Validación de la ecografía Point-of-Care para el diagnóstico de hernia diafragmática: a propósito de un caso / Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia

La ecografía Point-of-Care (POCUS) es una herramienta sensible y específica para diagnosticar de manera precoz la patología del diafragma en pacientes críticos. Presentamos un caso clínico de un paciente con antecedentes de hernia diafragmática iatrogénica que ingresó en la unidad de reanimación tras una laparotomía exploradora de emergencia. Aprovechando el diagnóstico conocido de hernia diafragmática, describimos los signos clínicos que debemos encontrar en la evaluación POCUS para establecer el diagnóstico de hernia diafragmática: 1)fracción de acortamiento diafragmático normal bilateral; 2)excursión diafragmática reducida, y 3)posición cefálica de la cúpula diafragmática 4)mayor en supino que en sedestación. Igualmente, proponemos una sistemática de exploración ecográfica del diafragma y una clasificación diferencial de la disfunción diafragmática evaluada mediante POCUS en función de la correcta integridad y el buen funcionamiento del músculo periférico y del tendón central diafragmáticos en el paciente crítico.(AU)

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1)normal bilateral diaphragmatic shortening fraction; (2)decreased diaphragmatic excursion, and (3)cephalic position of the diaphragmatic dome (4)greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.(AU)

Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia.

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1) normal bilateral diaphragmatic shortening fraction; (2) decreased diaphragmatic excursion; and (3) cephalic position of the diaphragmatic dome (4) greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.

A randomised controlled trial in patients undergoing arthroscopic shoulder surgery comparing interscalene block with either 10 ml or 20 ml levobupivacaine 0.25.

The interscalene brachial plexus block is recommended for analgesia after shoulder surgery but it may cause hemidiaphragmatic dysfunction. We tested whether ipsilateral hemidiaphragmatic contraction was better after a smaller dose of local anaesthetic without impairing analgesic effect. We randomly allocated 48 adults to 10 ml or 20 ml levobupivacaine 0.25% before arthroscopic shoulder surgery. The primary outcome was hemidiaphragmatic paralysis, defined as inspiratory thickness < 1.2 times expiratory thickness, measured by ultrasound 4 h after block. Hemidiaphragmatic paralysis was recorded for 6/24 vs. 23/24 supine participants after 10 ml vs. 20 ml levobupivacaine 0.25%, respectively, and for 4/24 vs. 23/24 sitting participants, respectively, p < 0.001 for both. Pain scores after 10 ml injectate were not worse than after 20 ml injectate. Median (IQR [range]) morphine doses in the first 24 postoperative hours after 10 ml and 20 ml levobupivacaine 0.25% were 2 (0-6 [0-23]) mg vs. 1 (0-2 [0-11]) mg, respectively, p = 0.12. No participant had a complication after 10 ml interscalene levobupivacaine, whereas seven had complications after 20 ml levobupivacaine, p = 0.009. Hemidiaphragmatic function was better after 10 ml vs. 20 ml interscalene levobupivacaine 0.25% without impairing analgesia for 24 postoperative hours.

Bloqueo del plano del erector del espinal para analgesia tras cesárea del segmento inferior: informe de caso / Erector spinae plane block for analgesia after lower segment caesarean section: Case report

La analgesia postoperatoria efectiva después de la cesárea de urgencia es importante porque proporciona una recuperación y deambulación temprana, así como el inicio precoz de la lactancia materna. El bloqueo del plano del erector del espinal guiado por ecografía ha sido descrito originalmente por Forero et al. para proporcionar analgesia torácica. Se realizaron bloqueos del plano del erector del espinal bilaterales postoperatorios con 20ml de bupivacaína al 0,25% al nivel de T9 en una embarazada para analgesia postoperatoria tras cesárea. En esta presentación describimos cómo el bloqueo del plano del erector del espinal bilateral en el nivel T9 proporciona analgesia postoperatoria efectiva y duradera para la cirugía abdominal inferior

Effective postoperative analgesia after emergency caesarean section is important because it provides early recovery, ambulation and breast-feeding. The ultrasound-guided erector spinae plane block has been orginally described for providing thoracic analgesia at the T5 transverse process by Forero et al. We performed post-operative bilateral erector spinae plane blocks with 20ml bupivacaine 0.25% at the level of the T9 transverse process in a pregnant woman after caesarean section. In this report, we described that bilateral erector spinae plane block at T9 level provides effective and long-lasting postoperative analgesia for lower abdominal surgery

Erector spinae plane block for analgesia after lower segment caesarean section: Case report. / Bloqueo del plano del erector del espinal para analgesia tras cesárea del segmento inferior: informe de caso.

Effective postoperative analgesia after emergency caesarean section is important because it provides early recovery, ambulation and breast-feeding. The ultrasound-guided erector spinae plane block has been orginally described for providing thoracic analgesia at the T5 transverse process by Forero et al. We performed post-operative bilateral erector spinae plane blocks with 20ml bupivacaine 0.25% at the level of the T9 transverse process in a pregnant woman after caesarean section. In this report, we described that bilateral erector spinae plane block at T9 level provides effective and long-lasting postoperative analgesia for lower abdominal surgery.

Valoración ecográfica de la función diafragmática y sus aplicaciones en el paciente crítico, en ventilación mecánica y en la anestesia del plexo braquial / Ultrasound evaluation of diaphragm function and its application in critical patients, mechanical ventilation and brachial plexus block

La valoración de la función diafragmática ha sido clásicamente poco considerada debido a la dificultad de su exploración. La aparición de la ecografía diafragmática ha aportado luz al problema y ofrece un terreno amplio que mejora significativamente nuestra capacidad diagnóstica y terapéutica en el paciente crítico o en los pacientes sometidos a anestesia regional del plexo braquial. La parálisis o la hipoquinesia diafragmática aparece como un problema mucho más frecuente de lo que se creía. La ecografía permite su diagnóstico precoz así como la cuantificación dinámica del problema facilitando la toma de decisiones preventivas y terapéuticas precoces. También se está delineando como un instrumento de guía en el proceso de destete de la ventilación mecánica y en el abordaje más seguro del plexo braquial. En este trabajo presentamos la sistemática de su exploración y su utilización clínica (AU)

Before diaphragm ultrasonography, assessment of diaphragm function was very difficult due to the complex nature of its exploration. The use of this new technique has shed light on diagnostic problems and treatment with an improvement in final outcomes for critically ill patients, in whom the incidence of diaphragm weakness or dysfunction has been underestimated. Better knowledge of diaphragm function enables us earlier diagnosis by quantification of diaphragm contractile activity or evaluation of functional status after delivery of plexus block anaesthesia, facilitating therapeutic decisions. It is also being used as a guide in the process of weaning from mechanical ventilation or as the safest approach for braquial plexus block. In this review we present how to perform a systematic exploration of diaphragm function and its clinical implications (AU)

Ultrasound evaluation of diaphragm function and its application in critical patients, mechanical ventilation and brachial plexus block. / Valoración ecográfica de la función diafragmática y sus aplicaciones en el paciente crítico, en ventilación mecánica y en la anestesia del plexo braquial.

Before diaphragm ultrasonography, assessment of diaphragm function was very difficult due to the complex nature of its exploration. The use of this new technique has shed light on diagnostic problems and treatment with an improvement in final outcomes for critically ill patients, in whom the incidence of diaphragm weakness or dysfunction has been underestimated. Better knowledge of diaphragm function enables us earlier diagnosis by quantification of diaphragm contractile activity or evaluation of functional status after delivery of plexus block anaesthesia, facilitating therapeutic decisions. It is also being used as a guide in the process of weaning from mechanical ventilation or as the safest approach for braquial plexus block. In this review we present how to perform a systematic exploration of diaphragm function and its clinical implications.

Imagen ecográfica pulmonar de punto delimitante entre neumotórax y derrame pleural / Pulmonary ultrasound image: the defining point between pneumothorax and pleural effusion

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Ecografía pulmonar básica. Parte 2. Patología parenquimatosa / Basic lung ultrasound. Part 2. Parenchymal diseases

En esta segunda parte se aborda de manera específica la patología del parénquima pulmonar. El tema está estructurado en diferentes partes que incluyen el estudio de las atelectasias, la neumonía y los abscesos, el patrón de infiltración intersticial y/o alveolar o patrón de líneas B, y finalmente se analiza el tromboembolismo pulmonar. Con esta segunda parte del texto hemos ofrecido los conocimientos básicos necesarios para realizar ecografías pulmonares en un servicio de anestesia (AU)

In this second part, an analysis is made of the pathology of lung parenchyma. This text is structured into different sections, including the study of atelectasias, pneumonia and abscess, interstitial/alveolar or B lines patterns, and finally an analysis is made of pulmonary embolism. With this second part, the basic knowledge to develop lung ultrasound in the anesthesia department has been presented (AU)

[Basic lung ultrasound. Part 2. Parenchymal diseases]. / Ecografía pulmonar básica. Parte 2. Patología parenquimatosa.

In this second part, an analysis is made of the pathology of lung parenchyma. This text is structured into different sections, including the study of atelectasias, pneumonia and abscess, interstitial/alveolar or Blines patterns, and finally an analysis is made of pulmonary embolism. With this second part, the basic knowledge to develop lung ultrasound in the anesthesia department has been presented.

Comentarios al artículo «Bloqueo paravertebral torácico, más bloqueo de nervios pectorales para mastectomía en un paciente con esclerosis lateral amiotrófica avanzada» / Comments to the article "Thoracic paravertebral block plus pectoral nerve block for mastectomy in a patient with advanced amyotrophic lateral sclerosis"

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Abordaje guiado por ultrasonidos de los nervios intercostales en la línea media axilar para cirugía de mama no reconstructiva y de la axila / Ultrasound-assisted approach to blocking the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery

Introducción. Recientemente se han descrito varios bloqueos nerviosos periféricos para el tratamiento del dolor en la cirugía de mama. El objetivo principal de nuestro estudio fue determinar la eficacia y seguridad del bloqueo ecoguiado de las ramas cutáneas anteriores y laterales de los nervios intercostales en la línea media axilar para cirugía no reconstructiva de mama y axila. Material y métodos. Estudio observacional prospectivo en 30 pacientes programadas para cirugía de mama no reconstructiva y axilar. Se realizó bloqueo de las ramas intercostales en la línea media axilar, guiado por ultrasonidos con levobupivacaína al 0,5% (3 ml en cada espacio intercostal). La eficacia clínica se evaluó en el periodo intraoperatorio mediante la respuesta hemodinámica al estímulo quirúrgico y la necesidad de opiáceos, y en el periodo postoperatorio mediante la valoración de la intensidad del dolor según escala verbal numérica y la necesidad de tratamiento de rescate. También se evaluó la calidad del sueño de la primera noche del postoperatorio, los eventos adversos acontecidos y la satisfacción de los pacientes y cirujanos con la técnica anestésica empleada. Resultados. El bloqueo de las ramas intercostales en la línea media axilar fue eficaz en la mayoría de los casos; solo 2 pacientes requirieron administración de opioides intraoperatorios y en un caso fue necesario rescate analgésico en el periodo postoperatorio. La duración de la analgesia postoperatoria fue de 19 ± 4 h. No se produjeron eventos adversos reseñables ni complicaciones. La satisfacción con respecto a la técnica elegida fue valorada como «muy buena» en todos los pacientes, y guiado por ultrasonidos. Conclusiones. El bloqueo de las ramas intercostales en la línea media axilar proporciona una adecuada analgesia intraoperatoria y postoperatoria para cirugía no reconstructiva de la mama y la axila. Es una técnica sencilla, reproducible en la mayoría de las pacientes de este estudio, con una ecoanatomía fácil de comprender, en la que mediante una punción única se puede ofrecer una adecuada analgesia, pudiendo ser una alternativa en estos casos a los bloqueos del neuroeje(AU)

Introduction. Several nerve blocks have recently been used for pain treatment in breast surgery. The main objective of our study was to determine the efficacy and safety of ultrasound-assisted blocking of the anterior and lateral cutaneous branches of the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery. Material and methods. A prospective observational study was conducted on 30 patients scheduled for non-reconstructive breast and axilla surgery. An intercostal branches block was performed in the mid-axillary line with 0,5% levobupivacaine (3 ml in each intercostal space). Clinical efficacy was assessed by standard intraoperative hemodynamic response to surgical stimulus and the need for opioids, and in the postoperative period, by assessing pain intensity as a verbal numerical scale and the need for rescue treatment. We also evaluated the quality of sleep the first night after surgery, any adverse events that occurred, and the satisfaction of patients and surgeons with the anesthetic technique. Results. The intercostal branches block in the mid-axillary line was effective in most cases, with only 2 patients requiring intraoperative opioids, and in one case analgesic rescue was necessary in the postoperative period. The duration of postoperative analgesia was 19 ± 4 h. There were no notable adverse events or complications. The satisfaction with the chosen technique was assessed as «very good» in all patients, and by 97% of the surgeons. Conclusions. Intercostal branches block in the mid-axillary line provides adequate intraoperative and postoperative analgesia for non-reconstructive breast and axilla surgery. It is a simple, reproducible technique in most patients of this study, with an easy to understand ultrasound anatomy, in which adequate analgesia could be provided through a single puncture, and may be an alternative to neuroaxial blocks(AU)

[Ultrasound-assisted approach to blocking the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery]. / Abordaje guiado por ultrasonidos de los nervios intercostales en la línea media axilar para cirugía de mama no reconstructiva y de la axila.

INTRODUCTION: Several nerve blocks have recently been used for pain treatment in breast surgery. The main objective of our study was to determine the efficacy and safety of ultrasound-assisted blocking of the anterior and lateral cutaneous branches of the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery. MATERIAL AND METHODS: A prospective observational study was conducted on 30 patients scheduled for non-reconstructive breast and axilla surgery. An intercostal branches block was performed in the mid-axillary line with 0,5% levobupivacaine (3ml in each intercostal space). Clinical efficacy was assessed by standard intraoperative hemodynamic response to surgical stimulus and the need for opioids, and in the postoperative period, by assessing pain intensity as a verbal numerical scale and the need for rescue treatment. We also evaluated the quality of sleep the first night after surgery, any adverse events that occurred, and the satisfaction of patients and surgeons with the anesthetic technique. RESULTS: The intercostal branches block in the mid-axillary line was effective in most cases, with only 2 patients requiring intraoperative opioids, and in one case analgesic rescue was necessary in the postoperative period. The duration of postoperative analgesia was 19±4h. There were no notable adverse events or complications. The satisfaction with the chosen technique was assessed as "very good" in all patients, and by 97% of the surgeons. CONCLUSIONS: Intercostal branches block in the mid-axillary line provides adequate intraoperative and postoperative analgesia for non-reconstructive breast and axilla surgery. It is a simple, reproducible technique in most patients of this study, with an easy to understand ultrasound anatomy, in which adequate analgesia could be provided through a single puncture, and may be an alternative to neuroaxial blocks.

Abordaje ecoguiado de las ramas cutáneas de los nervios intercostales a nivel de la línea media axilar para cirugía no reconstructiva de mama / A new ultrasound-guided cutaneous intercostal branches nerves blocked for analgesia after no reconscturctive breast surgery

Introducción: La anestesia regional ecoguiada permite la descripción de nuevos abordajes y técnicas para el manejo anestésico-analgésico en cirugía de mama no reconstructiva. Material y métodos: Descripción, de un nuevo abordaje ecoguiado para analgesia en cirugía no reconstructiva de mama. Realizamos un abordaje en plano e introducimos la aguja de caudal a craneal en la línea media axilar, posicionando la punta de la aguja entre la fascia del músculo serrato anterior y la fascia del músculo intercostal externo. Resultados y discusión: El bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar (BRILMA) es un bloqueo de baja dificultad de ejecución, con una ecoanatomía fácil de comprender, reproducible en la mayoría de los pacientes, que puede ser realizado de manera segura asociado a sedación o con el paciente anestesiado. Permite el bloqueo de las ramas anteriores y laterales de los nervios intercostales entre 2º y 6º espacios intercostales, proporcionando analgesia en cirugía de mama no reconstructiva, incluido el complejo areola-pezón (AU)

Introduction: The regional anesthesia ecoguiada allows the description of new boardings and technologies for the managing anesthesic-analgesic in surgery of not reconstructive breast. Methods: We described a new ultrasound-guided cutaneous intercostal nerve branches blocked to provide analgesia for no reconstructive breast surgery. We introduce needle the in plane and placed the tip of the needle between the serratus anterior muscle and external intercostal muscle at the mid-axillary line. Results and discussion: The block cutaneous branches of the intercostal nerves (BRILMA) is a new nerve block technique that is easy to perform. This block is an intermediate nerve block technique. Although in principle, the technique is similar to that of the intercostals nerve block, its anatomy and indications are sufficiently distinct to deserve separate consideration, and have a significant clinical applicability for surgical anesthesia and post-operative pain management. It allows the blockade of the previous branches and wings of the intercostal nerves between 2 º and 6 º intercostal spaces, providing analgesia in surgery of not reconstructive breast, included the complex areola-nipple (AU)

El bloqueo de los nervios pectorales guiado por ultrasonidos puede ser de utilidad en la cirugía de mama reconstructiva para control del dolor postoperatorio / The usefulness of ultrasound-guided pectoral nerve block for postoperative pain control in reconstructive breast surgery

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Bloqueo de las ramas cutáneas laterales y anteriores de los nervios intercostales para analgesia de mama / Analgesic combined lateral and anterior cutaneous branches of the intercostal nerves ultrasound block in ambulatory breast surgery

Introducción: proporcionar una buena analgesia postoperatoria en los procedimientos quirúrgicos no reconstructivos sobre la mama es una de las claves del éxito de los programas de cirugía ambulatoria y ello es posible incorporando a nuestra estrategia multimodal bloqueos de nervios periféricos eco guiados. Material y métodos: estudio observacional descriptivo en el que se evaluó de forma prospectiva a 44 mujeres programadas para cirugía de mama. El mismo investigador realizo un bloqueo de las ramas cutáneas laterales (BRCL)de los nervios intercostales, en todos los casos cuando la lesión a extirpar se localizó en la región del complejo areola-pezón, se asocio también el bloqueo de las ramas cutaneas anteriores de los nervios intercostales (BRCA). En todos los casos se le practico una RM tras la realización del bloqueo para observar la distribución y la extensión del anestesico local por la pared torácica. El estudio (..) (AU)

Introduction: Provide good postoperative analgesia in the non reconstructive surgical procedures on the breast is one of the keys to success in outpatient programs and this is possible by incorporating peripheral ultrasounds blocks multimodal approach. Patients and methods: Descriptive observational study which prospectively evaluated 44 women scheduled for breast surgery. In all of them the same researcher conducted a blockade of the lateral cutaneous branches(BRCL) of the intercostals nerves and when to remove the lesion was located from the complex areola-nipple to the sternum was also associated block of the anterior cutaneous branches (BRCA). All women also underwent an MRI after the blockade to observe the distribution and extent of local anesthetic through the chest wall. The extension study was completed with the (..) (AU)