Case report
BRILMA block for costal cartilage excision: Case report
Bloqueo BRILMA para extirpación de cartílago costal: caso clínico
T. Silva Pereiraa,
, C. Rodrigues Silvaa, N.F. Veigab, P. Alfaro de la Torrec, M. Kabiri-Sacramentod
Corresponding author
a Departamento de Anestesiología, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
b Departamento de Anestesiología, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
c Departamento de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Joan XXIII, Tarragona, Spain
d Departamento de Anestesiología, Hospital Infanta Leonor, Madrid, Spain
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Silva Pereira, C. Rodrigues Silva, N.F. Veiga, P. Alfaro de la Torre, M. Kabiri-Sacramento" "autores" => array:5 [ 0 => array:4 [ "nombre" => "T." "apellidos" => "Silva Pereira" "email" => array:1 [ 0 => "teresasrspereira@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Rodrigues Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "N.F." "apellidos" => "Veiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Alfaro de la Torre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Kabiri-Sacramento" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Anestesiología, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Anestesiología, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Joan XXIII, Tarragona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Anestesiología, Hospital Infanta Leonor, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo BRILMA para extirpación de cartílago costal: caso clínico" ] ] "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" => 1092 "Ancho" => 1500 "Tamanyo" => 134899 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Spread of local anesthetic between the serratus anterior muscle and the external intercostal muscle in the BRILMA block.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">AL: local anesthetic; Pleur: pleura; r: 6th rib; SAm: serratus anterior muscle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The number of ultrasound-guided regional techniques for anesthesia and analgesia of the chest wall and upper abdomen has increased in recent years. Blockade of the lateral branches of the intercostal nerves in the mid-axillary line (BRILMA) or serratus-intercostal plane block is an opioid-sparing, superficial ultrasound technique that can be used for anesthesia or analgesia in breast surgery, supraumbilical abdominal surgery, thoracotomy, rib fractures, or thoracic tube insertion.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–9</span></a> In these cases, BRILMA, which is a single-shot technique with few associated risks, is a good alternative to deep neuraxial techniques such as thoracic paravertebral block and epidural analgesia.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The chest wall is innervated by the intercostal nerves that travel along the lower portion of the internal intercostal muscle. The lateral perforating cutaneous branches emerge superficially at the mid-axillary line. The lateral cutaneous branch pierces the external intercostal muscle that runs deep to the serratus anterior muscle at this point. Subcutaneously, the nerve is divided into the anterior and posterior branches. BRILMA consists of the ultrasound-guided injection of local anesthetic between the serratus anterior muscle and the external intercostal muscle in the mid-axillary line in order to block the lateral cutaneous branch of the intercostal nerve before it divides into the anterior and posterior branches.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5</span></a> The spread of local anesthetic from the anterior and lateral chest wall to the posterior mid-axillary line has been evidenced in cadaver and MRI studies.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,9,10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the literature, 3<span class="elsevierStyleHsp" style=""></span>ml of local anesthetic are needed to cover each dermatome of the chest wall, giving a total of 15<span class="elsevierStyleHsp" style=""></span>ml for each block.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,7</span></a> A study in porcine models showed that the spread of local anesthetic in the BRILMA block depends on the volume: 31% greater spread is achieved with 20 versus 10<span class="elsevierStyleHsp" style=""></span>ml. Clinical studies on interfascial plane blocks describe the use of between 15 and 30<span class="elsevierStyleHsp" style=""></span>ml of local anesthetic.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> According to some authors, BRILMA-induced sensory blockade can last up to 24 h.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In breast surgery and rib repair, BRILMA was initially administered at the level of the 5th rib.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2,8</span></a> However, it has been successfully administered at the level of the 8th rib for analgesia in abdominal surgery.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the moderate to severe pain caused by subcostal incision,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> we describe the use of ultrasound-guided BRILMA block at the level of the 6th rib to provide analgesia in the removal of rib cartilage for a laryngeal flap.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">Our patient gave her informed consent for the anesthetic procedure and the publication of this report.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A 49-year-old woman was scheduled for idiopathic subglottic stenosis repair with a cartilage flap from the 10th rib and tracheostomy. The stenosis had recurred despite 5 previous subglottic dilations using rigid bronchoscopy. The patient also had a history of gastro-oesophageal reflux and received daily pantoprazole 20<span class="elsevierStyleHsp" style=""></span>mg, prednisolone 30<span class="elsevierStyleHsp" style=""></span>mg and budesonide 200 μg.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Surgery was performed under TIVA with propofol and remifentanil, securing the airway with orotracheal intubation under video laryngoscopy vision. The tracheostomy was performed at the end of the procedure. Intraoperative analgesia was administered with 1<span class="elsevierStyleHsp" style=""></span>g paracetamol and 6<span class="elsevierStyleHsp" style=""></span>mg intravenous morphine.</p><p id="par0045" class="elsevierStylePara elsevierViewall">At the end of surgery, a modified ultrasound-guided BRILMA was performed at the level of the 6th rib, with the patient lying supine with the right arm in abduction. In a sterile field, a linear ultrasound probe (L25xp, 13–6<span class="elsevierStyleHsp" style=""></span>MHz; Fujifilm SonoSite, Bothell, WA, USA) was placed on the right mid-axillary line at the level of the 6th rib. The cross section of the rib was visualized, identifying the serratus intercostal plane, the anterior serratus more superficially, the rib and the intercostal muscles in the intermediate plane, and the pleura and lung in the deep plane. An 80<span class="elsevierStyleHsp" style=""></span>mm echogenic needle (SonoPlex STIM, 22 × 80<span class="elsevierStyleHsp" style=""></span>mm gauge; Pajunk, Geisingen, Germany) was inserted in plane in a caudocranial direction. When the tip of the needle reached the 6th rib and aspiration was negative, 20<span class="elsevierStyleHsp" style=""></span>ml of 0.2% ropivacaine was injected below the serratus muscle and above the rib. The local anesthetic was observed to spread between the serratus muscle of the rib and the intercostal muscles (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The analgesic technique was performed without complications, and the patient was extubated as soon as anesthesia was confirmed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Postoperative analgesia consisted of 1<span class="elsevierStyleHsp" style=""></span>g paracetamol every 6<span class="elsevierStyleHsp" style=""></span>h, 30<span class="elsevierStyleHsp" style=""></span>mg ketorolac every 8<span class="elsevierStyleHsp" style=""></span>h and 100<span class="elsevierStyleHsp" style=""></span>mg tramadol every 8<span class="elsevierStyleHsp" style=""></span>h. She was transferred to the post-anesthesia unit and was discharged to the ward after 2<span class="elsevierStyleHsp" style=""></span>h, reporting a maximum pain level of 3/10 (mild/moderate pain) on the numerical analog scale (throat discomfort related to tracheostomy), with no need for rescue analgesia. She reported no pain in the rib cage, and did not require additional intravenous morphine. Tramadol was discontinued on the second postoperative day, and on the fourth postoperative day she resumed an opioid-free oral analgesic regimen. The patient was discharged from the acute pain monitoring unit on the fifth postoperative day. During follow-up she reported only discomfort/pain of up to 3/10 on the numerical analog scale, and did not require rescue analgesia. During follow-up by the acute pain unit she reported no rib pain, and was discharged home on the thirteenth postoperative day.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">We achieved positive results with unilateral BRILMA administered at the level of the 6th rib to produce postoperative analgesia for the removal of rib cartilage. There is reason to believe that anesthetic/analgesic techniques play an important role in reducing the use of postoperative opioids. BRILMA was proven to be an opioid-saving technique, since no rescue morphine was required, and opioids were discontinued after the second postoperative day, even though subcostal incision is known to be particularly painful.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This modified BRILMA technique provided effective subcostal analgesia. The patient reported only mild to moderate pain (mainly localized in the neck) during her hospital stay, with no pain in the rib cage, suggesting that the sensory block was effective. The fact that the patient was immediately extubated with no postoperative respiratory complications is further evidence of the effectiveness of chest wall anesthesia. Good analgesia after thoracic and upper abdominal surgery is key to preventing postoperative respiratory complications such as pneumonia, pneumothorax, and pulmonary thromboembolism.</p><p id="par0060" class="elsevierStylePara elsevierViewall">We believe there are some studies that report successful BRILMA technique at the level of the 8th rib, although there is no description in the literature of its use for surgical interventions on costal cartilage.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Being an interfascial plane blockade, a similar effect is to be expected even when administered at a lower level, as the costal cartilage is innervated by the intercostal nerves. In our approach, better analgesia would have been achieved and opioid requirements would have been reduced if we had performed the technique before the surgical incision; this is something to bear in mind in the future.</p><p id="par0065" class="elsevierStylePara elsevierViewall">BRILMA is a superficial interfascial plane block with simple sonoanatomy, and is easily reproducible in most patients. It can be performed safely under both sedation and general anesthesia, reducing the number of punctures necessary to cover multiple metameric levels of the chest wall, as well as the risk of pneumothorax and local anesthetic toxicity. This makes it a safe technique in thoracic surgery, particularly when compared with deeper techniques such as epidural or paravertebral block, or even multiple intercostal blocks.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> In this case report, BRILMA provided analgesia for the removal of the rib cartilage. We believe that further clinical studies in modified BRILMA techniques are needed to confirm the effectiveness of this technique for surgical procedures on the chest wall and upper abdomen, in addition to breast surgeries and cholecystectomies.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">No funding was received for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1347380" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1239860" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1347381" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1239861" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-13" "fechaAceptado" => "2020-01-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1239860" "palabras" => array:5 [ 0 => "Pain management" 1 => "Acute pain" 2 => "Intercostal nerves" 3 => "Local anesthetic" 4 => "Thoracic wall" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1239861" "palabras" => array:5 [ 0 => "Manejo del dolor" 1 => "Dolor agudo" 2 => "Nervios intercostales" 3 => "Anestésico local" 4 => "Pared torácica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The block of the lateral branches of the intercostal nerves in the middle axillary line (BRILMA) is an interfascial ultrasound-guided block for analgesia in thoracic wall and upper abdominal surgery, presenting as an adequate alternative to neuraxial techniques. We present the case of a 49-year-old female scheduled for idiopathic subglottic stenosis repair with a costal cartilage graft from the 10th rib and tracheotomy. At the end of the surgery, unilateral ultrasound-guided BRILMA block with 20<span class="elsevierStyleHsp" style=""></span>ml of ropivacaine 0.2% was performed at the level of the 6th rib, uneventfully. Postoperatively, the patient referred a maximum level of pain of 3/10. There was no opioid consumption after the 2nd postoperative day, although a subcostal incision may produce considerable pain. BRILMA is a superficial block, easily reproducible in most patients. It diminishes the number of punctures needed in the thoracic wall, as well as the risk for pneumothorax and local anesthetic toxicity.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El bloqueo de las ramas laterales de los nervios intercostales en la línea axilar media (BRILMA) es un bloqueo ecoguiado interfascial para la analgesia en cirugía torácica y abdominal, y es una buena alternativa a las técnicas neuroaxiales. Presentamos el caso de una mujer de 49 años programada para reparación de estenosis idiopática subglótica, con extracción de cartílago costal de la décima costilla y traqueotomía. Tras la cirugía se realizó sin incidencias el bloqueo BRILMA unilateral con 20<span class="elsevierStyleHsp" style=""></span>ml de ropivacaína al 0,2% a nivel de la 6.ª costilla. En el postoperatorio, la paciente refirió un máximo de dolor de 3/10. No requirió opioides tras el segundo día postoperatorio, aunque una incisión subcostal puede producir dolor de considerable intensidad. BRILMA es una técnica superficial, fácilmente reproducible en la mayoría de los pacientes. Mediante una sola punción se logra alcanzar analgesia efectiva en múltiples dermatomas, disminuyendo el riesgo de neumotórax y la toxicidad anestésica local.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Silva Pereira T, Rodrigues Silva C, Veiga NF, Alfaro de la Torre P, Kabiri-Sacramento M. Bloqueo BRILMA para extirpación de cartílago costal: caso clínico. Rev Esp Anestesiol Reanim. 2020;67:271–274.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1092 "Ancho" => 1500 "Tamanyo" => 134899 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Spread of local anesthetic between the serratus anterior muscle and the external intercostal muscle in the BRILMA block.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">AL: local anesthetic; Pleur: pleura; r: 6th rib; SAm: serratus anterior muscle.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bloqueo de las ramas cutáneas laterales y anteriores de los nervios intercostales para analgesia de mama" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Fajardo Pérez" 1 => "F.J. García Miguel" 2 => "S. López-Álvarez" 3 => "P. Dieguez García" 4 => "P. Alfaro de la Torre" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Cir May Amb" "fecha" => "2012" "volumen" => "17" "paginaInicial" => "95" "paginaFinal" => "104" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abordaje ecoguiado de las ramas cutáneas de los nervios intercostales a nivel de la línea media axilar para cirugía no reconstructiva de mama" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Fajardo" 1 => "S. López" 2 => "P. Diéguez" 3 => "P. Alfaro" 4 => "F.J. García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Cir May Amb" "fecha" => "2013" "volumen" => "18" "paginaInicial" => "3" "paginaFinal" => "6" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiological study to evaluate the spreading of two volumes (10 vs 20<span class="elsevierStyleHsp" style=""></span>ml) of radiological contrast in the block of cutaneous branches of intercostal nerves in medial axillary line (BRILMA) in a porcine experimental model" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Varela" 1 => "A. Melone" 2 => "R. López-Menchaca" 3 => "R. Sevilla" 4 => "D. Callejo" 5 => "S. López-Álvarez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2018.05.001" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2018" "volumen" => "65" "paginaInicial" => "441" "paginaFinal" => "446" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29887291" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A novel ultrasound-guided block: a promising alternative for breast analgesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P.A. De La Torre" 1 => "P.D. García" 2 => "S.L. Álvarez" 3 => "F.J.G. Miguel" 4 => "M.F. Pérez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Aesthetic Surg J" "fecha" => "2014" "volumen" => "34" "paginaInicial" => "198" "paginaFinal" => "200" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound-assisted approach to blocking the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Diéguez García" 1 => "M. Fajardo Pérez" 2 => "S. López Álvarez" 3 => "P. Alfaro de la Torre" 4 => "A.P. Pensado Castiñeiras" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2013.04.002" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2013" "volumen" => "60" "paginaInicial" => "365" "paginaFinal" => "370" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23742791" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case report: Serratus intercostal plane block/BRILMA and sedation for mastectomy in a high risk patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Sanllorente-Sebastián" 1 => "J.M. de Vicente-Lorenzo" 2 => "F.J. Mediavilla-Herrera" 3 => "S. Gutiérrez-García" 4 => "I.S. Alario-Poza" 5 => "Z. Bustinza-Beaskoetxea" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redare.2018.06.009" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2019" "volumen" => "66" "paginaInicial" => "46" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30115502" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Serratus-intercostal interfascial block as an opioid-saving strategy in supra-umbilical open surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.T. Fernández Martín" 1 => "S. López Álvarez" 2 => "M.A. Pérez Herrero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2018.03.007" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2018" "volumen" => "65" "paginaInicial" => "456" "paginaFinal" => "460" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29789137" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BRILMA, herramienta eficaz para la analgesia en Cuidados Intensivos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Fajardo-Pérez" 1 => "R. Blancas" 2 => "M. Chana" 3 => "P. de la Torre Alfaro" 4 => "B. Estébanez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2018.11.001" "Revista" => array:5 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2019" "volumen" => "66" "paginaInicial" => "137-143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30545702" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. González-García" 1 => "A. González-Bada" 2 => "J.M. López-Ramos" 3 => "M.A. Echevarria-Correas" 4 => "M.B.G. Muñecas-Herreras" 5 => "L. Aguilera-Celorrio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2018.11.001" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2019" "volumen" => "66" "paginaInicial" => "137" "paginaFinal" => "143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30545702" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BRILMA methylene blue in cadavers: anatomical dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Diéguez" 1 => "M. Fajardo" 2 => "S. López" 3 => "P. Alfaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2015.03.007" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2016" "volumen" => "63" "paginaInicial" => "307" "paginaFinal" => "308" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26036780" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006700000005/v1_202006120646/S2341192920300561/v1_202006120646/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006700000005/v1_202006120646/S2341192920300561/v1_202006120646/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920300561?idApp=UINPBA00004N" ]
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