See the more detailed walkthrough which explains how to get under the clavicle. kzbin.info/www/bejne/iYKvlWCVeMSkebs You don't HAVE to do this technique - a lot of the time an IJV or femoral line will serve the same purpose., as you say. However there are occasional times when this is the only way, or the most optimal. Learning and mastering a variety of techniques just makes one more clinically versatile.

Thank you so much for the kind words, and for pointing out the missed edit! Glad to hear that the content is useful to you.

@KiJinnChin I am honestly very grateful. Finding time for self education can be a challenge. Now I can study from a master while I exercise. I would never otherwise find time to read the various papers you quote. Also your content, is all CONTENT and no filler. The tips and tricks from a master are also almost never published. I can now supervise and teach others better as well, and in the end the patients will receive better and safer care. God bless you Sir.

@@Clarkson350 more often than not, especially in older patients, simply because some degree of cranial angulation is needed to walk off into the space. Nothing wrong with (gentle) bony contact, as long as you have a good idea of what you’re touching and where to go next. It’s an expected part of the process. I don’t often have to do a second needle insertion point through skin though, which is a different thing from needle passes/ redirections. Scouting with your LA infiltration needle usually takes care of that aspect of starting off in the right place.

@@LauraGallop-d8y no - there is no problem because once you have pierced the vein and obtained back flow, you must drop the syringe to flatten the needle trajectory to at least 30 degrees or less, pivoting around the needle tip to keep it in the vein. This is easily done because the overlying tissue depth is relatively shallow. It’s the same thing we used to do before US guidance. Visualizing the tip is not any harder - in fact it is easier because the tip won’t have travelled as far in a caudal direction. You won’t have to slide the probe as much to align the tip (vs shaft) with the beam. But most important reason to do steep and close is to prevent any risk of pleural puncture.

That's a common obstacle to learning US imaging of the spine. I certainly don't use it routinely; but when you do have a challenging patient (obese, spinal surgery, arthritic deformities), the US scan will actually save time. The issue is you have to already have the skills to make it work for you, so seek out opportunities to practice where you can.

High praise indeed from the OG of TAP blocks and paravertebrals - thank you, John! 😃

@@KiJinnChin think your videos are the best availabel and I always look at them and learn

LA for radial artery cannulation - yes, just a small little wheal at the insertion point is the best way to do this. Not this block. What this video should make you aware of (as it did for me) is the potential risk of injury to the SRN if you are not in line with the artery; nevertheless I think it's rare as it's relatively far away from the artery.

Thank you for your reply

It's a good question. The incidence with superior trunk is variable - ranges from 30-70% - ultimately it's all about spread, which is uncontrollable to some degree. I think that the risk of clinically-significant phrenic nerve palsy with a superficial cervical plexus block alone, if volumes are kept to 10ml or less are minimal. Hence I would personally be fine doing a bilateral SCP block for anterior neck surgery.

The deep cervical plexus block comes with a lot of collateral effects, since a higher chance of sympathetic block till motor block of muscles of the neck, for this cause being gradually abandoned in a few hospitals

It's semantics / terminology. Some people make a distinction between "superficial" = subcutaneous injection, and "intermediate" being injection another layer deeper under the superficial cervical fascia, as we would be doing when we inject under the edge of the muscle with US. I keep it simple personally, and only distinguish between superficial (which is either of these 2 variants) or deep (which is injection at the level of the roots), which I don't do (it's risky and difficult as the other commentator has noted).

@@KiJinnChin sir I have a doubt the difference between interscalene and supraclavicular brachial plexus block is that suprascapular nerve gets spared in supraclavicular block ... But some say suprascapular nerve is there within lateral part of bunch of grapes in supraclavicular region What is the basic diff between interscalene vs supraclavicular block? Sir

I have never observed it to prevent neuromonitoring, which is standard in our hospital. My neuromonitoring techs say the signals are fine. This is with both TLIP and ESP (at thoracic and lumbar levels).

It's a good point. You certainly could do that, especially if at that given moment in that given patient, the anatomy and visualization of target and needle were favorable. Sometimes needle visualization and alignment is challenging, in which case, reverting to simpler techniques may be required. It's the main reason I advocate for the parasagittal IP view as first line most of the time.

It is true. I always had a little better luck with the transverse because of the lack of rib in the lumbar view. But do you think it may confer any additional analgesic benefit to doing the double site injection? Or the target nerves should be sufficiently covered with just the ESP? And thank you for the reply!

@@aaronkugler8876 Hi Aaron - I think that the effect is good enough with just the one injection at the ESP. I would do one or the other of the TLIP or ESP, and try to preserve the full volume at one site to promote cranio-caudal spread and coverage (presuming this is for multi-level surgery)

Good observations - and there may also be a pannus that needs to be retracted by an assistant. In these cases, probably the best way around it is to use a Catheter-Through-Needle (CTN) set rather than the catheter-over-needle set. If you open up the fascial plane/space with the loading bolus, the catheter should thread through the Tuohy, turn the corner despite a steep needle angle, and find its way cranially under fascia iliaca.

@@KiJinnChin Thank you Dr Chin! Definitely will give that a try next time

Agree that depth and echotexture of muscle often hinder needle visibility. I presume that is what you are referring to, and not visibility of tissues? The landmark of the bony acoustic shadow is usually easy enough to see. Settings - at a simple level, I experiment with dropping the frequency to the low end of the range ("Pen" or "Deep" setting on Sonosite machines), and changing the gain. For needle localization, I track tissue motion, and use hydrolocation.

These are Plan B blocks for situations outside of the routine - (a) where you need to supplement or rescue an imperfect BPB, (b) scenarios where you don't want to perform a BPB, e.g. bilateral wrist fractures, wanting to preserve shoulder and even elbow mobility in certain patients. Knowing them makes you more versatile and flexible in what you can offer your patient.

An excellent question which highlights the importance of understanding the anatomy of the region. It's not a matter of how far/deep you insert the needle - it's whether you angle down (NOT recommended), or as in this case, keep the trajectory FLAT, that determines the risk of pneumothorax. If you are not angling downwards, you are unlikely to ever hit the lung. Please see the full video at kzbin.info/www/bejne/iYKvlWCVeMSkebs to appreciate why this is so, why this particular technique carries a minimal risk of PTX, and why the needle often needs to be inserted to close to its full lentgh.

Thank you for the comment. I recommend also checking out the series on the paraspinous approach and finding opportunities to practice this - I make it a priority for my trainees and it is my go-to approach in the difficult spine. kzbin.info/aero/PLrTgRae0xlkN2Tucs5gZ2JePSqafcNdDn&si=f1Gac3XEEmh357HH)