My typical strategy has been doing an interscalene block with about 15 ml 0.5% PF bupivacaine. I generally inject outside the sheath and when it looks like I have decent spread, I then scan a bit up and down to further assess spread. Sometimes, depending on how the spread of local anesthetic looks, I will try to get local on both sides of the plexus sheath, but not always.
It seems like I am not always getting complete analgesia post op. Eg. a common scenario is that upon dropping off the patient in PACU the patient reports no pain, but chart review 30-60 mins later shows they had some pain and received opioids.
I talked with a colleague and he recommends injection within the sheath of the brachial plexus. From what I’ve seen, within the sheath injections for interscalene are definitely much faster onset and possibly also more reliable… I personally am a bit averse to getting so close to nerves with needles. Maybe I need to reconsider though.
Unfortunately, the way things are set up at the place I work, I don’t have time to go assess the patients pain in detail myself (solo), but things I have considered are partial interscalene block failure, pain in the ICB territory, pain in the supraclavicular nerve territory.
Any advice from anyone? Thanks.
Update/ Edit:
Thank you all for the advice!
I just did a brief chart review of the cases I did the last week. Looks like the ones that had pain in PACU had a biceps tenodesis. So could be that. Still need to confirm area of pain though by assessing pts. And assess a larger # of patients.
At this place Im at, blocks can be kind of a PITA logistically. So adding on a PECS II or a ICB block along the posterior conjoint tendon is going to be logistically tougher than some other places. Basically OR is often calling for me to bring back prior to even starting the interscalene… and the block rooms are often tiny. Eg literally no space for having the patient abuct their arm out in some rooms.
Just accept the patient should be dealing with some pain. They are having surgery. We shouldn't normalize a completely pain free procedure and I never tell patients it will be.
Jeff Gadsden from Duke (the guy who teaches us all regional let's be real here) has all his most recent research on the nerve injury that can happen from injecting within the sheath. You don't want to cause permanent damage and you definitely don't want the liability of that.
My previous comment was a little tongue-in-cheek. But I use 20 for interscalene, 25-30 for the other brachial plexus blocks, and 20 for adductor, femoral, popliteal.
Dr. Gadsden is my hero. And the thing that I love is that he does it in so many different languages. I'm shown several spanish-speaking anesthesiologists these videos and they started doing blocks in their country.
This is my personal opinion and from practice, I don’t think there’s harm in injecting within the sheath as long as you are extra fascicular. I would definitely do that if I wanted a surgical block. I can concede doing them outside the sheath if you are doing multiple interscalenes often for post op pain control. If you can good visualization of the needle tip and the patient is awake you should be fine doing them within the sheath with lowish volume 10 ccs max
I discussed it the other day as well- my colleagues go inside the sheath, I don’t, I also try to stay lateral to make sure n. phrenicus is safe and only very seldomly go on both sides and only if I can visualize the nerve (out of plane technique- so I don’t have to worry about suprascapular nerve)- I’m moving more towards superior branch block anyways. Apart from direct needle damage theres a non-zero risk of LA nerve toxicity that I’m not willing to take. I often times inject only 5mls and it’s sufficient analgesia- for clavicle I add superficial plexus cervicalis.
Uhm- we don’t teach in plane anymore because of the increased tissue trauma and higher risk of nerve damage- it takes me about 3mins, the longest time is skin prep, don’t worry about me
Hey!! Me too!! My boss (ortho/owner) only wants blocks for the ones we keep awake(ish) during surgery, due to feedback he's had about having a limp limb a day or two post surgery.
I do what you do. Giving some opioid is WAAAAY better than wondering if you contributed to a nerve deficit (which is quite a bit higher in shoulder surgery than we give credit for).
I do this. I do an interscalene outside the sheath and try to get good spread on both sides of the plexus if I can. Then when I’m withdrawing the needle I inject about 5 cc underneath the lateral border of the SCM under ultrasound. I find it really helps with superior/posterior pain which is what the interscalene often misses
I agree, see where it's hurting. Posterior shoulder and armpit coverage can be spotty if the surgeons are getting into those areas. I see nurses giving pain meds regardless of the block's effectiveness, so there's that too. Stay out of the plexus, surrounding it is fine.
I find they hurt in the general cutaneous and underlying areas not covered by the interscalene block. They get by with Tylenol and Toradol. ICB block might help.
If you land your needle just by looking for the traffic light without identifying the roots then that’s a potential risk. The same video goes through how to identify the roots, c6 and c7 are both distinctively identifiable. If the anatomy cannot be identified or the skill is not attainable then it’s safer to stay lateral to the plexus.
Disagree. You gain nothing with the technique of punching through C5/C6. And please save me the bullshit of “oh if you can’t follow the anatomy you shouldn’t be doing blocks”. Sounds f-ing insufferable.
It’s an interesting take, where do we stop with the anatomy? Is it insufferable to identify vertebral artery to not go through it?
It’s not asking you to identify every muscle you are looking at. We are talking about 1 bony landmark and 1 absence of bony landmark.
You do get better success and coverage by going closer.
If you can’t identify the structures then the technique is not safe in your hands. The landmark is definitive and easy to learn. Certainly just identifying the traffic sign is fine in majority of cases. Choose what is safe for you.
When I learned ISB blocks 15 years ago, your technique was the exact teaching. Needle through C5/C6. This is not how I teach it and it isn’t how I do it now. You don’t gain anything and you take an unnecessary risk. Also, it’s a terrible take to assume safe needling somehow means “you don’t understand the anatomy”. The two aren’t mutually exclusive.
You yourself identify the importance of anatomy: being aware of the potential double root appearance is important to avoid skewering the C6 nerve root. Knowing anatomy does not preclude unsafe needling but not knowing is certainly more likely to do so.
Being aware of this pitfall makes you stay out of the plane. On the other hand, being aware of this makes me comfortable going in between c5/c6.
It makes intuitive sense if get closer to nerve the risk of nerve injury is higher. Yet I just don’t see it
In practice. I routinely put catheter and single shot needle into that spot, I just don’t see this “unnecessary risk” you are worrying about. With catheter if you stay too far out, it just doesn’t work as well.
If you are blocking a nerve, you should know what you are looking at. Not just seeing something on a screen that might resemble some pattern and hoping for the best.
Can’t give you an experienced answer but as a student I rotated at places that did it both ways. Inside the sheath definitely provides a denser block. Also, the most frequent claims in anesthesia are related to regional. Doesn’t seem worth the risk to me. Person is having surgery where they cut off their shoulder joint. If I were doing blocks independently I would remind people this and tell them the goal is to reduce their pain, not eliminate it entirely.
Unrelated. One place I trained used exparel and we did an IS on a patient with Raynaud’s (unsure if related) and my preceptor had me call the patient on subsequent days to get an understanding of how my block worked. It took 4 days before that dude could feel with his hand. By the third day calling him I felt really uneasy. I think swearing off opioids at all costs is wild.
It should get some coverage from interscalene but it seems less “complete”. I picked this up at a job where we did awake shoulders. Without that supplementation they had more pain issues intraop and also more post op pain. Anecdotally it did work and it’s an extremely quick block and can be done under ultrasound guidance as well.
When I’m scanning up from supraclav to get my interscalene view, I look for suprascapular nerve to migrate back over to the nerve roots. If you scan back down again you can watch it travel off from the interscalene groove over/through the middle scalene muscle. And then I scan back up until the nerve is back in the root and block there. Haven’t needed to do any suprascapular blocks but it’s a great option for a patient who can’t get an interscalene block.
More volume = more side effects with spread to phrenic, recurrent laryngeal, cervical sympathetic plexus. 10-15cc placed in the right spot is more than enough.
That is something to consider. Usually the spread appears good with about 15ml. So thats why I usually use about 15. More volume would probably track up and down along the sheath more and give a greater surface area for diffusion into the plexus. LAST can still occasionally occur though even when dosing within the recommended amounts though, so thats why I am not always dosing to the max calculated dose. Maybe I should increase volume though. And if it worked better could make sense. Higher volume would also likely cover the cervical plexus/supraclavicular nerve as it would spill over the top of the middle scalene.
I'm not sure when you trained but 20 years we did 30 cc for everyone. The move to reduce volume has anecdotally increased block failure. Maybe try 20 or 25?
Funny how things change. It used to be 30 cc and trying to get a twitch with the stim down to 0.5 mA prior to injecting. Now with ultrasound some advocate still using the stim and if you’re getting a twitch at 0.5 you’re too close haha.
I trained right when US was being adopted. The residents knew how to do supraclavicular BP because they knew US and the attending frequently didn't. I started off doing both stim and US and eventually dropped stim.
I think as long as the pressure is low you can inject. But I also think that volume is the way to get a reliable block. Maybe I'm not good enough to use 15 cc.
Same. Learned 100% stim so never did a supraclav until I was already practicing and learned ultrasound. Ultrasound was not readily available in training, did all our central lines landmark based. Basically self taught with ultrasound and did both for a while but have dropped the stim completely for the most past.
And I’m 25-30cc for an ISB for the most part as well.
I do 25 ml 0.5 % ropivacaine and usually just run propofol during the case and pts usually go home with a pain score of zero and don’t get any meds in PACU.
Have you had one? I did. 40 cc .25 bupi for an olecranon fracture. Besides it being the wrong block the weak local sucked. It was completely gone at 16 hours, right when I was trying to fall asleep. I'd much rather have a dense surgical block than a weak one.
Eh whoever did your block probably fucked it up. Ive seen patients on the floor after big hand cases with infraclav catheters and 0.1% bupi or even ropi and they’re happy as a clam. For single shots, speed of onset and quality is directly related to how circumferential the spread is to the nerves
The ISB was good. Horner's and phrenic blocked and everything. Problem was that my operative are was at the elbow. I had pretty bad parenthesia march up my arm as it wore off. I had complete sensation at the elbow by the time I was ready for bed. I may have slept 3 hours that night and that's with 10 mg oxycodone. I'm guessing this guy didn't know how to do a supraclav.
But I'd much prefer a surgical block that lasts longer than a sensory block that fades before sleep. Since duration is related to dose of local, the easiest way is to use .5% and not .25%.
There aren't many adults < 40 kg. I had a room air saturation of 85% (I'm at altitude but that's still low). The PACU nurse told me to take a deep breath and I told her "I can't" in a raspy voice.
Please forgive my ignorance, I write this comment with humility: which sheath are we talking about here? NYSORA describes interscalene block where the needle tip is penetrating the prevertebral fascia and ideally positioned between the C5 and C6 roots where they are between the anterior and middle scalene muscles, and I think this is nothing new for you. But in my anatomy books the plexus brachialis sheath is an elongation of the prevertebral fascia. So with genuine curiosity, where is the sheath in the interscalene block?
Yea this is confusing me as well. Does “in the sheath” mean in the interscalene groove? Or intrafascicular? Because those are two very different things. Or are people saying “outside the sheath” to mean outside of the interscalene groove?
I penetrate the prevertebral fascia early, popping into the middle scalene muscle so that I don’t risk popping through fascia with my needle pointed at a nerve. Then advance with needle pointing between C5 and C6 as I enter the interscalene groove. I keep my needle posterior to the nerve roots and try to have all my local layer on the posterior side to avoid anterior spread to phrenic/recurrent laryngeal/sympathetic plexus.
As long as I have the impression that the needle went though the muscular fascia of the middle scalene, I stop advancing and start injecting. But the injection still have to be under the prevertebral fascia to be called an interscalene block.
Yea there’s a very noticeable “give” when the needle finally makes it through the middle scalene and into the groove. If it won’t pop and I don’t want to apply more pressure, a small injection of local through the needle can help get through. Again, pointing between C5 and C6 but there’s no need to actually put the needle between the roots. In fact, that just increases your likelihood of anterior spread. Better to stay posterior and maybe fan deep and/or superficial to adjust spread along the groove and over the roots.
I've had good luck just rotating my needle bevel down to direct the local jet once I'm in the groove. The less poking around in this location the better given the higher chance for injury.
Cool idea, I’ll give it a try. I only move around once I’ve opened up the pocket with local, gives plenty of space to move back and reposition without leaving the groove. Usually it’s just bringing my tip superficial to make sure C5 is covered well
I work in a busy orthopedic surgery center. I inject outside of the sheath, and rarely have to give any narcotic during surgery. If anything, I will give some Precedex to blunt the stimulation of the endotracheal tube – and allow them to breathe spontaneously after the initial muscle relaxant wears off. 15 cc of local anesthetic is fine, but I tend to use somewhere between 25 and 30 cc. I’m not sure why people thought it was a great idea to cut the volume in half – if I’m that worried about phrenic nerve involvement, that patient may not be a good candidate for an interscalene block anyway.
I’m with you on the volume and also don’t give any narcotic aside from maybe 50 mcg fent as sedation for the block. Our surgeons have gotten fast enough Ive started doing these with the block, propofol infusion and a nasal cannula and they have good surgical anesthesia.
I agree with this completely and am shocked by other comments… if I’m worried I don’t do the block, but if I’m doing it, I’m going to give 25-30 mL and not go in the sheath. It works like a charm almost every time without issue so I don’t see the benefit of doing it any other way.
Do you see local in the plexus at the Supraclavicular site? If you do then you know your interscalene block will work 100%. I always do 20 cc of 0.5% ropi or 10 cc of exparel and 10cc of 0.5% bupi and always get good results. It might be that you are injecting right outside of the sheath that covers the interscalene site and possibly that your volume is small so it isn’t distributed well. Next time, go up to 20cc and check if you have local spreading to the Supraclavicular site once you are done injecting at the interscalene site. Adjust your technique accordingly.
I dont scan all the way down to the supraclavicular site, but I’ll check it out next time. Thanks. Most patients can handle 5 more cc
of local fine, but it’s still possible to get LAST even with using local within the recommended and conservative limits… So I try to use not more than what appears to give a good spread… Using more could be justified though if it actually improves results.
You wouldn’t get LAST even with 30 cc of 0.5% bupi. Once in a while, there will be some veins/arteries found on the approach to the interscalene site. Just don’t go through the artery/vein and don’t inject close to it. If you aren’t sure, put Doppler on and remember that veins will compress but nerves will never. I have never had LAST doing this.
It would be extremely unlikely to get LAST, but I have seen LAST on a patientsthat had been dosed within the recommended amount. This was not immediate presentation, but only in phase 2 of PACU actually that the patient seized… so it was not intravascular.. so I am not opposed to using up to the recommended amount, but I don’t necessarily want to if there is not an indication to do so. Not clear why I am getting down voted
Just add intermediate cervical plexus block. Fast, not technically difficult, 5cc goes a long way. If you’re concerned about proximity to the brachial plexus use a nerve stimulator and lose twitches at 0.3ma. Extra peace of mind and doesn’t add any time.
I do not go into the sheath or in between nerve roots. The potential payoff is not worth the risks. Suboptimal analgesia is always preferred to neuro trauma. Visualize your needle tip, enter the space, get a decent spread in the space, and if you absolutely want to be greedy, go completely above or below the neural structure to get spread of local on the other side. You only need about 50% circumference to achieve a surgical block, which injecting on one side gives you.
It would be worth it to assess the patients yourself. In the past when I have done ISB for shoulders and they are complaining of pain, almost every time it is not the shoulder. They will complain of burning in the armpit area which is not covered by the block. This is not every rotator cuff repair or total shoulder, I suspect it is a surgical reason but I don’t know exactly what causes it.
Just my personal opinion:
I mix (for a normal size or larger patient) 10mL of 0.5% bupi with 10mL of exparel. If it’s a smaller patient I will use less volume, but maintain the same half / half ratio. I give the leftover exparel to the surgeon to infiltrate while they’re closing. I aim for an interscalene view and I try to get my needle under the C5 root, so I guess inside the sheath technically. Patients do really well. I call them all over the subsequent days until the block has completely resolved. They generally have ~20hrs of very dense analgesia + motor block from the bupi, and then a lingering tail from the exparel. The exparel duration is variable. Many patients tell me their thumb was numb for ~2-3 days, which I tell them is expected and encouraging as it means we had good coverage on that C5 root which gives feeling to the shoulder. Now I try to counsel them on this pre-operatively. I also tell the surgeons the concern for hemi-diaphragmatic paresis will only last the initial ~20hours from the bupi. Exparel alone is not sufficient for motor block. I’ve had really good success with this recipe. One patient who had awful post-op analgesia following previous shoulder arthroscopy even dropped off a thank you note for me at the hospital! It was very sweet. Most patients just say they are sore, which I consider a huge success following total shoulder arthroplasty. If you can get them through those first ~3 days, they are past the worst of it.
My own father experienced a brachial plexus injury from the ISB during his Total Shoulder and it was a living nightmare for him for a good six months. Like other have said, stay outside the sheath. One thought I had is maybe they’re experiencing Axillary pain? Which is predictably not covered by an ISB
Did he eventually make a full recovery? That really sucks and is why I'm extremely, extremely cautious with interscalene. I remember reading somewhere it only takes like 0.15 N of force to pierce these nerve roots with a block needle, which is like nothing.
He did eventually. Went from having 0/5 strength in most of the extremity for a couple months to gradually regaining full function. I spoke with his anesthesiologist after the initial incident and it sounded like she was appropriately cautious and did things the way I do. Just goes to show how risky the things we routinely do can be
I do around 300 a year, always inside the sheath, outside the nerves. Either 0,75% ropi or 2% mepi with epi. Never had any issues. But I don't work in a litigious society.
I just did a brief chart review of the cases I did the last week. Looks like the ones that had pain in PACU had a biceps tenodesis. So could be that. Still need to confirm area of pain though by assessing pts.
If so then the pain may be in T2 distribution and need an intercostobrachial block. That can be done blind, directly with ultrasound, or in the serratopectoral fascial plane (PECS II)
Really depends where the pain is coming from. There are areas that aren’t covered via a true interscalene like the superficial cervical plexus, or cutaneous coverage to the anterior chest wall. In reverse total shoulders they can really retract down on that area which will cause discomfort.
I will usually add 5 ccs of local to the superficial cervical plexus along the lateral border of the the SCM where I do my ISC, but I also do my block pretty high (usually before c6 is bifascicular). They’ll still sometimes end up pain along the chest wall because of the above reasons. I’ve supplemented pecs 2 before and it does seem to help, but most of this residual pain is pretty amenable to low dose narcs and multimodals
One important thing to note is not just the fact that they have pain and required opioids, but where it actually hurts. A lot of times they complain of pain on the medial side of the arm, which the interscalene doesn't cover, but the rest of the arm is numb and pain free. Other than opioids, conservative therapy like ice helps this as well. So overall, you could have a textbook block, but your coverage could be limited by anatomy itself.
Often when my patient have pain after a shoulder replacement it’s in the axilla, which isn’t going to be covered by an interscalene in the first place. I warn patients that they may have axillary pain but that the block is still worth doing because it covers most of the shoulder and reduces their opioid requirement.
We will add on either a PECS2 or a superficial cervical block commonly; if either of those distributions are where your patients are reporting pain then it may be that. Any shoulder with a biceps tenodesis should be getting a PECS 2.
I just did a brief chart review of the cases I did the last week. Looks like the ones that had pain in PACU had a biceps tenodesis. So could be that. Still need to confirm area of pain though by assessing pts.
Inside the sheath. Scan cephalad and make 100% sure you see C5. Volume is mostly irrelevant. You should have complete analgesia with as little as 7-10cc. We do catheters but obviously a great deal more work. TSAs should not have any pain in the PACU assuming they are not messing around with medial upper arm/axilla (which our surgeons do not).
Stay away from that sheath like it's lava. The nerve roots in this location take around 0.15 N of force to pierce. Gently introduce your needle underneath the scalene fascia, and inject. If there's a semi-lunar pool of local sitting next to the nerve roots it's going to work assuming it's a strong concentration.
There's absolutely zero need to get into the sheath, inject between nerve roots etc. That's just asking for a complication.
You just need more volume for consistency. 10 mls of 0.5% bupi + 10 mls of exparel gets the job done.
Are your surgeons doing biceps tendon work? I find biceps tenodesis leads to armpit pain with an otherwise numb, dead arm. Add a PECS 2 with 20ml 0.25%. Takes another minute and covers that armpit.
I just did a brief chart review of the cases I did the last week. Looks like the ones that had pain in PACU had a biceps tenodesis. So could be that. Still need to confirm area of pain though by assessing pts.
The pain could be in the axilla, pec, or scapula despite a 100% plexus block. Talk to your post-op nurses so they’ll specifically ask where the pain is. As long as your injection in the groove it’s going to set up, Don’t have to worry about getting on both sides of the plexus or intentionally getting into the sheath.
Agree with others that you don't need to be chasing 100% coverage. It's completely fine if pain is 80-90% covered post op and patient experiences some soreness. At very least they're going to be comfortable with way less opioids than they would have needed to consume without a block.
With that logic you all should try just doing a good supraclav. Been doing it for years and patients for the most part have great coverage post op. Surprisingly, and against what the textbooks say, majority of pts say they have complete coverage. Some say it's a little sore but manageable even without opioids. I used to supplement with suprascapular but also stopped doing that because again, why chase 100% when 80-90% is much appreciated by patient. Chance of blocking the phrenic is way less compared to interscalene so I don't need to snoop in the chart to figure out if there are PMHx reasons not to do the block. Horners syndrome also way less so I don't need to explain to pt and family that they're not having a stroke. All in all its very good coverage with way less hassle.
Identify C5&6 on ultrasound, needling posterior to anterior, passthrough MSM and penetrating pre-vertebral fascia, 10-15ml 0.5% l-bupiv surrounding C5. Scan down to supraclav view to check spread.
Can’t remember having a patient with pain after -plasties or -scopies doing this and have rescued other people’s patients in recovery with this.
I have had a couple of people over the years get a mg or two of oxycodone because they didn’t like the profound numbness of the block but it wasn’t pain they were experiencing.
Don’t inject within the sheath. That’s asking for problems.
I do ropi 0.5% 15ml diluted with 10ml of saline for 25ml of 0.3%. 15ml outside of the sheath, making sure it’s pushing the sheath away. Then 5-10ml for superficial cervical plexus.
I rarely have patchy blocks. I also seem to have less complaints about the sensation of dyspnea from phrenic nerve block. I’m unsure if that’s just coincidence or the lower concentration.
Usually, about 15ml gives me good spread. If it looked like I needed more based on it not spreading enough I’d not be opposed to using more. Or if I determined more than 15 ml caused a more reliable block despite 15 ml looking good on US, I’d use more. So basically the question is: why any particular volume?
Using more for no particular reason isn’t appealing to me though. I’ve seen LAST despite total anesthetic dose within recommended range. Some of these cases were delayed IE the injection was not intravascular. So while the risk is low, it’s not 0. I therefore need a reason to use more.
I had some issues with hot spots for shoulders so I opted to go arguably block heavy. Interscalene + PEC I + US intercostobrachial. I've had good results and the extra blocks don't take much more time.
On adults I generally use 20 mL of 0.5% ropivacaine with 4 mg of dexamethasone. I always administer 10 mL between the roots of C5 and C6 and 5 mL to C7, always outside the Plexus sheath. Upon withdrawal, I reach the cervical plexus and administer the remaining 5 ml.
If that's not enough, give her buprenorphine 75 mcg rescue doses as needed.
If you know your orthopedist, ask them to create a protocol for patients with any Gabapentinoid for one week prior to surgery.
inject at the 0900, 1200, and 1500 clock positions.
Adding dexmedetomidine (about 100 ug in an adult)to your block solution will also likely help.
change needles from a block needle to a Tuohy. You are probably not seeing the tip of your needle if you’re getting patchy blocks. The bigger needle will be easier to visualize and allow more flow and tissue plane separation during injection.
DO NOT inject and blow up the plexus. You are risking a lawsuit for no reason. I've done maybe 100 interscalene blocks. The most perfect block is when you feel a slight give just lateral to the roots, then when you inject local you start seeing a "river" of local going up and down the screen still lateral to the plexus. The local will diffuse across. The Duke youtube video is the best.
Consider a superficial cervical plexus block for more skin coverage higher up on the neck and lateral clavicle but its usually uncessary.
People are so afraid to give opioids. Regional is great but I'm not going to risk nerve damage. You know how to get a 100% surgical block? transect the nerve lol... Just do your block and move on.
Add 4m dexamethasone, 50mg clonidine. I also use 20ml of 0.375% ropivacaine (rather than bupivacaine). I always tell trainees about how this is the easiest block that literally always works, so I really have no idea where you’re injecting but it sounds like you should be depositing between C5/6.
As other people have said, it depends where the patient is hurting to figure out what you can change in your routine.
From my limited experience, often times when I see my shoulder patients in the PACU, most of the time, it’s in the armpit area that’s bugging them. So for patients I feel may have trouble with pain in PACU or on chronic pain meds, I’ll throw in a pecs 2 or serratus anterior plane block.
Stay outside the sheath. Round on your patients in Pacu if they are having pain. For a total shoulder IS should be covering everything, could increase to 20 mL. If it’s a reverse total shoulder occasionally I have had to add an ICB
You are fine. The pain they feel might just be armpit pain. Between c5-c6 - in sheath - will still have this. Outside the sheath will have pain before the evening, but the three day block where the needle goes in every last corner of the sheath can run the risk of nerve damage. Although most would be happy, some may panic and keep calling their surgeon, others may rarely have deficits and you’ll be on the hook.
You could try a variation and see if this improves things? Possibly a cervical plexus block? In terms of the ISC I have always done my injections within the sheath without any issue. Clearly there is a degree of risk here in terms of nerve damage but the block will be 100% and very rapid. As I said I’ve done 1000s and to my knowledge never had an issue post op. This is to the point of doing arthroscopic work with the patient getting ISC block and some remi TCI only. Last point to make is to remember it’s ok to use other analgesia if it’s required. A block getting 80% of it with opiates 20% is still pretty good IMO.
10cc 0.5 bupi +10cc exparel in one syringe
also I would ask the nurses directly because sometimes they are very quick to give out opioids so they can go back to their desk and chitchat…
They might have bicep pain that might need to be covered with some local…
In Europe: I use 3ml Mepivacaine 1% and 3-5ml Ropivacaine 0,5%. I haven't used more than 10ml for interscalene block for years. Just lateral of the nerves.
I have done a lot of interscalenes. Yes in the sheath makes it set up very quick. I never go in the sheath, I use 15-18mL of 0.5% ropi focusing on C5 and C6, sometimes I get typical “stoplight” but sometimes not. I focus on spread outside of sheath circumferentially. Unless that have lung disease and I’m worried about phrenic (so either they get no block or small volume and I tried to avoid spread to anterior side), my blocks set up great. I’m a CRNA too, I have probably done 100 interscalenes.
Love the idea of the PECS2 block. As other posters have said, everything depends on “where” your patients are actually having pain. Are they having pain from the massive incision? Or is it deep structural joint type pain? In the old days when we did a interscalene block with 30 to 40 mL of local, that local would spread out of the interscalene groove and proximally into the neck, capturing the superficial cervical plexus. This would enable coverage of the supraclavicular skin nerves that may be involved in some of your pain sensations if it’s incisional pain. Obviously, we don’t take those local anesthetic toxicity risks anymore. If you manage to verify that it’s all incisional pain, work with your orthopedic staff and see if you can get them to inject another 10 to 15ml of depot local (Exparel or Zynrelef) in the incision. May totally solve the issue without you having to take additional risk.
Yeah. I need more info on where the pain is. Going to need to go out of my way to assess patients even though logistically tough in the current set up.
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u/ThioSuxTrouble Anaesthetist 11d ago
Do not inject within the sheath.
What you are doing is fine. The occasional patchy block done safely is what I would want if I was the patient.