INTERSCALENE BLOCK: DON'T DO THIS!

In this video Dr Hadzic explains why you should NOT use multiple injections in Interscalene Brachial Plexus Block. He argues that multiple injections do not have advantages and multiply the risk of nerve injury and systemic local anesthetic toxicity.
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Disclaimer:
Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publishers have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's KZbin channel is accurate.

[@davidbernstein3514]

I am guilty of moving around a bit in the sheath from time to time. Excellent video. I feel very confident you are correct.

[@ymc7496]

I’m so glad you made this video. It drives me NUTs when I see teachers teaching students to do multiple injections. Thanks for the validation 😂

[@M_J_nan]

Thank you for this! I have felt very alone in my work place, by aim for "enough is enough" and safeguarding the nerves.

[@franziskas932]

Is it just me or did anybody else notice that he has the exact same voice as David Schwimmer from Friends? Its like Ross is explaining anesthesia to me, i'm thrilled. Thank you very much Dr. Hadzic!

[@nysoravideo]

Hey Franziska! Thank you for your comment- Keep watching!

[@DRBLUESNYC]

Oh man. I just re-watched David - lol - indeed - there are similarities! Thanks for the comment and greetings to you and your colleagues.

[@carlosarellano5251]

Too funny...I hear it too with a slight accent

[@Poltergits-Lampost]

Yes definitely 😂

[@florhurtado3721]

Excellent as usual. Thank you 😊

[@nazarkalivoshko11]

Some very valid points from one of the best regional anesthesia scholars and specialists in the world! Thank you Dr. Hadzic! I am a very busy regional anesthesiologist (up to 30 blocks a day, with my own hands), I practice and teach regional anesthesia. While I agree that multiple injections increase the risk of the nerve injury I want to make few points. 1. Single injection, where the needle tip stays posteriorly to the plexus often pushes the nerves anterirly, while the LA not necessarily hydrodissects connective tissue to reach the anterior wall of the interscalene grove, therefore making it unlikely to have a “surround” bathing of the nerves in LA. The onset of such block and even the quality of anesthesia may be compromised. I think the operator in the video was trying to avoid that. 2. One should never move the needle around without seeing the entirety of the needle, but especially the needle tip and without recognizing the structures the needle is touching, gracing or penetrating. However in skilled hands, like in the block demonstrated, I would feel very confident regarding safety and extremely confident in the achievement of excellent block. 3. One point injection was the dogma in pre-ultrasound era, where after finding appropriate parasthesia or muscle twitch one would inject at that spot the entire volume, without knowing whether LA actually went into the place of interest. As we all witnessed with US, the injection from motionless needle often becomes ineffective as the tissues tend to move away from the needle tip under pressure of injection therefore providing less than adequate spread. 90% of the time I find myself needing to “chase” the nerve or the plane with the needle, hence moving it around. 4. Lastly, while interscalene block earned a title of the king of the UE anesthesia, being called “the spinal” of the hand, with the advances of US techniques I see very little reason to do it today. It is a very tight space, highly “populated” with nerve trunks, nance the spot makes the nerves vulnerable to injury, and Carrie’s high complication profile - mainly 100% of phrenic nerve paralysis. For the purposes of the shoulder surgery I have abandoned interscalene blocks altogether and do a superior trunk block, or even selective suprascalular and axillary nerve blocks. My success rate (quality of analgesia/anesthesia) is, without exaggeration, 100%, and phrenic nerve paralysis rate is in single digits. For the purposes of arm, elbow, forearm and hand surgery I chose supravlavicular, infraclavicular, axillary or even selective median/radial/ulnar blocks in the forearm.

[@nysoravideo]

Hi Nazar! Thank you for sharing! Greetings from NYSORA!

[@sajjadqureshi746]

Sir do u have any videos of suprascapular and axillary nerve blocks here on KZbin??would axillary nerve block alone suffice for shoulder surgery??

[@Kusumdubey26]

Excellent video 👍

[@sleepkeeper42069]

I agree with you, Dr Hadzic. I think the nerve stim is really still a great adjunct even with ultrasound guidance. Sometimes, pt has bad anatomy, and visualization is not great. Other times, you might be in a facility with a cheaper quality ultrasound, and landmarks are not so well defined. A nerve stimulator can provide secondary confirmation of location in relations to the nerve, and decrease chances of being mislead by poor visualization and thus the number of entry into the plexus area. Thank you.

[@nysoravideo]

Hi Sleepkeepr! Thank you! Your comments are much appreciated!

[@Kronbi]

And higher risk of nerve injury

[@kolton1688]

Do you have the studies on this? Pretty interesting. Thank you

[@saislam9]

Thanks 👍

[@sallehasamad9543]

Great info sir. Tq

[@zsuzsadr.szentimrey-perecz9483]

Thank you for the very useful video, what valve is used to check the pressure? Can we have your model number?

[@wagdog1]

I have had improvement in quality of block and time to onset for shoulder procedures with going above and below C5. Similarly for supraclavicular blocks, I find a lower failure rate when I go "below" to the "corner pocket" and above. I have to disagree based on my clinical practice and I don't find two deposition sites to be hazardous at this juncture in my practice.

[@intestinomedicino]

The idea of multiple injections does not make sense for me, but definitely is good to hear and see why it shouldn't be done.

[@DRBLUESNYC]

In theory - more injections - more precision - better spread - less local. In practice - HAZARD and UNNECESSARY. Greetings!

[@arrahman6876]

well, trainees can first use a low conc and dose of bupivacaine and use it as pain control.So that when the hand is good at the block then use as full anesthesia

Great video 🔥🔥

[@nysoravideo]

Glad you enjoyed-Keep watching!

[@DJTandJDvance24]

I had one and could feel the cuts it was greatly reduced, but I could feel it. The people in the operating rm didn’t believe me. Then after asking me a serious of does it hurt now? How about now? What about now? Then I heard the Dr say “put him out. I have no doubt he feels it. He was right every time”!

[@hadzojr]

Thanks!

[@luismanuel741]

Gracias doctor.

[@nysoravideo]

Hi Luis! Most welcome!

[@johnboy1064]

Hi Dr. Hadzic during a single injection with with just a nerve stimulation can you go anterior to posterior approach with no maping or ultrasound? Using the anterior approach isnt this exposing the Phrenic Nerve for damage? Is Posterior to Anterior alot safer approach?

[@VaGuS343]

Thanks.

[@nysoravideo]

You're welcome!

[@basmagaber4984]

Thank you God blesses

[@nysoravideo]

You are so welcome!

[@dman5715]

Is having the single injection method available at Mass General Hospital? If not in what hospitals is this ultrasound single injection method available?

[@mirmahmud1438]

Thank you very much for your kind sharing of a excellent topic.. how much ml are required for single injection..

[@DRBLUESNYC]

For surgical anesthesia we use anything between 7-15 ml. For analgesia - anything between 5 - 10 - depending on the adequacy of the spread. Greetings

[@skmbrd22]

I had this done and I have had eye issues on the side of injection weeks later. Pupil larger and brighter light

[@Stick2011]

Dr. Hadzic-do you use a different technique if using Exparel because it doesn't spread as well? Additionally, what adjuncts do you use to extend the duration of your blocks? Thank you for all that you do and share with our anesthesia community.

[@alirezamoradiforuz5018]

Excellent

[@DRBLUESNYC]

Thank you

[@DeepakJosephDr]

Thank you Dr Hadzic for your excellent videos. For shoulder surgery, when C5 is the primary focus of blockade, would you consider injecting LA above C5 in such a way that it travels below the cervical fascia to the other side or would you rather inject into the brachial plexus sheath between c5 and c6.

[@mikhailswartz]

As the brachial plexus sheath is not a diffusion barrier, you should actually be depositing the LA adjacent to the sheath. No need to pierce the it.

[@JasonGRichards]

Does exparel go into the sheath?

[@draditisuri4048]

Why do we have multiple injections in supra clavicular BP block ?

[@simerpaulmariano9231]

Thank you sir for Sharing.. Sir how can we ensure adequate spread of local anesthesia by single injection? Hopefully you can give us some tips.. You videos sir helps us a lot.. THANK YOU..

[@DRBLUESNYC]

Watch the brachial plexus during the injection. 1) If it moves away from the needle - you are in the good place - in the sheath. 2) Scan up and down from the site of injection - you will see the spread if injection is OK. Greetings. .

[@simerpaulmariano9231]

@@DRBLUESNYC thank you sir..

[@dcDOC19]

I’m guilty of multiple injections with the ISB. I’ll change my practice, thx Doc!

[@DRBLUESNYC]

Switch up to one or max 2 injections, if the first injection was not adequate - and you will save time and patients from unnecessary risk.

[@Ricardo-wr5sf]

Same here

[@nobragjustfact6107]

Bless me father, for I have sinned…

[@MacchiatoSwirlGirl]

​@@nobragjustfact6107ugh stop hurting us patients, not funny man😢

[@larrykester8593]

Dr Hadzic, I am currently a Surgical Technology Student. After graduation I will receive an Associates Degree in Applied Science in Surgical Technology. What would it take for me to possibly look at becoming an Anesthesia Tech?

[@anesthesia101online]

Interesting. Could link that article please? Thank you

[@DRBLUESNYC]

Greetings. Here's one of the references not mentioned: Intraplexus injection are NOT recommendedSpence BC, Anaesthesia, 2011

[@anesthesia101online]

@@DRBLUESNYC TY

[@PBAB17]

What part of the body is this? For what procedure?

[@amarsuljevic4499]

🎉🎉🎉🎉Thanks

[@omar-iv9xi]

of course very useful information. I feel you are very angry from the video posted in the social media, but i would be also very angry if i am in your postion☹️

[@DRBLUESNYC]

Greetings. Not really. But the subject is a serious matter - patient safety in the absence of practice standards for nerve blocks.

[@user-dy7mj2bs3u]

Does this hold for other blocks such as supraclavicular block, whereby certain elements/divisions might be separated from others by septae/fascia?

[@DRBLUESNYC]

Supraclavicular block requires different approach. We'll get to that in one of the next videos. Greetings!

[@abdulshirazi]

Why do single shot when your can do 0 and give tons of opiods? That's what i do and have never had an injury or phrenic block

[@maiffa7113]

Hi Dr Hadzic, sorry if my question is out of this topic. Where can I buy the scrub shirt that you're wearing? Or isit custom made?

[@DRBLUESNYC]

Lol. Thank you for the complement. This is our standard scrub shirt in the hospital. Of note - we will have some merchandise on this channel as many people have asked for NYSORA t-shirts etc. Greetings to you and your colleageus

[@camilodaza6382]

Thank you very much for this video, I'm guilty of multiple injections and LA mixing too. I had notice failure on suprascapular nerve block when I don't do Injection over C5, so I use to do to injection at least one over and one under C5, for shoulder surgery. How do you avoid suprascapular failure? Do you always aim an especific root for single injection? Thanks in advance

[@DRBLUESNYC]

Hi Camillo, the supraclavicular block is a different story. We'll cover that in the next video. Greetings

[@DRBLUESNYC]

Suprascapular nerve comes from the upper trunk, c5+c6 = so, for as long as your injection covers the upper trunk - which it should, suprascapular nerve should be blocked. Greetings!

[@MacchiatoSwirlGirl]

Does that mean in the neck?

[@abrorvalihanov9787]

Some valid points, but the message could be shorter, not that long. At the end of the day it’s a skill, more you do it, more small personal tricks you will develop over time.

[@nysoravideo]

Hey there, thanks for your feedback, we really do value it. Everybody learns different ways, but practice is indeed the best way of learning. Thank you for the feedback again.

[@xLu1G1x]

Many injections are often necessary to ensure adequate spread of LA into the nerve sheat for trainees. That is why it is important to have supervised practice and training.

[@DRBLUESNYC]

Respectfully disagree. Particularly with trainees - you do NOT want to do this as even in experts hands - there is a risk of root injury or intra-root injection. With trainees - their risk is much higher. Important for trainees - they should be reminded to decrease the pressure on the transducer - which prevents the distribution of the local anesthetic in the scalene space. Greetings.

[@xLu1G1x]

@@DRBLUESNYC I am afraid I didn't express myself correctly. It is not rare that in my city most practitioners are self educated in US-guided blocks, some centers are even proud of their skills in paresthesia guided Infiltration. I've come to notice in this unsupervised setting, they tend to make several attempts to inject LA properly, and I've seen, regretfully, some nerve lesions associated. Expert guidance and supervision from early practice are, in my opinion, key to avoid all of these complications in regional anaesthesia. Indeed, one must always look for one shot injection, even in trainee's hands. Practice AND quality education, should be a standard in any institution. Sadly, it is not the case in my city, for numerous reasons. In any case, props to you and Nysora team for this useful, short and understandable content, as always.

[@DRBLUESNYC]

@@xLu1G1x Thank you for clairfying. I agree with you. In fact, one of NYSORA's main missions is establishing standards that are easily reproduced and established as a service. Greetings.

[@vesnahacker8570]

Hello Dr. Hadzic, I had left RC surgery 5 months ago. It was a viv tear. I remember getting an injection to the left side of my neck as addition to full anesthesia...( if that is correct on my side). Suddenly I developed pain ( 5 on scale one to ten ) in my arm aafter two months of intensive PT .. i drove car twice last week , two hours each time long..Im sure I did not keep my posture properly although I tried.. Decided today to stop PT and see if I feel better. My doc suggested to wait two weeks and see if pain pass and then visit him if that does not happen. Hope you are willing to share some thoughts about my sityation with me. Patients sould be educated before the surgery the way you explain. I appreciate very much so detailed explanation and will follow your very good program. Thank you. Vesna, 68 old.

[@nysoravideo]

Hi Vesna, Thank you for watching our channel. However, it is difficult to give medical recommendation based on the short information you have provided. We are unable to do this in this on this platform. We would strongly recommend you contact your doctor for further management. Wishing you best for your recovery. NYSORA team!

[@chandrikakamath2707]

Thank you Dr Hadzic for this excellent video. We too are guilty of getting carried away with the volume and number of needle redirections to what we thought would maximize spread. Does volume of the injectate really decide duration of postoperative analgesia? Thanks in advance.

[@DRBLUESNYC]

The speed of onset will definitively increase with more injections. But so will the risk in exchange for a couple of minutes faster onset time. Remember - we never have a situation where the block must be obtained STAT. As for volume of injectate - yes - the block quality and duration increases with large volume. However, this has a ceiling effect - beyond 15 ml - there is no benefit. Greetings

[@chandrikakamath2707]

@@DRBLUESNYCsir thank you for clearing our concepts

[@cedivadenia]

excellent¡¡¡tk

[@scanningallvidzs]

Oh my god, seeing two injections is fine, sometimes it's necessary for full coverage of C5 and C6, but man all the ones after it were unnecessary. You can clearly see the hydrodissection inside the sheath if you simply keep pushing the syringe, it's totally unnecessary to keep stabbing since it's going to track along anyway and provide full coverage.

[@DRBLUESNYC]

Agree. This is an example of using ultrasound as a video game. The practitioner is clearly uber-competent with great control over needle-target relationships, and the video is reminiscent of a show-off - see what I can do. However, this is rather common in clinical practice - as someone who has supervised countless blocks, the urge to inject multiple times is common. Greetings

[@fatihaarif255]

Très utile et merci de le confirmer

[@nysoravideo]

Hi Fatiha! Thank you for your comment!

[@dahuang3910]

Thank you very much for sharing. I'm new here, sir, but how can I make sure that every nerve is surrounded adequately by anesthetic using single injection, because generally there are 3-4 nerves in interscalene?

[@nysoravideo]

Hey Da Huang! Thank you for your comment. You can visit our platform nysoralms.com/courses/nysora-compendium-of-regional-anesthesia/ for more details.

[@dahuang3910]

@@nysoravideo Could you please make it more precisely?

[@stomaccount1]

What do you think about multiple injections at the supraclavicular level? Isn’t that the same?

[@simoceci]

Supraclavicular requires multiple injections in my opinion

[@midhunk13]

Sir,What about supraclavicular block ?

[@DRBLUESNYC]

Hi there. Will cover supraclavicular in another video; it is a different level of risk and different strategy. Greetings!

[@sarasalam6571]

Hello! Thank you for the information. I’m doing my first year of anesthesia in southwest Germany.. we also do more than 6,000 blocks per year.. I’ve been taught to perform the ISB out of plane and all my experienced colleagues do the same. I find it difficult and kind of scary honestly. Is “in plane” the way to go?

[@DRBLUESNYC]

I agree with you on this one. Greetings!

[@DeepakJosephDr]

Hi Sarah, Please could you upload a video of the ultrasound images of an out of plane interscalene block?

[@nazarkalivoshko11]

In plane is the only way to go, in my opinion, in almost all blocks and situations.

[@vikaschawla5792]

Many thanks Dr Hadzic, can we add 8 mg of Dexamethasone routinely to the mls recommended for surgical anaesthesia ? Secondly is it necessary to mix lignocaine 2% along with bupivacaine 0.5% as this has been our institutional practice ? Apologies i took off a bit. Greetings n Regards

[@DRBLUESNYC]

NO. 1) Adding Dexamethasone in nerve blocks does not work; give it IV - the effects is the same with less risk. 2) Do not mix lidocaine and bupivacaine - you loose the advantages of both of these local anesthetics - you get a block that is a little faster to onset then with bupivacaine, but also a block that is SHORTER in duration then bupivacaine. Greetings.

[@vikaschawla5792]

Many thanks Dr Hadzic for your valuable reply, it will change our practice for the good. Regards

[@Ardathair]

@@DRBLUESNYC Excellent video, thank you Dr. Hadzic! We (small regional hospital with a focus on shoulder surgery) use mepivacaine and/or ropivacain (each 1%) for single-shot anaesthesia (i.e. for arthroscopy, catheters for TEPs etc). Can you recommend any other additives instead of dexamethasone if a longer single-shot blockade is intended? Best regards.

[@DRBLUESNYC]

@@Ardathair The only 2 additives that actually work are: 1) Epinephrine 1:300;000 - with bupivacaine only & 2) Exparel with Bupivacaine.

[@Ardathair]

@@DRBLUESNYC Thank you!

[@pamelaruigh8185]

Not sure what they did to me during arthroscopic shoulder surgery but the doctor stuck a huge needle in my neck and six months later my hand is still affected. 3 months of hand therapy and still cannot make a fist.

[@MacchiatoSwirlGirl]

Omgosh

[@mak23997]

Tough to blame it on the block for certain. You had surgery in your shoulder. Nerves could've been damaged from traction, positioning or another operative related issue. But nerve injury is definitely a risk and that's why doctors discuss this before placing a block and letting pts make an informed decision. I certainly hope the anesthesiologist and surgeon discussed their respective risks.

[@gyo1439]

"If i dont kill the ulnar, then it wasnt a good block"

[@sam-dhana6153]

Even i feel single injection of LA directed towards lower trunk make the drug ascend up soak all three trunk through my 13yrs of experience

[@DRBLUESNYC]

100%

[@BassGuyNL]

After the initial 5 ml, I usually try to advance the needle a few mm into the puddle of LA already there. After careful aspiration, I then inject more LA. I would not call this multiple injection, but I would be interested to learn if you disagree. By the way, anyone who wants to move sphere shaped objects with a rigid stick, like in the video you showed, should quit anesthesia and go should some pool.

[@DRBLUESNYC]

That is what I firmly believe is the prudent practice. And agree with the pool. However, poll parties are much more common than you think - observe in your own practice and let us know if we wrong with this assumption. Greetings!

[@alvaroalfaro9478]

We can also do spinal with multiple punctures and passes for video game fun

[@Ardathair]

Multiple injections are only necessary if the anatomy is unfavourable. Else, singe injection is absolutely enough

[@DRBLUESNYC]

100%

[@HomoNeuraxis]

I cringed so hard after watching the 2nd injection 😫

[@DRBLUESNYC]

I do not blame you. How did you feel after the injection #8? Greetings ;)

[@miraadi97]

But indian physician especially anesthesiology resident still doesn't have access to USG guided practice because of the Law of Sex Selection on USG the PC/PNDT Prenatal Diagnostic just couldn't pass the stigma barrier to make health a political tool and maintaining status quo by physicians especially with no national surgical obstetrics anesthesia plans NSOAPs for right to east surgery access for citizens.

[@praxisdr.sergiubianu5139]

Vous êtes sérieuse?!?! Are you serious?!?!