Combination of thoracic blocks as a main anesthetic tecnique in modified radical mastectomy for patients with severe respiratory disease. / Combinación de bloqueos torácicos como método anestésico principal en mastectomía radical modificada para pacientes con compromiso respiratorio severo.

The addition of ultrasound to locoregional anaesthesia in the last few years has led to the description of various fascial thoracic blocks with analgesic purposes: PECS 1 and 2 block, serratus plane block, serratus intercostal fascial block, blockade in the plane of the thoracic transverse muscle..., which have been added to other well-known nerve blocks, such as thoracic paravertebral block or intercostal block. In this sense, locoregional anaesthesia has been universally recommended in patients with severe respiratory processes in order to avoid ventilatory support and subsequent weaning that considerably increases postoperative morbidity and mortality rates. However, as regards thoracic wall and axillary hollow, there are very few references which detail the use of nerve or fascial blocks as a main anaesthetic method. Two extreme cases are presented of multi-pathological patients with serious respiratory disease who successfully underwent a modified radical mastectomy plus surgery in the axillary space using a combination of ultrasound-guided thoracic blocks that allowed surgery without general anaesthesia, avoiding mechanical ventilation, and maintaining spontaneous breathing throughout the surgical procedure. The main indications of the anaesthetic blocks used are described, focusing on the performance of the technique and underlining, in a novel way, the possibility of facing aggressive surgery at the level of the armpit with only locoregional anaesthesia.

Anaesthetic management of breast surgery in a patient with Eisenmenger syndrome. / Anestesia para cirugía de mama en una paciente con síndrome de Eisenmenger.

Eisenmenger syndrome (ES) is a complex combination of cardiovascular abnormalities defined as pulmonary hypertension with investment or bidirectional flow through an intracardiac or aortopulmonary communication, usually secondary to a congenital heart disease not resolved promptly. It carries a significant risk of perioperative mortality, with an incidence close to 30% for non-cardiac surgery. We report the anaesthetic management in a ES patient undergoing breast surgery, which was successfully performed under general anaesthesia combined with thoracic analgesic blocks. The main pathophysiological implications of this syndrome are discussed, emphasizing the importance of appropriate preoperative evaluation with thorough assessment of associated risks, careful intraoperative management, and postoperative care, which should be initially performed in a critical care unit. The need to individualize and tailor the choice of drugs and anesthetic technique to the hemodynamic condition of the patient and the surgical procedure is highlighted.

[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]. / Bloqueo paravertebral torácico frente al bloqueopararavertebral torácico más bloqueo de nervios pectoralesen cirugía reconstructiva de mama.

INTRODUCTION: Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements. MATERIAL AND METHODS: An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block. RESULTS: In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II. CONCLUSIONS: Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.

Bloqueo paravertebral torácico frente al bloqueo pararavertebral torácico más bloqueo de nervios pectorales en cirugía reconstructiva de mama / Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery

Introducción: La cirugía mayor de la mama se realizaba habitualmente con anestesia general hasta que aparecieron las primeras series publicadas con bloqueos paravertebrales torácicos. En nuestro centro hospitalario se introdujo este bloqueo con el objetivo de obtener un mayor confort perioperatorio, posteriormente se asoció el bloqueo de los nervios pectorales. En este trabajo comparamos ambas técnicas anestésicas, en cuanto a control del dolor postoperatorio, incidencia de náuseas y vómitos postoperatorios y requerimientos de sedación. Material y métodos: Se realizó un estudio observacional con 60 pacientes programadas para cirugía de mama con sustitución de dispositivos subpectorales (expansores y/o prótesis). Se estudiaron dos grupos. El primero (grupo I) fue seleccionado aleatoriamente de una base de datos histórica de pacientes a las que se practicó bloqueo paravertebral torácico y sedación. En el segundo (grupo II) se realizó prospectivamente un bloqueo de nervios pectorales asociado al bloqueo paravertebral torácico. Resultados: En el grupo I, el 33,3% tuvo un valor <= 3 en la escala visual analógica (EVA) a las 8 h y el 66,7%, un valor en la EVA >= 4 a las 24 h, frente al 80% de pacientes del grupo II que tuvieron un valor <= 3 en la EVA a las 8 h y el 20%, un valor en la EVA >= 4 a las 24 h. La diferencia de medias en la puntuación EVA a las 8 h entre los dos grupos alcanza la significación estadística: media en el valor de la EVA a las 8 h en el grupo I de 4,23 +/- 2,4 frente a 1,77 +/- 2,2 en el grupo II. No hubo diferencia en el valor de la EVA a las 24 h. No encontramos diferencias estadísticamente significativas entre ambos grupos en la incidencis de náuseas y vómitos postoperatoiros. La necesidad de suplementación de sedación intraoperatoria con bolos de propofol fue menor en el grupo II, el 40 frente al 90% del grupo II. Conclusiones: El bloqueo de los nervios pectorales es una técnica que mejora los resultados obtenidos con el bloqueo paravertebral torácico en la cirugía reconstructiva de la mama, con mejor control de la analgesia postoperatoria inmediata y menor necesidad de sedación(AU)

Introduction: Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements. Material and methods: An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block. Results: In Group I, 33.3% of the patients had a score of <= 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of >= 4 at 24h, compared to 80% of the Group II patients who had a VAS score of <= 3 at 8 hours and 20% with a VAS score >= 4 at 24 h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23+/-2.4 compared to 1.77+/-2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II. Conclusions: Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation(AU)

[Multiple-injection thoracic paravertebral block for reconstructive breast surgery]. / Bloqueo paravertebral torácico con punción múltiple en cirugía reconstructiva de la mama.

OBJECTIVE: To describe the use of multiple-injection thoracic paravertebral blockade, with intravenous sedation, for anesthesia during reconstructive breast surgery. MATERIAL AND METHODS: Descriptive, prospective study in 100 scheduled operations for major reconstructive breast surgery. The paravertebral block was performed by means of 3 injections at the lower edges of the vertebral apophyses at T3-5. We recorded time performing the procedure, latency (time until block onset), dermatomes blocked, degree of effectiveness, conversion to general anesthesia, postoperative complications and pain, and patient satisfaction. RESULTS: Dermatomes T3, T4, and T5 were blocked in 99% of the patients. The block took 7.39 minutes to perform and latency was 7.37 minutes. Postoperative analgesia with anti-inflammatory drugs was adequate for most patients. There were 3 cases of epidural diffusion, 10 patients with hypotension, 12 with postoperative nausea or vomiting, and 3 with symptoms of epidural blockade. Intravascular puncture occurred, without complications, in 3 cases. There were no cases of pneumothorax or intrathecal injection. Ninety-one percent of the patients declared they were satisfied or very satisfied with the technique. CONCLUSIONS: Triple-injection paravertebral blocks, in which 3 fractions of the total anesthetic dose are delivered to block dermatomes T3-5 is an effective technique that is easy to perform and leads to few complications. Most patients express a high degree of satisfaction with this anesthetic technique.

Bloqueo paravertebral torácico con punción múltiple en cirugía reconstructiva de la mama / Multiple-injection thoracic paravertebral block for reconstructive breast surgery

INTRODUCCIÓN: Estudio descriptivo con pacientessometidas a cirugía reconstructiva de la mama con bloqueoparavertebral torácico como única técnica anestésica,asociado a sedación endovenosa.MATERIAL Y MÉTODOS: Estudio descriptivo y prospectivoen 100 pacientes para cirugía mayor reconstructivade la mama. Se realizó el bloqueo paravertebral mediantetriple punción en el extremo inferior de las apófisistransversas T3-4-5. Se midieron: tiempo de realización dela técnica, periodo de latencia hasta la instauración delbloqueo, dermatomas bloqueados, grado de eficacia delbloqueo, reconversión en anestesia general. Tambiéncomplicaciones perioperatorias, el control del dolor postoperatorioy el grado de satisfacción de la paciente.RESULTADOS: En el 99% de las pacientes se bloquearonlos dermatomas T3-4-5. El tiempo de realización de latécnica fue de 7,39 min y el periodo de latencia 7,37 min.El control analgésico postoperatorio con antiinflamatoriosfue adecuado en la mayoría de los pacientes. Hubo3 casos de difusión epidural, 10 casos de hipotensiónarterial, 12 pacientes con náuseas o vómitos en el postoperatorioy 3 casos con clínica de bloqueo epidural.Hubo 3 punciones intravasculares sin repercusión. Noobservamos ningún caso de neumotórax ni de inyecciónintratecal. El 91% de los pacientes declararon sentirsesatisfechos o muy satisfechos con la técnica anestésica.CONCLUSIONES: El bloqueo paravertebral con triplepunción dividiendo en tres fracciones la dosis total deanestésico local, consiguiendo bloquear los dermatomasT3-4-5 es una técnica efectiva, sencilla y con baja incidenciade complicaciones. Además aportó un alto grado desatisfacción de la mayoría de los pacientes(AU)

OBJECTIVE: To describe the use of multiple-injectionthoracic paravertebral blockade, with intravenous sedation,for anesthesia during reconstructive breast surgery.MATERIAL AND METHODS: Descriptive, prospectivestudy in 100 scheduled operations for majorreconstructive breast surgery. The paravertebral blockwas performed by means of 3 injections at the loweredges of the vertebral apophyses at T3-5. We recordedtime performing the procedure, latency (time until blockonset), dermatomes blocked, degree of effectiveness,conversion to general anesthesia, postoperativecomplications and pain, and patient satisfaction.RESULTS: Dermatomes T3, T4, and T5 were blocked in99% of the patients. The block took 7.39 minutes toperform and latency was 7.37 minutes. Postoperativeanalgesia with anti-inflammatory drugs was adequatefor most patients. There were 3 cases of epiduraldiffusion, 10 patients with hypotension, 12 withpostoperative nausea or vomiting, and 3 with symptomsof epidural blockade. Intravascular puncture occurred,without complications, in 3 cases. There were no cases ofpneumothorax or intrathecal injection. Ninety-onepercent of the patients declared they were satisfied orvery satisfied with the technique.CONCLUSIONS: Triple-injection paravertebral blocks,in which 3 fractions of the total anesthetic dose aredelivered to block dermatomes T3-5 is an effectivetechnique that is easy to perform and leads to fewcomplications. Most patients express a high degree ofsatisfaction with this anesthetic technique(AU)

[Anesthetic considerations in sickle cell anemia: a case report]. / Descripción de un caso de drepanocitosis y consideraciones anestésicas.

Sickle cell anemia is the most common hemoglobinopathy. Advances in therapeutic techniques and anesthetic procedures have led to a considerable increase in the success of surgical procedures in these patients. We report the case of a 16-year-old black boy diagnosed with sickle cell anemia and beta-thalassemia who presented with chronic osteomyelitis of the tibia. He was scheduled for debridement of the lesion and musculocutaneous flap repair. We emphasize the importance of communication between anesthesiologists, surgeons, and hematologists in the perioperative period in order to determine the risk of complications and anticipate them.

Descripción de un caso de drepanocitosis y consideracionesanestésicas / Anesthetic considerations in sickle cell anemia: a case report

La drepanocitosis es la forma más frecuente de hemoglobinopatíaestructural. El avance en las técnicas y en eltratamiento anestésico de estos pacientes han determinadoun aumento importante en el éxito de los procedimientosquirúrgicos. Presentamos el caso de un varón de16 años, de raza negra, diagnosticado de drepanocitosisy ß-talasemia, que presentó osteomielitis crónica tibial yfue programado en quirófano para desbridamiento de lalesión y colgajo musculocutáneo. Destacamos la importancia,en el período perioperatorio, de la intercomunicaciónentre anestesiólogos, cirujanos y hematólogos,teniendo como propósito determinar el riesgo de padecercomplicaciones para poder anticiparse (AU)

Sickle cell anemia is the most commonhemoglobinopathy. Advances in therapeutic techniquesand anesthetic procedures have led to a considerableincrease in the success of surgical procedures in thesepatients. We report the case of a 16-year-old black boydiagnosed with sickle cell anemia and ß-thalassemia whopresented with chronic osteomyelitis of the tibia. He wasscheduled for debridement of the lesion and musculocutaneous flap repair. We emphasize theimportance of communication between anesthesiologists,surgeons, and hematologists in the perioperative periodin order to determine the risk of complications andanticipate them (AU)

Réplica a la carta al director titulada "Bloqueo paravertebral en cirugía de mama" / No disponible

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Anestesia subaracnoidea tras bloqueo del plexo braquial por vía posterior / No disponible

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