Case report
Unintended intrapleural insertion of an epidural catheter in thoracic surgery: regional analgesia game over, or is there another way out?
Inserción intrapleural involuntaria de un catéter epidural en cirugía torácica: ¿está fuera de juego la analgesia regional o existe otra salida?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "597" "paginaFinal" => "601" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Ribeiro, I. Castro, S. Lopes, G. Paupério" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Ribeiro" "email" => array:1 [ 0 => "carolinasbribeiro@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" => "I." "apellidos" => "Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Lopes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Paupério" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anesthesiology, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Anesthesiology, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Thoracic Surgery, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Inserción intrapleural involuntaria de un catéter epidural en cirugía torácica: ¿está fuera de juego la analgesia regional o existe otra salida?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1275 "Ancho" => 906 "Tamanyo" => 133664 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epidural catheter (white arrow) in the thoracic cavity relocated to the paravertebral space.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pain following thoracic surgery is not only uncomfortable, but can also be associated with serious complications arising from interference with cardiorespiratory mechanics, with a consequent increase in morbidity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Various techniques are used to provide thoracic analgesia, with epidural anesthesia (EA) and paravertebral block (PVB) being the most popular. Both are equally effective, but PVB is associated with fewer side effects.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Accidental intrapleural placement of the thoracic epidural catheter is a rare technique-related complication<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> that is rarely reported. It is usually resolved by removing the catheter or by administering intrapleural analgesia.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> We present a case of unintended intrapleural insertion of an epidural catheter, which was relocated to the paravertebral space by the surgeon and subsequently provided good postoperative analgesia.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 69-year-old man (height: 160<span class="elsevierStyleHsp" style=""></span>cm; weight: 100<span class="elsevierStyleHsp" style=""></span>kg; BMI 39.1<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), American Society of Anesthesiologists (ASA) physical status class III, presented for resection of a granular cell tumor in the right lower lobe by video-assisted thoracoscopic surgery (VATS). His medical history included hypertension, obesity, dyslipidemia and chronic kidney disease stage 3. Preoperative pulmonary and cardiac testing was generally unremarkable for acute processes, and blood investigations were within normal limits.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A combined anesthesia technique was proposed and the patient gave his informed consent. After standard ASA monitorization, the patient was placed in a sitting position for insertion of the thoracic epidural catheter and given 5 mcg of fentanyl for comfort. Epidural anesthesia was performed with an 8<span class="elsevierStyleHsp" style=""></span>cm 18-gauge Tuohy needle, and difficulties in identifying the midline were encountered due to patient biotype. The needle was finally inserted midline at the level of T6-T7, loss of resistance was encountered at a distance of 8<span class="elsevierStyleHsp" style=""></span>cm from the skin, and needle placement was confirmed using the hanging-drop technique. This was followed by the introduction of a 4.5<span class="elsevierStyleHsp" style=""></span>cm epidural catheter, which was uneventful. Depth of anesthesia was monitored using processed EEG monitoring (BIS), and after preoxygenation, general anesthesia was induced with an additional 50 mcg of fentanyl, 150<span class="elsevierStyleHsp" style=""></span>mg of propofol and 100<span class="elsevierStyleHsp" style=""></span>mg of rocuronium. The airway was secured with a 37 French left double-lumen endobronchial tube inserted using a McCoy laryngoscope blade. A fiberscope was used to confirm correct pulmonary exclusion. An arterial line was inserted in the left radial artery and a second large venous access (16<span class="elsevierStyleHsp" style=""></span>G) was obtained. Intravenous dexamethasone 4<span class="elsevierStyleHsp" style=""></span>mg and parecoxib (COX-2 inhibitor) 40<span class="elsevierStyleHsp" style=""></span>mg were administered immediately after induction, and epidural anesthesia was started with a bolus dose of 4<span class="elsevierStyleHsp" style=""></span>ml ropivacaine 0.5%. After 20<span class="elsevierStyleHsp" style=""></span>min, the patient showed signs of hypotension (baseline arterial pressure 150/95<span class="elsevierStyleHsp" style=""></span>mmHg, with a low of 85/48<span class="elsevierStyleHsp" style=""></span>mmHg) but responded well to 6<span class="elsevierStyleHsp" style=""></span>mg of ephedrine. Good hemodynamic stability was maintained, with mean arterial pressure above 70<span class="elsevierStyleHsp" style=""></span>mmHg, and no signs of analgesia inefficacy. One hour after the start of surgery, the surgical team decided to convert to open thoracotomy due to difficulties encountered in resecting the tumor by VATS. Another bolus of 4<span class="elsevierStyleHsp" style=""></span>ml of ropivacaine 0.5% was administered at that time. When surgeons had secured access to the open surgical field, they observed the tip of the epidural catheter in the right pleural cavity. After tumor removal with bronchial sleeve resection of the right intermediary bronchus was complete, the anesthesia team asked the surgeon to relocate the epidural catheter to the corresponding paravertebral space (PVS) at T6 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Under direct vision, it was relocated to the adipose tissue that fills the PVS, adjacent to the thoracic spine. Following this, a 12<span class="elsevierStyleHsp" style=""></span>ml bolus of ropivacaine 0.2% was administered, and absence of leakage into the pleural space was confirmed. During closure of the rib cage, 1<span class="elsevierStyleHsp" style=""></span>g of intravenous acetaminophen was administered. General anesthesia was reversed at the end of surgery with sugammadex, and the patient was extubated and transferred to the Post-Anesthesia Care Unit, hemodynamically stable and with good analgesia. However, he was later admitted to the Intensive Care Unit for vigilance due to respiratory insufficiency type 2 with acidosis, in the context of hypoventilation associated with obesity. Patient-controlled paravertebral analgesia was started immediately after surgery, with baseline perfusion of ropivacaine 0.2% 12<span class="elsevierStyleHsp" style=""></span>ml/h in 8<span class="elsevierStyleHsp" style=""></span>ml bolus doses with 120<span class="elsevierStyleHsp" style=""></span>min lock-out (maximum dose 70<span class="elsevierStyleHsp" style=""></span>ml over 4<span class="elsevierStyleHsp" style=""></span>h). Multimodal analgesia was also maintained with acetaminophen 1<span class="elsevierStyleHsp" style=""></span>g every 6<span class="elsevierStyleHsp" style=""></span>h and parecoxib 40<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h. Hemodynamic stability was maintained, and respiratory insufficiency was resolved 4<span class="elsevierStyleHsp" style=""></span>h later, with no need for noninvasive or mechanical ventilation. Pain was assessed on a 10<span class="elsevierStyleHsp" style=""></span>cm visual analog scale (VAS), with 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>no pain and 10<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>unbearable pain. On the first postoperative day, the patient reported a VAS score of 0 at rest, and <4 on movement, with 7 paravertebral boluses on demand over 24<span class="elsevierStyleHsp" style=""></span>h, for a VAS score >4. That day he was transferred to the Intermediate Care Unit. On the second postoperative day, analgesia was still effective, with 7 boluses over 24<span class="elsevierStyleHsp" style=""></span>h, and he was then transferred to the Thoracic Surgery ward. On the third postoperative day, he had a VAS score of 0 at rest, and <4 on movement and had started ambulation, with no boluses administered over 24<span class="elsevierStyleHsp" style=""></span>h. The paravertebral catheter was removed 12<span class="elsevierStyleHsp" style=""></span>h after prophylactic enoxaparin administration that day, and the chest drain was removed the following morning. Intravenous opioids were not required in the postoperative period. On the fourth day, he was discharged home with no complaints, and no lateral effects or PVB-related complications.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Although several reports of unintended intrapleural catheter placement following thoracic epidural have been published, the exact incidence cannot be accurately determined, because some cases go unnoticed.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> Misplacement is often the result of problems in identifying superficial landmarks, which was our main difficulty due to the patient’s obesity. The loss-of-resistance and hanging-drop techniques cannot distinguish between the pleural cavity and the epidural space, so correct placement must be confirmed by evaluating neural blockade.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In our patient, we administered epidural anesthesia after induction of general anesthesia, so we were unable to confirm neural blockade before the start of surgery. However, the hemodynamic response was consistent with thoracic epidural analgesia: hypotension after initial epidural bolus and no need for additional parental analgesia during VATS surgery. This was surprising, considering our subsequent finding, and it was remarkable that hemodynamic stability was maintained without the need for additional parental opioids during surgery. One possible explanation for successful analgesia was intrapleural analgesia. On the other hand, the catheter could have migrated between doses, since the first dose caused hypotension and the second dose did not, even though hemodynamics remained stable, with no hypertensive episodes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Standard practice after this complication is removal of the catheter, although some authors describe maintenance of the catheter for intrapleural analgesia.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> Opinions vary with regard to this type of analgesia. Many studies describe it to be insufficient even with large doses of local anesthetic, although in some reports it was considered effective for postoperative analgesia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The anatomical landmarks of the thoracic PVS are easily identified by direct vision in thoracoscopy or thoracotomy: medially, the vertebral bodies, the intervertebral discs and the intervertebral foramina; laterally, the PVS tapers and continues into the intercostal space near the costotransverse joint; superiorly and inferiorly, the PVS is partially separated from the adjacent levels by the ribs and transverse processes at each thoracic level; adipose tissue at the anteromedial corner is continuous over all thoracic levels; posteriorly, the PVS is bounded by the transverse process, the ribs, and the superior costotransverse ligament. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows an axial cross-section of a thoracic vertebra and the key anatomical PVS landmarks. In some centers, PVB performed under direct vision by the surgical team is considered as efficient as epidural analgesia for lung resection.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Even though the outcome in this case was uneventful, it serves as a reminder of the importance of paying attention to signs of potential problems when performing any invasive technique. Migration of the epidural catheter into the contralateral pleural cavity would have gone unnoticed, since the hemodynamic profile was consistent with epidural analgesia, but it could have caused complications such has pneumothorax, hemothorax or pulmonary injury, as previously described by other authors.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7</span></a> In challenging cases, such as obesity, we recommend using ultrasound to identify the midline and the depth of the epidural space in order to minimize the risk of incorrect epidural placement, and confirming correct positioning by testing the depth of blockade before administering general anesthesia.</p><p id="par0040" class="elsevierStylePara elsevierViewall">If our analgesic technique had failed, we could have performed erector spinae plane block (ESPB) - a new regional technique for postoperative analgesia that is becoming widely used in several interventions, including thoracic surgery. ESPB is an indirect PVB that targets a more superficial plane that is distant from the pleura and neuraxial structures.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Recent trials in VATS surgery have shown that it reduces both intra- and postoperative opioid consumption, and attenuates the postoperative release of inflammatory cytokines.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> However, further studies are needed to evaluate its analgesic efficacy after the first 24 postoperative hours, which would require a perineural catheter, and its effect on chronic pain after thoracotomy, a serious yet common problem.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Thoracic epidural is considered the gold-standard analgesia technique in thoracic surgery. Recent studies, however, have shown EA to be as effective as PVB, but with few of the contraindications and side effects associated with PVB.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,10</span></a> There are varios different techniques for inserting the paravertebral catheter, and the procedure can be performed by either the anesthesiologist or the surgeon under direct vision.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,11,12</span></a> When the catheter was found to have been misplaced in our patient, we searched for signs of complications, such as bleeding or lung injury. Since they were absent, and given the intrapleural position of the catheter near the paravertebral space, we decided that PVB would be a more reliable and effective option for analgesia in thoracotomy than parenteral opioids. To the best of our knowledge, relocation of the epidural catheter after initial misplacement has not previously been reported. In this case, it was successful, and shows that if such complications occur, we can look for alternatives to give our patient the best treatment possible.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors of this article have no conflicts of interest to declare.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have not received any type of funding for this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The patient gave his written consent for publication of this case.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1796070" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1572079" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1796069" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1572078" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Informed consent" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-03-27" "fechaAceptado" => "2021-05-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1572079" "palabras" => array:5 [ 0 => "Thoracic epidural" 1 => "Paravertebral block" 2 => "Thoracotomy" 3 => "Regional anesthesia" 4 => "Anesthesia complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1572078" "palabras" => array:5 [ 0 => "Epidural torácica" 1 => "Bloqueo paravertebral" 2 => "Toracotomía" 3 => "Anestesia regional" 4 => "Complicaciones de la anestesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia (EA) and paravertebral block (PVB) are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery (VATS). There was difficulty in epidural insertion related to patient’s obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En cirugía torácica, el control optimizado del dolor es esencial para prevenir disfunciones de la mecánica cardiorrespiratoria. La anestesia epidural (AE) y el bloqueo paravertebral (PVB) son las técnicas analgésicas más populares. La inserción intrapleural involuntaria de un catéter epidural es una complicación infrecuente.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nuestro informe presenta un caso de un paciente sometido a resección de tumor pulmonar mediante cirugía toracoscópica asistida por video (VATS). Existió dificultad para la inserción del catéter debido a la obesidad del paciente, pero tras la inducción de la anestesia no se necesitó analgesia intravenosa adicional tras la inyección epidural. Se requirió convertir la cirugía en toracotomía, con identificación intrapleural del catéter epidural. Al finalizar la cirugía los cirujanos reorientaron el catéter en el espacio paravertebral, con confirmación de ausencia de fuga tras la inyección de anestesia local a través del catéter. En el periodo postoperatorio el control del dolor fue eficaz y sin complicaciones.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se trata de un caso exitoso que muestra que cuando encontramos complicaciones imprevistas podemos buscar soluciones alternativas para proporcionar a nuestro paciente el mejor tratamiento.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1275 "Ancho" => 906 "Tamanyo" => 133664 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epidural catheter (white arrow) in the thoracic cavity relocated to the paravertebral space.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1160 "Ancho" => 2510 "Tamanyo" => 151614 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Anatomy of the paravertebral space (yellow). 1 – lung; 2 – oesophagus; 3 – azygos vein; 4 – thoracic duct; 5 – aorta; 6 – vertebral body; 7 – transverse process; 8 – spinous process; 9 – sympathetic ganglion; 10 – intercostal nerve; 11 – dorsal ramus of the spinal nerve; 12 – rib.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paravertebral block versus thoracic epidural for patients undergoing thoracotomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.H. 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