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Interscalene Approach to the Brachial Plexus

Objectives. Review of Brachial Plexus anatomyOverview of classical and contemporary approaches to interscalene blocksComplications of interscalene blocks. Outline. Anatomy of the brachial plexus at the level of the interscalene blockIndications/ ContraindicationsTraditional approaches Ultrasoun

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Interscalene Approach to the Brachial Plexus

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    1. Interscalene Approach to the Brachial Plexus January, 2010

    2. Objectives Review of Brachial Plexus anatomy Overview of classical and contemporary approaches to interscalene blocks Complications of interscalene blocks

    3. Outline Anatomy of the brachial plexus at the level of the interscalene block Indications/ Contraindications Traditional approaches Ultrasound-guided approach Complications

    6. Anatomy Ventral rami C5 to T1 (Roots) Shoulder joint capsule Axillary, Suprascapular, Lateral Pectoral Cutaneous Supraclavicular (C3-C4)

    7. Anatomy Sheath Cervical & Brachial Between anterior & middle scalene Cricoid cartilage (C6) Phrenic Accessory nerve

    8. History 1925 - Etienne Midpoint between lateral border of sternocleidomastoid and anterior border of the trapezius 1970 - Winnie Palpate groove between the anterior and middle scalene muscles

    9. Indications Shoulder (arm, elbow) Upper trunk Inadequate inferior trunk blockade Ulnar sparing (50% - Cousins) Rehabilitation & functional recovery Continuous technique

    10. ISB vs GA Better analgesia Greater patient satisfaction Fewer side effects Pain, Nausea, Admission, Sedation Fewer perioperative delays PACU bypass Hemodynamics

    11. Technique

    12. Technique - Classical Supine, head rotated 45° away from operative side Patient lifts head, palpate contracting sternocleidomastoid Patient relaxes and move fingers laterally and into the interscalene groove

    14. Technique - Classical Needle held perpendicular to all planes Level of the cricoid cartilage Endpoints Arm/shoulder paresthesia Deltoid twitch Similar efficacy with paresthesia and nerve stimulation

    16. Nearby Nerves Phrenic Hiccups/ hiccoughs - needle too anterior Accessory Shrug - needle too posterior

    18. Modified Lateral Approach

    19. Nerve Stimulation Similar landmarks NYSORA landmarks Clavicular head of sternocleidomastoid Clavicle External jugular vein 0.2 - 0.4 mA (pectoralis, deltoid, arm, forearm, hand) 35 - 40 mL of local anesthetic

    21. Nerve Stimulation and Catheter Locate interscalene groove Insert needle caudally Watch for brachial plexus twitch at 0.2 - 0.5 mA Retract external jugular from needle insertion site Inject 20 - 40 mL of local before catheter

    22. Ultrasound-Guided Techniques

    23. NYSORA USRA

    28. In Plane

    29. Out of Plane

    30. Complications Phrenic nerve block Recurrent laryngeal nerve block Pneumothorax LA toxicity Brachial plexus palsy Subarachnoid injection Epidural injection Vertebral artery injection Stellate ganglion block Bronchospasm

    31. References Cousins, M. Neural Blockade: In clinical anesthesia and management of pain, 4th edition. NYSORA. Continuous Interscalene Brachial Plexus Block & US-Guided Interscalene Brachial Plexus Block USRA. US-Guided techniques: Interscalene Block Mulroy, M. Regional Anesthesia: An Illustrated Procedural Guide, 3rd Edition. Long, T. Perioperative Interscalene Blockade: An Overview of its history and current clinical use. J Clin Anes 14:546-556, 2002.

    32. Questions? Comments?

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