsevierStyleHsp" style=""></span>ml &#40;5<span class="elsevierStyleHsp" style=""></span>ml per intercostal space&#41; was injected between the external intercostal muscles and the serratus anterior muscle&#44; confirming the spread of local anaesthetic &#40;LA&#41; from the sixth to the fifth&#44; fourth&#44; third and second intercostal spaces&#44; and advancing the needle to ensure correct LA spread at these levels&#46; Prior to this&#44; 30<span class="elsevierStyleHsp" style=""></span>min before the end of surgery&#44; 50<span class="elsevierStyleHsp" style=""></span>mg of dexketoprofen&#44; 1<span class="elsevierStyleHsp" style=""></span>g paracetamol and 4<span class="elsevierStyleHsp" style=""></span>mg of ondansetron were administered&#46; If the patient continued to present nausea and&#47;or vomiting&#44; they were given a rescue dose of 0&#46;625<span class="elsevierStyleHsp" style=""></span>mg of droperidol&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 0 &#40;G0&#41;</span>&#58; 30<span class="elsevierStyleHsp" style=""></span>min before the end of surgery&#44; 50<span class="elsevierStyleHsp" style=""></span>mg dexketoprofen&#44; 1<span class="elsevierStyleHsp" style=""></span>g paracetamol and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron were administered&#46; If the patient continued to present nausea and&#47;or vomiting&#44; they were given a rescue dose of 0&#46;625<span class="elsevierStyleHsp" style=""></span>mg of droperidol&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The postoperative analgesia regimen used in the Major Outpatient Surgery &#40;MOS&#41; unit was 1<span class="elsevierStyleHsp" style=""></span>g intravenous paracetamol every 6<span class="elsevierStyleHsp" style=""></span>h&#44; 50<span class="elsevierStyleHsp" style=""></span>mg intravenous dexketoprofen every 8<span class="elsevierStyleHsp" style=""></span>h&#44; and 50<span class="elsevierStyleHsp" style=""></span>mg intravenous tramadol for rescue analgesia&#46; The MOS post-discharge analgesia regimen was 600<span class="elsevierStyleHsp" style=""></span>mg oral ibuprofen q8<span class="elsevierStyleHsp" style=""></span>h&#44; 1<span class="elsevierStyleHsp" style=""></span>g paracetamol q6<span class="elsevierStyleHsp" style=""></span>h and 575<span class="elsevierStyleHsp" style=""></span>mg oral metamizol for rescue analgesia&#46; This treatment was continued in the home for 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patient characteristics</span><p id="par0080" class="elsevierStylePara elsevierViewall">All patients were followed up for the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; Demographic variables were collected &#40;age&#44; sex&#44; body mass index&#44; ASA physical status&#44; intraoperative fentanyl&#44; type and length of incision&#44; and duration of surgery&#41; and the main study variable&#44; pain rated on a verbal numerical rating scale &#40;NRS&#41; was collected at 30<span class="elsevierStyleHsp" style=""></span>min&#44; 2 and 6<span class="elsevierStyleHsp" style=""></span>h in the MOS&#44; and at 24<span class="elsevierStyleHsp" style=""></span>h <span class="elsevierStyleItalic">via</span> phone call to the patient&#39;s home&#46; The NRS scores ranged from 0 &#40;no pain&#41; to 10 &#40;worse pain imaginable&#41;&#44; and tramadol was administered for rescue analgesia in the MOS when the NRS was greater than 5&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We also reviewed the appearance of surgery-related adverse effects&#58; surgical wound infection or haematoma&#59; and LA-related toxicity&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Two days after discharge home&#44; patients were contacted by phone to complete a global satisfaction survey on the analgesic treatment received and their quality of sleep during treatment&#46; Patients were asked to rate satisfaction and sleep quality as&#58; unsatisfactory&#44; neither unsatisfactory nor satisfactory&#44; satisfactory&#44; and excellent&#46; Finally&#44; at 1&#44; 3 and 6 months&#44; patients were again contacted by phone and asked whether they were still experiencing pain&#44; whether they had any other surgical wound symptoms&#44; and whether they required rescue analgesia&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">Study data from both the overall sample and from each study group were initially analysed using descriptive statistics&#58; means and standard deviations were found for continuous variables&#44; and frequencies and percentages for qualitative variables&#46; For this purpose&#44; the nonparametric Wilcoxon test for independent samples was used &#40;for continuous variables&#41; and the chi-square test &#40;for categorical variables&#41;&#46; Study variables were NRS score and opioid consumption&#46; NRS was additionally divided into 3 different groups &#40;&#8804;3&#44; 4&#8211;6&#44; &#8805;7&#41;&#46; The mean and standard deviation of each measurement and treatment group were determined for both variables&#46; The differences in means between both groups were compared at each measurement point using the nonparametric Wilcoxon test for independent samples&#46; The chi-square test was used to compare the percentages of the different NRS scores between the 2 groups &#40;control group and treatment group&#41;&#46; The evolution of NRS score and consumption of tramadol in both study groups were analysed and compared over time Finally&#44; the presence of various complications associated with&#58; &#40;1&#41; insertion of the needle used to perform the block&#44; or the administration of LA &#40;toxicity&#44; haematoma&#44; infection&#41;&#59; &#40;2&#41; the consumption of tramadol &#40;nausea&#44; vomiting&#44; itching and paralytic ileus&#41; were compared between groups&#46; Fisher&#39;s exact test was used to determine the correlation between complications and treatment groups&#46; Statistical analyses were performed on the statistical package SAS System &#40;v9&#46;2&#41;&#46; The significance level 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><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 75 patients were included in the study&#44; 38 in the interfascial block group &#40;G1&#41; and 37 in the standard analgesia group &#40;G0&#41;&#46; No patients were excluded after recruitment and prior to randomisation&#46; In addition&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; groups were well-matched in terms of sociodemographic variables&#44; preoperative baseline status&#44; and surgical variables&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Patients receiving BRILMA block&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; reported less overall pain in the immediate postoperative period&#44; measured by the NRS&#44; compared to patients receiving standard analgesia&#46; Significant differences were observed in overall scores&#44; and scores at 30<span class="elsevierStyleHsp" style=""></span>min&#44; 2<span class="elsevierStyleHsp" style=""></span>h&#44; 6<span class="elsevierStyleHsp" style=""></span>h and 24<span class="elsevierStyleHsp" style=""></span>h respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">With regard to use of tramadol as rescue analgesia for acute postoperative pain &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; significant differences were found between both groups throughout the treatment period&#44; both in partial &#40;30<span class="elsevierStyleHsp" style=""></span>min&#44; 2&#44; 6 and 24<span class="elsevierStyleHsp" style=""></span>h&#41; and overall consumption&#46; At the end of the study&#44; mean total consumption was 10&#46;5<span class="elsevierStyleHsp" style=""></span>mg in the BRILMA group compared with 34&#46;3<span class="elsevierStyleHsp" style=""></span>mg tramadol in the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The appearance of tramadol-related adverse effects did not differ significantly between groups&#44; although more patients in the standard analgesia group presented nausea and vomiting&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">No BRILMA-related complications or LA-related toxicity were observed&#46; No other complications or adverse effects were observed in any patients during the study period&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Overall&#44; overall satisfaction scores were higher and quality of sleep was better in G1&#46; It is also interesting to note that all patients in G1 would be willing to receive the same analgesic treatment in the future&#44; compared with 5 G0 patients that would not&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Finally&#44; one month after the surgical intervention&#44; persistence of surgical wound pain was greater in G0&#46; This difference was statistically significant&#44; and patients required minor analgesics for pain relief&#46; At 3 months&#44; despite the prevalence of persistent surgical wound pain in G0&#44; differences between groups were not statistically significant&#46; At 6 months&#44; no patients in either G1 or G0 reported persistent surgical wound pain &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">BRILMA was developed after extensive study of the anatomy of the anterolateral region of the thorax&#44; a review of regional anaesthesia techniques reported in breast surgery&#44; and the application of ultrasound anatomical imaging skills to identify thoracic structures&#46; This knowledge was applied to a pilot cadaver study in which the spread of methylene blue dye was observed in the serratus-intercostal fascial plane after performance of BRILMA block&#46; One of the advantage of this new ultrasound-guided technique guided is that a single injection site is sufficient to reach the anterior and lateral cutaneous branches of the intercostal nerves of the different metameric levels involved in non-reconstructive breast and axillary surgery &#40;from the second to the sixth intercostal nerves&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We have found that performing BRILMA as a complement to conventional analgesia in non-reconstructive breast surgery considerably lowers pain scores&#44; which reduces the need for rescue analgesia and results in important tramadol savings in the postoperative period&#46; Our results are consistent with those reported by Dieguez Garc&#237;a et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> and confirm our working hypothesis that BRILMA produces optimal analgesia in non-reconstructive breast surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The spread of the LA into the fascial space effectively blocks the lateral and anterior cutaneous branches of the intercostal nerves&#46; The nerve branches are blocked at their point of bifurcation or&#44; as previously described in a pilot cadaver study in which this approach was used to infiltrate methylene blue in 12 hemithoraxes of 6 cadavers&#44; by the spread of LA from the external to the innermost intercostal muscles where it contacts the anterior cutaneous branches of the intercostal nerves on their course towards the parasternal line before they emerge at the level of the skin to innervate the corresponding cutaneous region&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#8211;14</span></a> The results of cadaver studies describe the spread of the dye in the interfascial spaces&#46; However&#44; such studies cannot reflect the dynamic factors found in <span class="elsevierStyleItalic">in vivo</span> experiments&#44; such the effect of respiratory activity on the spread of the LA&#46; Furthermore&#44; in cadaver studies&#44; dissection is performed at room temperature&#44; and it is unclear whether this factor can influence the spread of methylene blue&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The results support the safety of the technique&#59; however&#44; the trajectory and tip of the needle must be observed at all times to reduce the risk of complications derived from incorrect placement&#46; It is important to avoid injecting the LA in the intercostal muscles&#44; since this would generate an intercostal nerve block&#44; which would expand the intercostal space and cause the parietal pleura to descend&#44; thus preventing the spread of LA to the superior costal levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15&#8211;17</span></a> Similarly&#44; if the LA is infiltrated in the serratus anterior muscle&#44; it will cause it to bulge and prevent spread of the LA&#44; limiting the block to the nerve fibres in the vicinity of the injection site&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">BRILMA is an uncomplicated&#44; technically simple procedure that is easily reproduced and has a short learning curve for anaesthesiologists who are highly skilled in regional ultrasound-guided anaesthesia&#46; It has a short latency and blocks all cutaneous sensory innervation of the breast region with a single entry site&#46; The combination of ultrasound guidance and low-dose LA increase the safety margin of this technique&#44; and allow it to be used in awake patients&#44; or in patients under conscious sedation or general anaesthesia&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Other interfascial blocks have also been described for non-reconstructive breast surgery&#44; such as the interpectoral block&#44; in which LA is infiltrated between the pectoralis major and minor muscles&#46; However&#44; recent studies<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20&#44;21</span></a> have shown that the use of this nerve block in this type of surgery does not reduce opioid requirements when compared to conventional analgesia&#46; However&#44; like our findings&#44; these reports must be analysed with caution due to their single-centre design and small sample size&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For this reason&#44; our small sample size&#44; despite its homogeneity&#44; is an important limitation of our study&#44; and further studies with a larger sample of heterogeneous patients will be required to increase statistical power and external validity&#46; In addition&#44; this was a simple&#44; randomized&#44; prospective study&#44; which provides limited scientific evidence&#44; and new comparative studies and randomized clinical trials are called for&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0170" class="elsevierStylePara elsevierViewall">There are currently many different strategies for the management of postoperative pain using ultrasound-guided regional nerve blocks&#46; The emergence of level A scientific evidence for regional techniques<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;22&#44;23</span></a> as a coadjuvant to general anaesthesia in breast surgery now compels anaesthesiologists to learn the different techniques and update their anatomical knowledge&#46; This approach improves management of acute postoperative pain&#44; reduces the incidence of chronic pain&#44; improves postsurgical rehabilitation&#44; and reduces pulmonary and cardiovascular complications&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show that ultrasound-guided BRILMA block is an effective alternative to conventional opioid-based analgesia in non-reconstructive breast surgery&#46; It effectively reduces both postoperative pain levels and opioid consumption&#46; It is a simple&#44; easily repeated technique with a short learning curve that can be used in daily practice in this type of surgery for effective pain control with few&#44; very minor&#44; potential complications&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Material and methods"
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              "titulo" => "Results"
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              "titulo" => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec1086802"
          "titulo" => "Keywords"
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        2 => array:3 [
          "identificador" => "xres1160502"
          "titulo" => "Resumen"
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            0 => array:2 [
              "identificador" => "abst0025"
              "titulo" => "Objetivo"
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              "titulo" => "Material y m&#233;todos"
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              "titulo" => "Resultados"
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              "titulo" => "Conclusiones"
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        3 => array:2 [
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Material and methods"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Sample size"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Patient selection and randomisation"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Surgical technique and treatment"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Patient characteristics"
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              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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          "titulo" => "Discussion"
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          "titulo" => "Conflicts of interest"
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        10 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-07-31"
    "fechaAceptado" => "2018-11-09"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1086802"
          "palabras" => array:6 [
            0 => "Nerve block"
            1 => "Intercostal nerves"
            2 => "Regional anaesthesia"
            3 => "Breast-conserving surgery"
            4 => "Opioids"
            5 => "Ultrasound"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1086801"
          "palabras" => array:6 [
            0 => "Bloqueo nervioso"
            1 => "Nervios intercostales"
            2 => "Anestesia regional"
            3 => "Cirug&#237;a conservadora de mama"
            4 => "Opioides"
            5 => "Ultrasonograf&#237;a"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of this study is to determine whether the accomplishment of an interfascial blockade&#44; the blocking of the cutaneous branches of the intercostals nerves in the axillary line &#40;BRILMA&#41; associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; randomized and simple blind study was conducted on patients that underwent non-reconstructive breast surgery&#46; The patients were randomly assigned to the blocking group&#44; or to the standard post-operative analgesia group &#40;paracetamol and dexketoprofen&#41;&#46; The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Statistically significant differences were observed in the consumption of tramadol during the study period &#40;10&#46;5<span class="elsevierStyleHsp" style=""></span>mg in the BRILMA group&#44; compared to 34&#46;3 in the control group&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; There were also differences in the pain assessment&#44; with lower values found in the BRILMA group&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In non-reconstructive breast surgery&#44; performing a BRILMA block allows obtaining lower pain scores&#44; which implies less need for rescue analgesics and a significant saving of tramadol in the study period&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo es evaluar si la realizaci&#243;n de un bloqueo interfascial&#44; el bloqueo de las ramas cut&#225;neas de los nervios intercostales en la l&#237;nea axilar media &#40;BRILMA&#41; asociado a una pauta analg&#233;sica multimodal mejora la analgesia postoperatoria y permite ahorrar opioides tras cirug&#237;a no reconstructiva de mama&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Realizamos un estudio aleatorizado y prospectivo simple&#44; donde los pacientes fueron sometidos a cirug&#237;a no reconstructiva de mama&#46; Los pacientes fueron asignados aleatoriamente al grupo de realizaci&#243;n del bloqueo&#44; o al grupo de analgesia postoperatoria est&#225;ndar &#40;paracetamol y dexketoprofeno&#41;&#46; Las variables principales analizadas fueron la intensidad del dolor evaluada mediante la escala num&#233;rica verbal y las necesidades de rescate analg&#233;sico con tramadol&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se observaron diferencias estad&#237;sticamente significativas en el consumo de tramadol durante el periodo de estudio &#40;10&#44;5<span class="elsevierStyleHsp" style=""></span>mg en el grupo BRILMA&#44; frente a los 34&#44; 3 en el grupo control&#44; p&#61;0&#44;0001&#41;&#46; Asimismo tambi&#233;n hubo diferencias en la evaluaci&#243;n del dolor con valores m&#225;s bajos en el grupo BRILMA&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En cirug&#237;a no reconstructiva de mama la realizaci&#243;n de un bloqueo BRILMA permite obtener unas puntuaciones de dolor m&#225;s bajas&#44; lo que implica menor necesidad de rescate y un importante ahorro de tramadol en el periodo&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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            "identificador" => "abst0035"
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    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gonz&#225;lez-Garc&#237;a J&#44; Gonz&#225;lez-Bada A&#44; L&#243;pez-Ramos JM&#44; Echevarria-Correas MA&#44; Mu&#241;ecas-Herreras MBG&#44; Aguilera-Celorrio L&#46; Estudio prospectivo&#44; aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cut&#225;neas laterales de los nervios intercostales frente a analgesia convencional en cirug&#237;a no reconstructiva de mama&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;137&#8211;143&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar20005">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58; www&#46;elsevier&#46;es&#47;redar&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolution of NRS scores over time&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Evolution of tramadol consumption over time&#46;</p>"
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      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Results are shown as absolute frequency &#40;percentage&#41; except &#42; which is shown as mean &#40;SD&#41;&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; American Society of Anesthesiologists&#59; G0&#58; group without BRILMA&#59; G1&#58; group with BRILMA&#59; NS&#58; not significant&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Demographic data</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Men&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#46;54&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#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">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fentanyl &#40;mcg&#41;&#42;</td><td class="td" title="table-entry  " align="left" valign="top">245&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#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">251&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">249&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1981125.png"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patient demographics&#44; preoperative baseline status&#44; and surgical variables&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at2"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Results are shown as mean &#40;SD&#41;&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">NRS&#58; numerical rating scale&#59; G0&#58; group without BRILMA&#59; G1&#58; group with BRILMA</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">G0&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">G1&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> value&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">30<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" 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">2<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">1&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#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;8<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="left" valign="top">0&#46;00&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">6<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">1&#46;20<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><td class="td" title="table-entry  " align="char" valign="top">0&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;00&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">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">0&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&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;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;00&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">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9&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;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">NRS pain scores by groups&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Tramadol consumption shown in milligrams&#46; Results are shown as mean &#40;SD&#41;&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">G0&#58; Group without BRILMA&#59; G1&#58; group with BRILMA</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">G0&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">G1&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> value&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">30<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#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">32&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#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">0&#46;03&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">2<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">33&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#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">0&#46;00&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">6<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">18&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;00&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">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">14&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;00&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">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1981130.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Need for rescue tramadol&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Results are shown as absolute frequency &#40;percentage&#41;&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Non-opioid drugs&#58; paracetamol&#44; ibuprofen&#44; metamizole&#59; G0&#58; group without BRILMA&#59; G1&#58; group with BRILMA&#59; NS&#58; not significant&#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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><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="" 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">G0&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">G1&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">Total&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> value&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" title="table-entry  " rowspan="5" align="left" valign="top"><span class="elsevierStyleItalic">1 month</span></td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Pain persists</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">0&#46;00</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&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><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">0&#46;01</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Every day&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><td class="td" title="table-entry  " align="char" valign="top">0&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><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;2 times per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&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><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top"><span class="elsevierStyleItalic">3 months</span></td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Pain persists</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&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><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No medication&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;2 times per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&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><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><span class="elsevierStyleItalic">6 months</span></td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Pain persists</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">NS</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Pain at 1&#44; 3 and 6 months after surgery&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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