Name:
ACA- Hadzic- Peripheral Nerve Block 3e- Continuous Interscalene Block
Description:
ACA- Hadzic- Peripheral Nerve Block 3e- Continuous Interscalene Block
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/62508dff-df5a-4b29-a0d3-ce01df5d4c69/thumbnails/62508dff-df5a-4b29-a0d3-ce01df5d4c69.jpg?sv=2019-02-02&sr=c&sig=dZm2GxNt0Fdz%2FIPTaxHwbK94U53IkovJrw1KZ%2F%2FOoD4%3D&st=2023-03-24T00%3A07%3A41Z&se=2023-03-24T04%3A12%3A41Z&sp=r
Duration:
T00H07M50S
Embed URL:
https://stream.cadmore.media/player/62508dff-df5a-4b29-a0d3-ce01df5d4c69
Content URL:
https://asa1cadmoremedia.blob.core.windows.net/asset-f67dd2c0-88fd-426b-8694-f6f544010cdf/ACA- Hadzic- Peripheral Nerve Block 3e- Continuous Interscal.mov
Upload Date:
2022-02-23T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DIGITAL INTRO TUNE:
DR. HADZIC: So, we're going to do now a continuous interscalene catheter here. And in here, we can see the subclavian artery, again, very nice image of the brachial plexus, over here we can see the sheath around it. Superior, middle, and inferior trunks are all here, and here we can see the first rib, because there's no shadow underneath, there's no structures which gives us a clue that this is the rib, whereas in here, we see the pleura, because we can see the appearance of the lung's structures underneath.
DR. HADZIC: So that's the image. We could also decrease the depth a bit more to get a bit more granularity. Now we're going to advance the probe proximally, as we're advancing the probe proximally, what we see is the middle scalene muscle, anterior scalene muscle, and in here, we can see the elements of the brachial plexus, centered between the middle and anterior scalene muscles.
DR. HADZIC: In here is likely the phrenic nerve, In here is likely the phrenic nerve, which moves underneath the fascia of the anterior scalene muscle right there. Okay. So, this is the dorsal scapular nerve right in here, in the body of the middle scalene muscle. And again, one other reason why we routinely use nerve stimulation, because if a needle encounters the dorsal scapular nerve, there could be elicitation of the unexpected distal motor response of the shoulder, which allows one to stop further advancing of the needle, and avoid damage to the nerve.
DR. HADZIC: So we have an image in which we were looking for middle scalene muscle, anterior scalene muscle, this is the interscalene brachial plexus space, and that's the phrenic nerve underneath the anterior scalene muscle. Okay. The procedure starts with injecting local anesthetic for the skin, as we are going to use a continuous needle, or large gauge needle, which is 18-gauge needle, usually Tuohy-style needle for this particular procedure is what we use.
DR. HADZIC: We usually use this opportunity also to visualize the needle as well, because visualizing the needle gives you an indication also, because visualizing the needle gives you an indication also, what angle you will need to introduce your needle for the catheter. So we use this as a seeker needle, if you will, it just gives us a rough estimation of the angle that will be required to reach the brachial plexus.
DR. HADZIC: Okay, so now we insert in the needle, the needle is pre-loaded with a catheter as it could be seen, so that makes advancement of the catheter simpler. Now the needle has been advanced in the subcutaneous tissue, and enters now the middle scalene muscle. You can see the perceptible loss of resistance as the needle passes underneath the fascia of the middle scalene muscle.
DR. HADZIC: Now we're looking at the needle tip, which is now very close to the brachial plexus space. So we're going to try to insert the needle tip between the C5 and the C6, while avoiding the motor response. Visualization of the needle here creates a shadow, which is normal. Okay. At this point in time we're going to get the nerve stimulator, it's set up at 0.5 mA.
DR. HADZIC: We have no motor response, aspiration here is negative, and an injection should result, if successful, in the displacement of the brachial plexus which is the case. Now this injection and displacement, allows us an opportunity to approach the plexus a little closer with the needle, which we can see right there. Okay. We can see how the local anesthetic injection basically separates the brachial plexus elements.
DR. HADZIC: Good. At this point in time, we're going to insert the catheter. Okay. So that's the catheter tip now exiting the needle, and as the catheter exits the needle, it tends to push the brachial plexus. We want to avoid the catheter going through the anterior scalene muscles, so we start withdrawing the needle slowly, while advancing the catheter.
DR. HADZIC: If we now decrease the depth a bit more, we will see the needle track, we will see the catheter, and let's bring the brachial plexus a little bit more into the picture, and that's the brachial plexus. So that's the catheter, that's the brachial plexus, middle scaling muscle, anterior scalene muscle, and the brachial plexus sheath in between. Adjusting the focus point here, little over, can be useful in outlining the anatomy as well.
DR. HADZIC: Okay. Quite nicely seeing the image of the catheter. Okay. Quite nicely seeing the image of the catheter, this is the elements of the brachial plexus. Okay. Now the next step in performing a catheter technique is now to adjust the catheter position, aspiration through the catheter, and an injection, as we can see, results in a nice displacement of the brachial plexus and the local anesthetic spread inside the interscalene space.
DR. HADZIC: Okay. So that was the procedure, next comes securing the catheter. So now we're preparing the area with ether. Next comes the application of the Dermabond, which we use not to do the catheter, but actually to prevent the leakage around the catheter insertion site. The catheter is typically smaller than the needle, The catheter is typically smaller than the needle, and therefore the injection of the local anesthetic tends to leak outside the interscalene space by tracking alongside the catheter, application of a little bit of the Dermabond, or skin glue, prevents that.
DR. HADZIC: Now the next what we do is, apply a large Tegaderm that fixes the catheter in the desired position, and preferably away from the site of surgery. The final step consists of attaching the catheter port, for injection, and securing it on the anterior chest wall, again, away from the site of surgery.
DIGITAL OUTRO TUNE:
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