Name:
Matthes (Supplemental Video 1)
Description:
Matthes (Supplemental Video 1)
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/8dd35567-92cb-4b3d-8390-c6f7e556b52d/thumbnails/8dd35567-92cb-4b3d-8390-c6f7e556b52d.jpg?sv=2019-02-02&sr=c&sig=JoCrcwV%2Bqx2p%2BhI7G5PV5mSWAG2OKIDUFHc2HQKMhhY%3D&st=2025-05-09T10%3A20%3A51Z&se=2025-05-09T14%3A25%3A51Z&sp=r
Duration:
T00H08M58S
Embed URL:
https://stream.cadmore.media/player/8dd35567-92cb-4b3d-8390-c6f7e556b52d
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/8dd35567-92cb-4b3d-8390-c6f7e556b52d/Matthes2028Supplemental20Video20129.mov?sv=2019-02-02&sr=c&sig=8AZ1AVkEguRZr7AfrjwdWbxEItEhiWZmJtPE2AMCdhM%3D&st=2025-05-09T10%3A20%3A51Z&se=2025-05-09T12%3A25%3A51Z&sp=r
Upload Date:
2022-02-27T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
INSTRUCTOR: The interscalene brachial plexus block is indicated for anesthesia and analgesia of surgical procedures involving the upper arm and shoulder. It can be used both intra and postoperatively either by single shot injection or continuous infusion of local anesthetic through a nerve catheter. The contraindications are similar to those for other nerve blocks, such as patient refusal, coagulopathy, infection or significant malformation at the block site and hypersensitivity to local anesthetics.
INSTRUCTOR: Contraindications specific to this block are diaphragmatic paralysis on the contralateral side and severe respiratory compromise. Risks associated with an interscalene block are mostly due to spread of the local anesthetic to surrounding tissues. Ipsilateral diaphragm paralysis occurs nearly all of the time, given the phrenic nerve's location on the anterior scalene muscle in close proximity to the brachial plexus.
INSTRUCTOR: Studies have shown a dose response relationship in phrenic nerve blockade with less local anesthetic dose being associated with less risk of phrenic nerve blockade. Additionally, Horner's syndrome with ptosis, myosis, and anhydrosis may occur due to local anesthetic spread to the sympathetic chain. A hoarse voice may also result from spread to the recurrent laryngeal nerve. Other rare risks include pneumothorax, vertebral artery injection of local anesthetic, and injection into the epidural or subarachnoid spaces.
INSTRUCTOR: Ropivacaine 0.2% or bupivacaine 0.25% are good local anesthetic choices to achieve a longer acting block. Higher concentrations, such as 0.5% bupivacaine may be appropriate for a surgical level block. Addition of lidocaine or mepivacaine may be beneficial for a rapid onset of the block. Typically, the local anesthetic is administered at volumes ranging from 0.2, to 0.5 mLs per kilo.
INSTRUCTOR: Consider using the lowest volume possible to achieve an adequate block as low volumes of local anesthetic have been shown to produce similar postoperative pain scores while decreasing the risk of phrenic nerve blockade and Horner's syndrome. The equipment needed for an ultrasound-guided interscalene block include an ultrasound machine and a linear transducer with scanning frequency greater than 10 MHz.
INSTRUCTOR: A standard nerve block tray, sterile transducer sleeve and gel, sterile gloves, antiseptic solution for skin, syringe containing local anesthetics solution, block needle, and continuous catheter kit and dressing if placing a catheter. To achieve optimum ergonomics, the patient should be positioned supine with the head at approximately 30 to 45 degrees and turned to the contralateral side.
INSTRUCTOR: A pillow may be placed under the patient's upper back and head in order to obtain better exposure. The proceduralist stands on the side to be blocked with the ultrasound on the opposite side. The clinician should have a direct view of the ultrasound screen, the ultrasound probe, and the needle. Let's take a look at the anatomical landmarks on a live patient.
INSTRUCTOR: First, identify the clavicle and the posterior border of the sternocleidomastoid muscle. Having the patient lift the head up may help this muscle pop out a little more. Just under the posterior border of the sternocleidomastoid muscle and at the C6 level, identify the interscalene groove in between the anterior and medial scalene muscles. Be aware of the external jugular vein, which often traverses the interscalene groove.
INSTRUCTOR: The ultrasound probe should be placed transversely at the C6 level to view the brachial plexus for an inner scalene block. A nice way to visualize the plexus is to start in the supraclavicular area. The brachial plexus is seen as a bundle lateral to the subclavian artery. Move the probe slowly in a cephalad direction, keeping the bundle in the middle of the screen until you see the sternocleidomastoid muscle above and the anterior and middle scalene muscles on either side of the plexus.
INSTRUCTOR: The C5 to C7 nerve roots often appear in a stoplight formation. Let's take a look at an inner scalene block and catheter placement performed on a 12-year-old patient brought to the operating room for right shoulder surgery. After cleaning the skin with antiseptic solution and isolating the block area with sterile drapes, the transducer is placed on the patient's neck and the anatomy is viewed.
INSTRUCTOR: The sternocleidomastoid muscle is visualized at the top left of the screen, as well as the anterior and middle scalene muscles and the brachial plexus in between them. The needle is inserted in plane and advanced under ultrasound guidance.
INSTRUCTOR: The bundle is hydro-dissected with injection of local anesthetic. The needle is advanced further around the bundle and more local anesthetic is injected. The local is seen spreading around the C5 to C7 nerve roots.
INSTRUCTOR: A continuous infusion catheter is inserted one to two centimeters past the needle while visualizing the tip on the ultrasound screen. Once the catheter is in proper position, the needle is then removed. In this patient, the catheter is tunneled with an 18 gauge angio catheter.
INSTRUCTOR: Tunneling can be used to decrease the rate of dislodgment, especially when the catheter will remain in place for a prolonged period. Risks of tunneling include inadvertent catheter removal during tunneling, nerve damage, and skin bridge formation. Catheter placement can be confirmed in the following ways. Injecting a small volume for confirmation of adequate spread with the ultrasound, ultrasound visualization of an echogenic catheter, use of a stimulating catheter, air injection, or Doppler confirmation by looking for turbulent flow when injectate is given through the catheter.
INSTRUCTOR: Secure the catheter with a skin sealant and clear occlusive dressing. Now the patient is ready for surgery.
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