RESUMO
BACKGROUND: The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit. METHODS: Mortality and Glasgow Outcome Scale, Barthel Index, and 5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in the Medical Information Mart for Intensive Care III (MIMIC-III) database. RESULTS: The median (25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II (APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90 days was 56%, mortality at 1 year was 59.2%, and mortality at 5 years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6 months, in 25.5% of patients after 1 year, and in 22.1% of patients after 5 years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6 months, 70 (35-95) points at 1 year, and 90 (40-100) points at 5 years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1 year and 5 years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90 days and 56.2% after 5 years. CONCLUSIONS: In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90 days after admission is very high. Between 90 days and 5 years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.
RESUMO
BACKGROUND: Alcohol, illicit drugs, and psychotropic medications are well-known causes of traumatic events. However, the association of each type of substance with trauma recidivism remains unclear. OBJECTIVES: The purpose of this study was to quantify the strength of associations between the type of substance detected in patients admitted for traumatic injury and trauma recidivism, defined as a documented history of past trauma. METHODS: The presence of alcohol and drugs (cannabis, cocaine, amphetamines, methamphetamines, benzodiazepines, opiates, methadone, barbiturates, and tricyclic antidepressants) was analyzed in 1,156 patients between 16 and 70 years old, hospitalized in a trauma hospital between November 2011 and March 2015. Their past trauma history was retrieved from the health information system, which included patient health histories since 1999. Multinomial logistic regression analysis was used to estimate the strength of the association between types of substances detected in current trauma patients and trauma recidivism (documented history of past trauma). RESULTS: At least one substance was detected in 521 patients (45.1%): only alcohol in 159 (13.7%), only cannabis in 62 (5.4%), only psychotropic medications/opioids in 145 (12.5%), only cocaine/amphetamines in 14 (1.2%), and a combination of these groups in 141 (12.2%). The consumption of alcohol, illicit drugs, and/or psychotropic medications was associated with increased recidivism in all substance groups; the adjusted odds ratio for multiple recidivism was 3.17 (95% CI [2.29, 4.39]). CONCLUSION: Patients who screened positive for alcohol, illicit drugs, and/or psychotropic medications had a higher frequency of past trauma history compared with patients with negative tests, independently of age, gender, or the presence of previous psychiatric disorders.
Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Hospitalização/estatística & dados numéricos , Psicotrópicos/efeitos adversos , Transtornos Relacionados ao Uso de Substâncias/complicações , Ferimentos e Lesões/induzido quimicamente , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Adulto JovemRESUMO
OBJECTIVE: To conduct a survival study and evaluation of surgical treatment in a cohort of patients with diagnosis of supratentorial spontaneous intracerebral hemorrhage (ICH). MATERIALS AND METHODS: The study included all consecutive patients with supratentorial ICH admitted to the Intensive Care Units of three Spanish hospitals with Neurosurgery Department between 2009 and 2012. DATA COLLECTED: age, APACHE-II, Glasgow Coma Score (GCS), and pupillary anomalies on admission, intracerebral hemorrhage (ICH) score, location/volume of hematoma, intraventricular hemorrhage (IVH), surgical evacuation alone or with additional external ventricular drain, and 30-days survival and at hospital discharge RESULTS: A total of 263 patients were included. Mean age: 59.74±14.14 years. GCS: 8±4 points, APACHE II: 20.7±7.68 points. ICH Score: 2.32+1.04 points. Pupillary anomalies were observed in 30%. The 30-day mortality: 51.3% (45.3% predicted by ICH-score), and 53.2% at hospital discharge. A significant difference (p=0.004) was observed in hospital mortality rates between surgically treated patients (39.7%, n=78) versus those conservatively managed (58.9%, n=185); specifically in those with IVH surgically treated (34.2%, n=38) versus non-operated IVH (67.2%, n=125), p<0.001. No significant difference was found between mortality rates in patients without IVH. Multiple logistic regression analysis showed an OR for surgery of 1.04 (95% CI; 0.33-3.22) in patients without IVH versus 0.19 (95% CI; 0.07-0.53) in patients with IVH (decreased mortality with surgical treatment). The propensity score analysis for IVH patients showed improved survival of operated group (OR 0.23, 95% CI; 0.07-0.75), p=0.01. CONCLUSIONS: Hospital mortality was lower in patients who underwent surgery compared to patients conservatively managed, specifically for the subgroup of patients with intraventricular hemorrhage.
Assuntos
Hemorragia Cerebral/mortalidade , Mortalidade Hospitalar , Idoso , Hemorragia Cerebral/cirurgia , Drenagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVES: To compare the ability of the Glasgow Coma Scale (GCS) score, the GCS Pupils (GCS-P) score, and the Pupil Reactivity Score (PRS) to predict mortality in patients with severe head injury. MATERIAL AND METHODS: Retrospective analysis of all patients with severe head injury and initial GCS scores of 8 or lower on initial evaluation for whom records included pupil dilation information and clinical course after admission to intensive care units of participating hospitals. We assessed the ability of each of the 3 scores (GCS, GCS-P, and PRS) to predict mortality using discrimination analysis. Discrimination was estimated by calculating the areas under the receiver operating characteristic curves (AUC) and 95% CIs. RESULTS: A total of 1551 patients with severe head injury and pupil dilation records were studied. The mean age was 50 years, 1190 (76.7%) were males, and 592 (38.2%) died. No pupil dilation was observed in 905 patients (58.3%), 362 (23.3%) had unilateral mydriasis, and 284 (18.3%) had bilateral mydriasis. The GCS-P score was significantly better at predicting mortality, with an AUC of 0.77 (95% CI, 0.74-0.79), versus 0.69 (95% CI, 0.67-0.72) for the GCS, and 0.75 (95% CI, 0.72-0.77) for the PRS. As the GCS-P score decreased, mortality increased. CONCLUSION: The GCS-P was more useful than the GCS for predicting death after severe head injury.
OBJETIVO: Analizar la capacidad para predecir la mortalidad hospitalaria de la Escala de Coma de Glasgow con valoración pupilar (GCS-P) comparado con la Escala de Coma de Glasgow (GCS) y con la escala de reactividad pupilar (PRS) en pacientes con traumatismo craneoencefálico (TCE) grave. METODO: Análisis retrospectivo de cohortes de todos los pacientes con TCE, puntuación en la GCS # 8 en la atención inicial, datos de exploración pupilar inicial y del desenlace hospitalario ingresados en las unidades de cuidados intensivos participantes. Se determinó la capacidad predictiva de mortalidad de la GCS, PRS y la GCS-P mediante un análisis de discriminación. La discriminación se analizó empleando curvas operativas del receptor (COR), el área bajo la curva (ABC) y su intervalo de confianza del 95% (IC 95%). RESULTADOS: Se analizaron 1.551 pacientes con TCE grave y datos sobre exploración pupilar. La edad media fue de 50 años, 1.190 (76,7%) eran hombres, y hubo 592 (38,2%) defunciones. Hubo 905 (58,3%) pacientes sin alteraciones pupilares, 362 (23,3%) con midriasis unilateral y 284 (18,3%) pacientes con midriasis bilateral. El análisis del ABCCOR para predecir la mortalidad hospitalaria mostró de forma significativa una mejor capacidad predictiva del GCS-P con ABC = 0,77 (IC 95% 0,74-0,79) respecto al GCS con ABC = 0,69 (IC 95% 0,67-0,72). La reactividad pupilar mostró un ABC = 0,75 (IC 95% 0,72-0,77). Se observó un incremento de mortalidad con la disminución del GCS-P. CONCLUSIONES: La escala GCS-P presentó mejor rendimiento que la GCS para predecir mortalidad en el TCE grave.
Assuntos
Traumatismos Craniocerebrais , Midríase , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Escala de Coma de Glasgow , Estudos Retrospectivos , Traumatismos Craniocerebrais/diagnóstico , PupilaRESUMO
INTRODUCTION: Preload parameters in postresuscitation phase are not sufficiently sensitive to guide fluid therapy in critically ill patients. We analyzed modifications in the fluid therapy and vasoactive drugs of critically ill patients that were produced by inclusion of extravascular lung water (EVLW) data in the treatment protocol and evaluated the short-term response. METHODS: This observational and prospective study included consecutive patients with hypotension or hypoxemia, comparing the therapeutic plan for fluid and vasoactive drug treatment between before and after knowing the EVLW value. RESULTS: We studied 42 patients. After knowing the EVLW, 52.4% (n = 22) of initial therapeutic plans were changed, modifying fluid therapy in all of these cases and vasoactive therapy in 22% of them. EVLW value was 13.91 +/- 5.62 in patients with change of therapeutic plan versus 10 +/- 4.52 in those with no change (p < 0.05). No differences were found in preload parameters as a function of change/no change. The most frequent decision change (n = 13) was to fluid reduction plus diuretic administration, and patients with this modification had significantly (p < 0.05) higher EVLW values compared with the remaining patients with a change in fluid therapy. Out of the 22 patients with a modified therapeutic decision, the therapy proved effective in 18 patients CONCLUSION: Quantification of EVLW in patients who can be considered euvolemic induces important modifications in fluid and vasoactive therapy. These changes generally resulted in a lower volume loading and a positive outcome for the patient.
Assuntos
Estado Terminal/terapia , Água Extravascular Pulmonar/fisiologia , Hidratação/métodos , Hipotensão/terapia , Hipóxia/terapia , Síndrome do Desconforto Respiratório/terapia , Sepse/terapia , Análise de Variância , Fármacos Cardiovasculares/uso terapêutico , Distribuição de Qui-Quadrado , Feminino , Hemodinâmica , Humanos , Hipotensão/mortalidade , Hipotensão/fisiopatologia , Hipóxia/mortalidade , Hipóxia/fisiopatologia , Técnicas de Diluição do Indicador , Masculino , Estudos Prospectivos , Respiração Artificial , Síndrome do Desconforto Respiratório/fisiopatologia , Sepse/fisiopatologiaRESUMO
OBJECTIVE: The effect of drugs other than alcohol on severity of trauma remains unclear. Pooled data analyses in previous studies that grouped substances with opposite effects on the central nervous system (CNS) may have masked the influence of substances on injury severity. The aim was to analyze the effect of stimulant, hallucinogenic and depressant drugs other than alcohol on injury severity in trauma patients. METHODS: The presence of alcohol, stimulant drugs (cocaine, amphetamines and methamphetamines), depressant drugs (benzodiazepines, opiates, methadone and barbiturates) and hallucinogenic drugs (THC and PCP) was analyzed in 1187 patients between 16 and 70 years old admitted to a trauma hospital between November 2012 and June 2015. Injury severity was determined prospectively as the Injury Severity Score. A multivariate analysis was used to quantify the strength of association between exposure to substances and trauma severity, using the presence of alcohol as a stratification variable. RESULTS: Drugs other than alcohol were found in 371 patients (31.3%): 32 (2.7%) stimulants, 186 (15.3%) depressants, 78 (6.6%) hallucinogenics and 75 (5.6%) polydrug use. The presence of CNS depressant substances was associated with increased injury severity only in patients also exposed to alcohol, with an adjusted odds ratio of 4.63 (1.37-15.60) for moderate injuries and 7.83 (2.53-24.21) for severe. CONCLUSION: CNS depressant drugs had a strong influence on injury severity in patients who screened positive for alcohol consumption.
Assuntos
Depressores do Sistema Nervoso Central/farmacologia , Estimulantes do Sistema Nervoso Central/farmacologia , Etanol/farmacologia , Alucinógenos/farmacologia , Escala de Gravidade do Ferimento , Transtornos Relacionados ao Uso de Substâncias , Ferimentos e Lesões , Adolescente , Adulto , Idoso , Depressores do Sistema Nervoso Central/sangue , Estimulantes do Sistema Nervoso Central/sangue , Feminino , Alucinógenos/sangue , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Substâncias/sangue , Transtornos Relacionados ao Uso de Substâncias/complicações , Ferimentos e Lesões/sangue , Ferimentos e Lesões/complicações , Adulto JovemRESUMO
OBJECTIVE: Validation of the intracerebral haemorrhage (ICH) score in patients with a diagnosis of spontaneous ICH admitted to the intensive care unit (ICU). METHODS: A multicentre cohort study was conducted in all consecutive patients with ICH admitted to the ICUs of three hospitals with a neurosurgery department between 2009 and 2012 in Andalusia, Spain. Data collected included ICH, Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores. Demographic data, location and volume of haematoma and 30-day mortality rate were also collated. RESULTS: A total of 336 patients were included. 105 of whom underwent surgery. Median (IQR) age: 62 (50-70) years. APACHE-II: 21(15-26) points, GCS: 7 (4-11) points, ICH score: 2 (2-3) points. 11.1% presented with bilateral mydriasis on admission (mortality rate=100%). Intraventricular haemorrhage was observed in 58.9% of patients. In-hospital mortality was 54.17% while the APACHE-II predicted mortality was 57.22% with a standardised mortality ratio (SMR) of 0.95 (95% CI 0.81 to 1.09) and a Hosmer-Lemenshow test value (H) of 3.62 (no significant statistical difference, n.s.). 30-day mortality was 52.38% compared with the ICH score predicted mortality of 48.79%, SMR: 1.07 (95% CI 0.91 to 1.23), n.s. Mortality was higher than predicted at the lowest scores and lower than predicted in the more severe patients, (H=55.89, p<0.001), Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva calibration belt (p<0.001). The area under a receiver operating characteristic (ROC) curve was 0.74 (95% CI 0.69 to 0.79). CONCLUSIONS: ICH score shows an acceptable discrimination as a tool to predict mortality rates in patients with spontaneous ICH admitted to the ICU, but its calibration is suboptimal.
Assuntos
Hemorragia Cerebral/diagnóstico , Unidades de Terapia Intensiva/estatística & dados numéricos , APACHE , Idoso , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/patologia , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , EspanhaRESUMO
BACKGROUND: Injury patterns may differ in trauma patients when age is considered. This information is relevant in the management of trauma patients and for planning preventive measures. METHODS: We included in the study all patients admitted for traumatic disease in the participating ICUs from November 23rd, 2012 to July 31st, 2015 with complete records. Data on epidemiology, injury patterns, severity scores, acute management, resources utilisation and outcome were recorded and compared in the following groups of age: ≤55years (young adults), 56-65 years (adults), 66-75 years (elderly), >75years (very elderly). Quantitative data were reported as median (Interquartile Range (IQR) 25-75) and categorical data as number and percentage. Comparison between groups of age with quantitative variables was performed using the analysis of variance (ANOVA) test. Differences between groups with categorical variables were compared using the chi-square test. A value of p<0.05 was considered significant. RESULTS: We included 2700 patients (78.9% male). Median age was 46 (31-62) years. Blunt trauma was present in 93.7% of the patients. Median RTS was 7.55 (5.97-7.84). Median ISS was 20 (13-26). High-energy trauma secondary to motor-vehicle accident with rhabdomyolysis and drugs abuse showed an inverse linear association with ageing, whilst pedestrian falls with isolated brain injury, being run-over and pre-injury antiplatelets or anticoagulant treatment increased with age (in all cases p<0.001). Multiple injuries were more common in young adults (p<0.001). Acute kidney injury prevalence was higher in elderly and very elderly patients (p<0.001). ICU Mortality increased with age in spite of similar severity scores in all groups (p<0.001). The main cause of death in all groups was intracranial hypertension. CONCLUSIONS: Different injury patterns exist in relation with ageing in trauma ICU patients. Adult patients were more likely to present high-energy trauma with significant injuries in different areas whilst elderly patients were prone to low-energy falls, complicated by antiplatelets or anticoagulants use, resulting in severe brain injury and increased mortality.
Assuntos
Injúria Renal Aguda/mortalidade , Envelhecimento , Anticoagulantes/uso terapêutico , Unidades de Terapia Intensiva , Hipertensão Intracraniana/mortalidade , Traumatismo Múltiplo/mortalidade , Centros de Traumatologia , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Anticoagulantes/efeitos adversos , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/fisiopatologia , Traumatismo Múltiplo/terapia , Estudos Prospectivos , Espanha/epidemiologiaAssuntos
Comércio , Difusão de Inovações , Medicina Baseada em Evidências/economia , Motivação , Prevenção Secundária/economia , Ferimentos e Lesões/prevenção & controle , Prevenção de Acidentes/economia , Descontaminação , Uso de Medicamentos , Trato Gastrointestinal/microbiologia , Humanos , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Recidiva , Choque Hemorrágico/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Ácido Tranexâmico/economia , Ácido Tranexâmico/uso terapêutico , Ferimentos e Lesões/etiologiaRESUMO
PURPOSE OF REVIEW: Accurate quantification of extravascular lung water is an important issue in the management of patients with pulmonary edema. The single transpulmonary thermal indicator method has been available since the late 1990s. Its simplicity and easy application make it clinically attractive. RECENT FINDINGS: Several experimental studies have confirmed the accuracy of the single transpulmonary thermal indicator technique in comparisons with postmortem gravimetric method. Whereas changes in extravascular lung water of less than 100-200% are undetectable by other clinically applicable methods of lung injury assessment (chest radiograph and oxygenation), the single transpulmonary indicator has proven highly sensitive to small (10-20%) increases and is therefore useful to detect incipient pulmonary edema. In patients with sepsis or acute respiratory distress syndrome, extravascular lung water measurement offers information unobtainable by other means. SUMMARY: Extravascular lung water can be considered a relevant parameter that contributes to rational management of fluid and vasoactive therapy of many critically ill patients and offers a fuller picture of their overall lung function.
Assuntos
Água Extravascular Pulmonar/química , Edema Pulmonar/diagnóstico , Síndrome do Desconforto Respiratório/diagnóstico , Doença Aguda , Cuidados Críticos , Hidratação , Humanos , Prognóstico , Edema Pulmonar/patologia , Edema Pulmonar/terapia , Síndrome do Desconforto Respiratório/patologia , Síndrome do Desconforto Respiratório/terapia , Índice de Gravidade de Doença , Perfil de Impacto da DoençaRESUMO
OBJECTIVE: To study the mortality and quality of life (QOL) of survivors at 6 yrs after intensive care unit (ICU) admission for chronic obstructive pulmonary disease. DESIGN: Prospective, multiple-center cohort study. SETTING: A total of 86 ICUs throughout Spain. PATIENTS: Patients in the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) project with chronic obstructive pulmonary disease were included. MEASUREMENTS AND MAIN RESULTS: The sample comprised 742 patients; 508 of them were admitted for acute exacerbation of chronic obstructive pulmonary disease, and 379 of these required intermittent positive-pressure ventilation. The mean age of the patients was 65.2 +/- 9.89 yrs, Acute Physiology and Chronic Health Evaluation (APACHE) III score was 66.6 +/- 21.04; preadmission QOL questionnaire score was 7 +/- 4.82 points, and hospital mortality was 31.8%. At 6 yrs, 32.2% had died after hospital discharge, 21.6% could not be traced, and 107 patients were alive (18.3% of the 582 followed-up patients). QOL of survivors was worse than preadmission (6.55 +/- 5.6 vs. 4.92 +/- 4.5 points, p < .05), but 72% of patients were self-sufficient. Among the 379 patients admitted to the ICU for acute chronic obstructive pulmonary disease exacerbation and requiring intermittent positive-pressure ventilation, 36.7% died in the hospital; at 6 yrs after hospital discharge, 31.4% had died, 18.7% could not be traced, and 50 patients (16.2% of followed-up patients) were alive. Multivariate analysis with logistic regression showed that the mortality at 6 yrs was related to age (odds ratio, 1.046; 95% confidence interval, 1.023-1.071), APACHE III score (odds ratio, 1.013; 95% confidence interval, 1.001-1.024), and preadmission QOL score (odds ratio, 1.139; 95% confidence interval, 1.078-1.204). CONCLUSION: The 6-yr mortality of patients with chronic obstructive pulmonary disease requiring ICU admission is high. Mortality is mainly influenced by pre-ICU admission QOL. At 6 yrs, at least 15% are alive; survivors have a worse QOL compared with pre-ICU admission, although three quarters of them are self-sufficient.
Assuntos
Estado Terminal , Doença Pulmonar Obstrutiva Crônica/mortalidade , Qualidade de Vida , APACHE , Fatores Etários , Idoso , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Respiração com Pressão Positiva , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/terapia , Espanha/epidemiologia , Inquéritos e QuestionáriosRESUMO
El bloqueo paravertebral torácico o bloqueo intercostal extrapleural consiste en la administración de anestésicos locales en el espacio paravertebral adyacente al foramen intervertebral por donde emergen los nervios espinales, obteniendo un bloqueo somático y simpático ipsilateral en varios dermatomas contiguos, por encima y abajo del sitio de inyección. Es una técnica muy fácil de realizar y con una alta tasa de éxito. Este tipo de bloqueo puede estar indicado en cualquier tipo de patología dolorosa que afecte a la región toracoabdominal de forma unilateral. La realización de un bloqueo paravertebral continuo como parte de un régimen de analgesia balanceada proporciona una analgesia óptima tras toracotomías, comparable con el estándar de oro como es la analgesia epidural torácica y a la que se podría considerar como una alternativa segura y con menos riesgo de complicaciones.
The thoracic paracertebral block or the extrapleural intercostal block is the technique of injecting local anesthetic paravertebral space adjacent to the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramina. This results in ipsilateral somatic and sympathetic nerve blockade in multiple contiguous thoracic dermatomes above and below the site of inyection.It is a technique very easy to make and with a high rate of success. This type of blockade can be indicated in any type of painful pathology that affects the toracoabdominal region of unilateral form. The accomplishment of a blockade paravertebral continuous as it leaves from a regime of balanced analgesia provides an optimal analgesia after toracotomías, comparable with the gold standard like it is the thoracic epidural analgesia and to which it would be possible to be considered like a safe alternative and with less risk of complications.