S1:E10 "Giving You the Cold Shoulder (Nerve blocks for Shoulder Surgery from Awake to Phrenic-Free)"

Barbie, Ken, and Will Smith. What have they got to do with shoulders? Check out this episode to find out. I'm Amit Pawa. You don't need to know prime numbers to know that interscaling is numero uno. 

I'm Jeff Gadsden, and this is Block it like it's hot. Yo. Yo. Yo, Jeff. We're back again. 

This time to drop episode 10 with tips cool like ice. You know it's gonna get colder. It's time to talk all about numbing the shoulder. Hey, Jeff. How you been? 

Oh my god. How do we even how do I top that? That's great work on that. Have you been working on your wrapping? That's that's you are improving. 

But why do you No. So the issue the issue I had is whether to to try and do, like like, a grime British accent or to go American, and I I think I ended up with a hybrid. I don't even know what I am. Don't know who I am either way, colder with shoulder, that's that's amazing. Good job. 

It I see you are practicing for our season finale where we where we did promise to wrap, I think. Right? Well, you promised on my behalf, and and then I suddenly start thinking, I've gotta do some work on this. So so I've I've been doing a bit of practicing. You're absolutely right. 

Speaking of which, I better get on that backflip business. Oh, yes. The backflip was definitely a New Year's resolution, that sounded almost unbelievable. So I'd be very, very interesting, to see that. Yeah. 

I think a lot of it's preparation. Right? So I'm thinking about how to do a backflip. You're manifesting it. Right? 

Right. Yeah. Just I'm just visualizing it in my head. We'll see. Stay tuned. 

How you been? Listen. I've been good, man. I've as usual, I've got some some lectures I'm supposed to be writing, and I always tend to leave them to the last minute. So I'm I'm just battling that baseline level of that I have, you know, year round. 

It tends to come in swings. So, yeah, I I've gotta get that sorted. And once I get those lectures done, I'll feel a bit more relaxed. But one of these days, I'll learn. But, you know, apart from the usual stuff, I went to see a movie recently. 

I bet you can't guess which one I went to go and see. Was it Oppenheimer? You know, it probably should have been, but actually it was the Barbie movie. I went to go and see the Barbie movie. That is so that is so on brand. 

But you know so so one of my daughters has seen it four times. Oh, wow. Yeah. I haven't seen it. Is it is it good? 

Was it good? It's really good, actually. And I know, again, this is one of those things a bit like the ESP block or, like, the Marmire blocks. There are some people that that that don't dig it, but absolutely, I loved it. It's it deals with a lot of important, aspects and elements and, really? 

But oh, it re no. It re Seriously? That's not that's not what I would have thought you were gonna say. No. It really does, but it does it in a way that makes you think. 

Okay. And also, I've decide it's it's it's influenced my wardrobe. There's a hoodie in there that I've gotta get. It's kinda like a rainbow tie dye kind of hoodie, and it says, I am Kenough. Enough with a k in front of it. 

It's a Ken. I am Kenough. Kenough. And do know what? I'm gonna get that. 

Please tell me it's sleeveless. It's not sleeveless. Unfortunately, Ryan Reynolds is, like, so buff. So if it had been sleeveless, that would be a reason that I wouldn't have got it. But this is, like, a big oversized hoodie type thing, so I can definitely rock that. 

The the sleeveless stuff, not so much. There was a lot of six pack and chest exposure in that film. He's I mean, yeah, it could and Margot Robbie. I I mean, she's amazing. Everything I've ever seen her in has been has been great. 

So we'll get to it. Yeah. I how what have you been up to? You know, it's been kind of a quiet quiet time. We went and saw Mission Impossible as a family. 

That's, like, the first movie you've seen since gosh. I don't know when the last time I went to the movies was. It's been a while. So so which which number is that? Is it this is number four, is it? 

I've I don't I've lost track of which Mission Impossible. I think we're up to six now. Is that right? I think this is yeah. And and this is a part one of two. 

So you'd you'd give it you'd give it a thumbs up? Yeah. That was great. I mean, like, Tom Cruise, action movie. Come on. 

What's not to like? That Gong Lee, that guy is amazing. He just never seems to get older. He just seems to get sort of more athletic, more adventurous. It reminds me of somebody. 

I can't think who. But it reminds me of you, man. Well, I do all my own stunts as well. Yeah. Well, exactly. 

As we said, the the the the back flip is is coming up. Listen, man. We've had a a few, questions and interactions from our previous podcast that we never got a chance, to deal with. Right. Should we should we do those? 

Yeah. Let's do that. Some shout out. So again, here's one from our friend. This is a really interesting one. 

This is from, from Mick Kerrigan. He's getting lots of shouts on the podcast. He asked us a question directly, which is what apps, processes, and workflow do you use to keep track of your reading or knowledge? This is a great question. Have you have you got an answer for this? 

I think it's it is a good question because there is just so much now. Right? And There's so much to keep up to date with. Yeah. I I I mean, a source of anxiety in my life is the ever increasing stack of unread journals that I keep beside my desk here. 

It's like, ugh. I feel so guilty. I subscribed to this journal, but I never read it. And every once in a while, I sort of, like, quickly shuffle through to see what I'm what I'm missing. But one thing we do, and this is more for the trainees, but it helps helps me personally too, is we have a sort of compendium of must read articles that are sort of, you know, seminal or really instructive or good points or that that sort of thing. 

And then, of obviously, it's it's good to keep up with all the YouTube type videos from, like, yourself and and and Mick and and other people that are doing great, great work on in the video space. So I I, you know, I wish I I wish I could tell you that I had a one stop solution for knowledge management, but I don't. Do you? No. So it's really interesting. 

So I, there's a number of things here. One of them is how do you keep track of all the things that you wanna share with people. And one of the simplest things we did was we created a, an online folder. So we happen to use Dropbox, but you could use Google Drive, whatever. And in that that folder, we share with every regional anesthesia fellow that comes through. 

And everyone whenever we come across a paper or or an article or something that's useful, they get popped in that Dropbox, which will over time become a as you've got a compendium of knowledge and information. And these are things that we've curated, I think are worthwhile reading. So that's one process. In terms of how do I keep, track of what I need to do, this has been a source. I'll use the term anxiety. 

I don't use the term lightly because, actually, once you get to a certain level of busyness, it's difficult to keep track of everything. So I keep it really simple. I have got a notes app on my phone, which is called urgent things to do, And I will alter the level of priority depending upon deadlines and all the rest of it. And the reason I've got that list is when you say yes to doing something, sometimes you forget that you've agreed to do something, especially with via email. So the moment I agreed to do a task, it goes in that notes app. 

I've got to have some way of one source because I used to have pieces of paper, which should start off in my jacket pocket and my trouser pocket, and then I'd lose a piece of paper and then I have that would be a nightmare. And then I had a whiteboard. I used to write on a whiteboard that I forget to update it. So actually, the thing I carry with me the whole time is my phone. So, yeah, the notes app I find really useful. 

And actually, you know, dare I say it again, it can be controversial, but things like Twitter are a great way of highlighting papers, certainly the early ahead of print, those type of things. Yeah. Yeah. The moment something comes out, if there's early access to it, I'll immediately bookmark it. So I use the bookmark function, on Twitter to save things to one side so that at least I'll know I'll come back to it. 

The question is whether I actually do come back to it. Well, hopefully, I do, but I only bookmark things that are really important. So it's difficult. I don't have a perfect solution. Yeah. 

Yeah. It's tough. I mean, it's just reams and reams of information that's flying at you at all times. If anyone has a good solution or a a good workflow that they wanna share with us, please do. Yeah. 

Absolutely. For sure. I'm desperately, looking for the perfect solution. Now the other thing is we've got an, an amazing emergency physician colleague from Australia. Her name is Kylie Baker. 

She's from Queensland, and she was asking a question about the block that we talk about a lot here, the block that may not be named. She says, if using an ESP block for for a chest drain insertion, do you keep local anesthetic back to anesthetize the pleura, or how do we specifically anesthetize the pleura? Now I'm guessing, Jeff, you may have been involved with chest drain insertion, more recent than me, but but but share your thoughts on that. Oh, it's been a while. When I was a when I was a a PGY one trainee way back in the day, I did a thoracic surgery rotation, and I was a basically, the chest tube monkey. 

Oh, right. Just went and ran around the hospital putting in chest tubes. So I got really good at it. And I remember, you know, we didn't use blocks for that. We just anesthetized the skin and the muscle and got down to the rib and anesthetized the periosteum and then tried just tried to jam a bunch of local around where you're about to make this incision in between the ribs. 

But So you did make a concerted effort to anesthetize the layer of pleura before you punctured it. Right? At least the parietal pleura. I guess some local got inside the the pleural cavity, but but it's a good question that Kylie asks. I think part of the answer would be for me is Uh-huh. 

Do you believe that the ESP block gets the visceral component? And certainly, there there is there is data to support that. Right? So that's I I think so. Personally, I'm a belt and suspenders kind of person. 

I do like to hedge my bets when it comes to keeping people comfortable. So I I would do a little bit of infiltrating as well as an ESP block. Yeah. I mean, I think if I, again, I'm now talking theoretically. I hope it's been a long time since I've had to put a chest straight in line. 

I hope I don't have to do it in my regular regional anesthesia practice. Otherwise, things have gone very badly wrong. But if I did have to do it, I think I probably would still put certainly use local for skin infiltration despite having done the block. And I think I can't see any harm with putting a bit of local anesthetic just prior to passing the, the catheter into the pleura. So I guess indirectly, we both sort of said that we would, but as somebody hasn't done it regularly, you can take my comment with a pinch of salt. 

So listen. I kinda gave you a hint with the rap, what we're gonna talk about, but I I kinda figured today, we talk about shoulders. So you think we should start? Yeah. Love shoulders. 

Let's let's do this. Okay. So listen. The thing that comes up a lot in exams is innovation of the shoulder. So if I think back to my sort of pre FRCA days, the only thing I take on board is that, yeah, c five, c six, that was the I've got that picture in my head, the dermatomes. 

That's what we need for shoulders. Right? So we just need to take out c five, c six. Is there any more to it than we need to know other than that? Well, I yeah. 

It I think it depends on your goals and and what you're after. But if you're if you're truly trying to think through how best to provide analgesia for shoulder surgery and alternatives to the most common blocks, it is important to understand the innervation. So there's dermatomes. So what is the skin that is overlying the shoulder that the surgeon is going to be cutting through? What are the osteotomes? 

So what what innervates the humer the head of the humerus and the distal clavicle and the scapula and the myotomes and, and so forth. So I I I like that framework, and I think a lot of our trainees get sort of start and end, at least in their early stages, with dermatomes. Yeah. Okay. What what is the what's the skin innervation? 

But, you know, we try to encourage them to think about the muscles and the bones as well. But do do you feel the same way? I do. You you know, I have to be honest. When I first started learning, regional anesthesia, the first thing that was a bit of a, an epiphany for me was to understand a bit more about that because definitely my knowledge dropped to c five and c six. 

I never thought about osteotomes or sclerotomes, and certainly not myotomes. But the the one bit of knowledge that kind of was used to be thrown around as a statement was, the suprascapular nerve is responsible for 70% of the innervation of the shoulder. That was a number that came out. Now I know there's been a lot of work done by Philip Peng. He's of question that statement, but certainly understanding that I should break it down into the individual nerves was was a real epiphany for me. 

So, the type of the so the only two nerves I became aware of in the early days of my regional anesthesia training were suprascapular nerve and the axillary nerve. But, you know, we now know there's lots more, there's a lot more lots more to it. There's the lateral petrol, the subscapular, and the supraclavicular nerves. I think it's useful to know all of that. Right? 

So I I used to just focus on c five, c six, and now I think about those other nerves. So why why is it important to know this? You know, apart from academic, interest, why is it important to know that? What's so do you think and also, do you quote 70%, or or do you think it's relevant that we don't really care what the number is? What do you what are your thoughts? 

No. I do I do quote 70%. I and so just just to reframe that. So if you were to do a block at c five and c six, you can do awake shoulder surgery. Right? 

Like Uh-huh. That is that is possible. We we do it every day. That's the elegant thing about an interscalene or a superior trunk block for shoulder surgery. It's just a small application of local anesthetic at that spot, and you can do awake surgery on a major joint, which kind of still blows my mind in a way. 

Uh-huh. Right? But then there there are when we'll talk about this, there are downsides. There are sort of pitfalls to doing a brachial plexus block that high up in the neck. And so I think of this similar to femoral block is to knees and how we've deconstructed the femoral block and now we do an adductor canal block and the geniculars and everything else. 

You can you can break it down into those individual nerves that are actually getting to the joint, like you said, the suprascapular. And the suprascapular is the is the biggest one, I think. Yes. And the proof for me is in studies that compare a single suprascapular block versus interscalene or suprascapular plus an axillary nerve block versus interscalene. And they're not quite the same, but they're pretty close. 

Right? So so if you that that tells me that, okay, those are the two most important nerves or suprascapular is the most important and then axillary maybe the second most important. And then you've got your your other bits and pieces like the lateral pectoral and subscapular and branch from the musculocutaneous and that sort of thing. Uh-huh. I think it's important to understand that you can do shoulder surgery with just a c five six block. 

Right. But if you don't want to do that for whatever reason, you can get very good effects by attacking one or two of the five or so nerves that make up the shoulder. Well, the other thing that's really useful is I remember certainly when, again, my early parts of my training, there used to be the statement people used to say, you can't use supraclavicular brachial plexus blocks for shoulder analgesia. And that was just a stain that was made. It wasn't qualified. 

And I I really had to to to search for the answer. But again, this comes down to the principle that if you do a traditional supraclavicular brachial plexus block, you are blocking it once the suprascapular nerve has left the superior trunk. And for those of who don't remember, c five, c six come together to form the superior trunk or the upper trunk, and the suprascapular nerve leaves the upper trunk. So when you're doing a supraclavicular brachial plexus block, by definition, this suprascapular nerve will either be in your needle path or but it should have left the plexus. That's not to say you won't get analgesia and you may get some local antidote by proxy, but that's where the whole thing came from. 

So if you're gonna do a superior trunk block, which we'll talk about later, it's really important that you block that superior trunk or upper trunk before the suprascapular nerves left it. Right? I think that's that's absolutely correct. I think you have to be cognizant of where that's that suprascapular nerve is coming off. And most times when I've scanned it in patients, it's not that far away. 

So I do feel that you if you do and I guess it all depends on volume too. Right? If you're using 20 or 30 mils in the supraclavicular brachial plexus block You're gonna get it. Right? I can't imagine. 

You're you're gonna get it. Right? So because it spreads spreads everywhere. I think part of the wisdom about, well, interscaling would be the gold standard or first choice single injection technique, and then supraclavicular would be a second choice. Has to do with the spread to the cervical plexus too. 

Uh-huh. Certainly in the old days when we used a gazillion mils of local anesthetic for our inner scalenes. What's your record, by the way? I think 50. What? 

Yeah. Yeah. Yeah. Okay. I was gonna say 40 for me, but 50 is okay. 

Yeah. And after the patient stopped seizing, then we would do the surgery. And, you know, this is this is pre ultrasound. This is, you know, back in the dinosaur days, but you got every nerve in the neck. You got the Yes. 

Stellate ganglion. You got everything. So You got every nerve in the body, man. But we're doing, though, those blocks for, quote, unquote, awake shoulder surgery. And so getting the cervical plexus is important for that if the surgeon's gonna be, you know, making port incisions for rotator cuffs in the sort of cape of the shoulder where the skin is, you know, being served by the supraclavicular nerves. 

That's all to say if you were to do a supraclavicular brachial plexus block, you might not get the cervical plexus in the same way that you would with interscalae. So But these are these statements that used to be banded around during your training that were were, you know, maybe passed down through folklore or or based upon some textbook evidence pre ultrasound era. And, you know, it's important that we challenge some of these things because that you know, don't just let them sit out there in the So I think so what I've got from what you said so far is, interscalene is kind of the, you know, it's the plan a block for the shoulder. It's the bog standard, and we can use it for most of our patients. But there may be some situations where we need to think about looking at some of these alternatives. 

And that's why it's important to know some of the other nerves that we've talked about because we can use them as part of some, maybe, some phrenic nerve sparing strategies. And and we're gonna get into that. We're talk about awake shoulder, and I'm looking forward to you sharing your recipe and tips and tricks at the end of the podcast. But let's let's get back into the main thing. Right? 

So when I first started doing interscaling brachial plexus blocks, I used to do what one of our mutual colleagues, one of your mentors, Admiral Hadzik, used to refer to as video gaming. Right. I used to go over c five, come back, go between c five and c six, come back, go below c six. So I used to do that whole thing, and that was very much an intraplexus needling technique. I used to do on awake patients. 

I used to do it on on patients under GA. Don't tell anybody that. No. It's I used to do it under GA and awake, but I was very aggressive. And, actually, now we don't need to do that at all, do we? 

There's an alternative to doing intra plexus, and that that's periplexus. Do you think that's the default place? That's what we should be doing for every every interscaling brachial plexus block? I do. I do. 

Yeah. And that's that's like you, I did intra plexus blocks when I first picked up an ultrasound probe and stuck a needle in somebody's neck because it felt right. It felt like, okay. There's my local, like, completely surrounding and and getting all around each of those each of those nerve roots. But there was some work done out of, Dalhousie University in in Halifax, Canada showing, that with a periplexus approach, which is we'll just define this for for the listeners. 

So interplexus would be inside the sheath, so between c five and c six nerve roots, and periplexus is beside the sheath. And so as you you can imagine, as you inject, rather than the c five and c six sort of separating and being pushed apart, they get pushed medially usually because it lean was coming from lateral. So, we'll we'll see that whole plexus as sort of on block move medially. And so you're not technically inside the brachial plexus sheath. And then and what the Dalhousie group showed was there was a difference in cadavers in the incidence of intranural, and by that I mean, intrafascicular dye deposition, with a very, very small, like, point two milliliters of India ink when they did these injections. 

So so that was enough to change my practice. This I can point to a handful of papers in the course of my career with that have that have changed my practice sort of overnight. When I read that one, I'm like, oh, that's it. I'm no longer doing intra plexus because I just don't want to put someone at risk for an intrafascicular local anesthetic injection. How about you? 

Absolutely. Yeah. So so, eventually, there there was another paper, with a similar vein that definitely changed my practice, and that was this up and down study looking at they did a periplexus injection first, and then assuming it was successful, the next patient, they brought the needle back a bit, and they did the next injection. And then they kept withdrawing the needle within the body of the middle scaly muscle till the point that they got a block failure. And, actually, what they showed was in up to fifty percent of patients, they were getting successful blocks with the needle tip 8.5 millimeters away from the nerves. 

I'm not saying that's our gold standard, but the point was it really emphasized the point that you can get a successful block just by being periplexus and being further away. So a 100% that changed my practice. So I, you know, I do I I'm I am an in plane guy, but what's interesting is my volumes of local anesthetic have definitely dropped over the years. So I used to be, I guess, the very first one I did with ultrasound, I used forty mils back in the day, and that felt uncomfortable. And then I was hovering around 20, and now I'm a prime number kind of guy. 

And this come from Gordon Lancelot. Prime number. Yeah. So he 21 mills. C bases 21, that's not a prime number. 

Right? Oh my god. Okay. Yeah. Yeah. 

Alright. Fair enough. Math was math was never my strong point. 19. 19 is a prime number. 

That is brilliant. So five seven five seven or 11 mils. That's what I inject. Five seven or eleven mils. Okay. 

And it's just it's now become a thing. So if I've if I've completed the block in, in in, I don't know, six mils or, just gonna put one mil more to make it a prime number. And and, actually, the I guess the point I'm trying to make is you don't need as much volume to get a successful block, certainly when you're visualizing under ultrasound. How about you? Yes. 

I agree. I I use way less. I mean, I just admitted that I used 50 mils at some point, but our sort of typical volume now is between 15 to 20. I I can't remember the last time I went over 20 in interscaling. It's it's unnecessary. 

And we there's data to show that in a CT image with dye, that that injectate goes everywhere. And so if your if your goal is, you know, I want this block to last as long as possible, then better to use a sort of a higher concentration, lower volume, and just put it in the right place. Just to get back to your point about that study where the the up and down, where they pull the needle back and they were in the middle scaling, I think that is illustrative of how local anesthetics diffuse through tissues. And I'd love to see sort of a radio labeled image of local anesthetic in the neck and showing that it just it spreads through tissues to to to get to all the different places. I I will say our goal still is to not be in the muscle. 

Yes. A 100%. So that that shouldn't have been the take home point yet. We don't wanna be in the muscle, but that was just an illustrative point. Right? 

Yeah. You you you can get a block. You can get an okay block if you're in the muscle because it'll diffuse, but it we're trying to or at least I'm trying to be between the epimysium of middle scaling and the plexus sheath. That's the ideal spot if between balance between efficacy and safety. Absolutely. 

And now the other thing that I, I began to learn the more scanning I did is that there's some some cheeky guys that hide out within the middle scaling muscle. And if you're an in plane neither like myself, it becomes very relevant. I am, of course, referring to the dorsal scapula and the long thoracic nerve. Those those nerves that kind of feature somewhere on that brachial plexus diagram that you're drawing you that never refer to again. These are real nerves, guys. 

They're real nerves and they do important things. And actually, they hide out within the muscle. And certainly the dorsal scapula is generally easier to see, whether you and once you've got your eye in, you'll always see it. So that's a that's a real thing. Certainly, when we start scanning the necks, we should make an effort to set to identify things that you may mistake as being fascial plane or blobs of fascia within the muscle. 

You can actually trace these structures up and down the muscles. So we've gotta be careful when needling. Right? Absolutely. And so I'm just trying to think out loud here. 

So if you had if you're bringing a needle across the screen and you've got you suspect there's gonna be a nerve in your pathway, but you're not exactly sure where that nerve is and you can't really see it on ultrasound, is there a technology that might help us identify that nerve? You know what? I just it just occurred to me. Nerve simulation. That might be useful. 

Yeah. Yeah. Call back to our pro pro con debate. Now that's a good point. I do I do have colleagues that like an out of plane technique, especially when they're threading a catheter because it just feeds easily. 

And and and I I had I fully admit that coming in plane from lateral and then expecting the catheter to make a 90 degree turn and then sort of head down the plexus is is challenging. And to your point, those you need to be careful of those those two nerves in the middle scaling. Absolutely. So now let's you know, we've we've started off from the interscaling. Now we're gonna move down a bit. 

So superior trunk. So this gained popularity and, you know, has annoyed some an an anatomical purists because it's that we don't call it you know, Grey's Anatomy doesn't call it the superior trunk. It calls it the upper trunk. The upper trunk block doesn't quite sound so exciting, does it? But yeah. 

I wasn't aware of that controversy of the controversy, amongst anatomists. Wow. Okay. Yeah. That's that's a bit controversial. 

I only know that because of the, the international delphys that we've done where it's kind of come up in discussion. Oh, okay. I can only imagine. But, yeah, the superior trunk bulky sort of came about with this concept of bit you know, we're we're not quite up at root level. The roots have formed the superior trunk or the upper trunk. 

We're a little bit further away. And and one of the one of the proposed, ways of using this block is to treat the superior trunk like a peripheral nerve. So you surround the whole superior trunk before suprascapular nerve leaves it as a, as a peripheral nerve block in a way. And, you know, there's a thought that it reduces the incidence of phrenic nerve block. What are your thoughts on that? 

So I do have a thought on that, and that thought is that any volume, any clinically useful volume of local anesthetic put at the brachial plexus above the clavicle will put your phrenic nerve at risk. It's a non zero incidence. So if you're Mhmm. And and honestly, next time you're scanning the brachial plexus, find c five and c six and say, okay. This is where I do an interscaling. 

And then I'm not telling you this, Ahmed. I'm telling the I'm asking the listeners that What do you do tell me? I'm listening in to To do this do this little experiment. So find c five and c six. Okay. 

And then slide down a little bit and find where you might tell, okay, that's a superior trunk. Honestly, guys, that that is a one centimeter difference. And so if you think, okay, I'm my fifteen mils here is gonna cause phrenic nerve paresis, whereas my fifteen mils here is not I think I think you're fooling yourself. I think But this is and and I and I a 100% take your point about 15 mils one, you know, one centimeter apart or maybe less than a centimeter. But what about what about if you use lower volumes? 

So if you use a volume of less than five mils, do you think it makes a difference if you put, say, four mils around the superior trunk or four mils in the integrating brachial plexus block? Mean, I know I'm talking semantics here, but I guess the point we're trying to make is any significant volume anywhere in the neck is likely to cause front end of that. Right? Yeah. I think that I mean, it get that we're getting to practical issues too. 

I mean, what are your goals for this block? Do you want it to work? Do you want yeah. I mean, mean, I I look. I I I've done a lot of nerve blocks in my time, and I I feel like maybe I could get a good block most of the time if I used four mils, but I want that block to to be as effective as possible and to last as long as possible for shoulder surgery. 

So I mean, I guess it depends. Are you are you using it for anesthesia, in which case you probably got less room to maneuver in terms of dropping your volume or whether using it for analgesia. And then as you say, how long do want the block to last? My my concern and my my thought process when you might wanna reduce your volumes are in patients where they have significant respiratory pathology or maybe contralateral diaphragmatic paresis, and then you wanna do everything you can to reduce the risk. So if we don't do an endoscalene and we don't do a superior truncan block in those patients, what about doing isolated suprascapular nerve? 

So that's that's that has some legs. If I think the patient is at risk for complications if I take out their diaphragm, so if a patient's morbidly obese, has restrictive lung disease, I don't so much care about obstructive lung disease because there those patients with the, you know, with severe emphysema, their diaphragm is not really contributing much to their tidal volume anyway. Okay. So taking out the diaphragm is not gonna hurt them as much. It's the restrictive lung disease person I care about. 

So if I make that clinical assessment and say, okay. I I I don't want to touch this person's diaphragm. I will not do inner scaling or superior trunk or a subclavicular. I'll choose something else. And to your point, I I see two alternatives that I I we teach our trainees. 

One is the suprascapular has to be involved because we we talk about this being the nerve that contributes the most to the to the shoulder joint. Mhmm. So I'm gonna do suprascapular, and I'm gonna do it behind. So on, in the supraspinatus fossa. So you're literally moving as far away from the neck as possible. 

So you don't wanna do an anterior suprascapular nerve block underneath omohyoid. You don't wanna do that because you don't wanna take the risk. I challenge you to to prove to me that any substantial volume of local anesthetic that would give you a good block for shoulder surgery put underneath omohyoid would not would give you a zero percent incidence of phrenic nerve blockade. I take you. I sold debate one. 

So you go to the back and pop your local anesthetic in that supraspinous fossa. Yep. And and so that's that's block one, and I'll I'll always combine it with Okay. Another one, oftentimes axillary nerve because it's it's very easy to to do. So I'll have the patient sitting up sort of like, you know, slumped over. 

It's easy to feel the spine of the scapula, put a probe on on the supraspinous fossa, and see the The floor of that fossa. Yeah. Yeah. The floor. It's really easy to see the spinal glenoid notch there and bring a needle down. 

It's kinda like a ping block of the shoulder. So you say a bone underneath the muscle, hit the bone and and go. So easy to do, easy to teach, and usually easy to image even in in larger patients. And the axillary nerve, a little harder to image sometimes because of the just the ergonomics of putting the probe on the proximal humerus. But then Let's just be specific. 

We're talking about axillary nerve as opposed to axillary brachial plexus. Right? You're talking about the axillary nerve. Correct. Yeah. 

Thank you. That's I should have made that. But, yeah, that's the axillary nerve is is it winds sort of around the the neck of the humerus. So those two blocks are are common combination that we'll do as a plan b for those patients who are at risk for pulmonary complications. Can I make a can I make a confession here? 

Oh, yeah. True confessions. So the the the the posterior approach to the supraspinatus nerve, I've kind of I've now got my head around that, and I've used that. You know, you go through trapezius and supraspinatus, and you see that little hockey hockey stick shaped divot in the floor of the supraspinatus fossa. Boom. 

Next to the artery, happy. Done that. How is it that the the guy from The UK is making the hockey stick analogy and not the Canadian guy? I don't know. I thought I can't believe you didn't take that. 

But anyway okay. But my confession is the axillary nerve block of the poster aspect of the of the humerus, I don't find easy. I find it a bit fiddly certainly in patients who well, actually, irrespective whether they've got muscle, whether they've got sort of less muscular tissue at the back of the humerus. I don't always find it easy. So I need to somehow get myself on the, on the humerus and then slide my my probe kef lad or north towards that sort of light bulb appearance of the head of the humerus. 

But I I don't find it easy to find to find my probe position. I I totally agree. And I think, part of the issue is the actual ergonomics of it because the patients I got a patient sitting up. The arm is very mobile. So as you put pressure with a probe from from behind, the shoulder tends to move forward in this gel, and it's slipping. 

And I and the humerus is not that big, so it's easy to to slip off and and, and lose your spot and then to and you're sliding up and down. So I I agree. I agree. It's it's the harder of the two to do for sure. But how Jeff, how do you challenge people that say, if you're doing your auxiliary block once it's already left the posterior cord, by then, it's too late. 

You've missed some of that vital innovation of the shoulder. You need to do it more proximally. Do do you have an approach or a thought about that? So I I don't disagree with that notion because I will say that doing a suprascapular nerve block and an axillary nerve block as it comes around the posterior part of that, the neck of the humerus, you you are missing some upstream fibers on that ax axillary. So it it's it's a compromise. 

Right? And that's that's what we're doing here is we're we're saying what's the next best choice if we can't do interscaling or superior trunk. So there's another option that we teach our trainees, is to say, if you think about all the nerves that we've talked about that make up innervation of the shoulder, you've got lateral pectoral, a branch of the musculocutaneous, axillary, the subscapular nerves. In addition to the suprascapular, you can get those four in one shot by doing an infraclavicular brachial plexus block because everything comes off either distal to or at the site where you're doing that that that injection. So to put that another way, if you wanna do a phrenic nerve sparing shoulder technique that gets the most bang for your buck, can do a suprascapular back behind the shoulder and then an infraclavicular brachial plexus block. 

And the only thing you're missing at that point is the skin, of the of the cervical plexus. So you could you could do a cervical plexus, being very careful Yeah. Not to get the phrenic. Otherwise, that would be a real shame. That would kind of defeat the whole Yes. 

Point. Yeah. So, yeah. Just just do a little subcutaneous injection there. But that that would be essentially reconstituting your interscaling. 

So hold on. Let this is this is boom, mind blowing stuff here. So let me get my head right. So you're saying if you wanna do a phrenic nerve sparing approach to the shoulder, do a suprascapular at the back. Got that. 

But you're saying do an infraclavicular brachial plexus block. What? Aiming to take out the whole infraclavicular brachial plexus or just the posterior cord? Yeah. The people have done both. 

I mean, so the if you do it at the posterior cord, that's gonna get most of what you, of what you need. But, ultimately, to get the entire thing to all the all the nerves to the shoulder, you you would need to anesthetize all all the entire area. Love it. Yeah. You heard it here, folks. 

That's great. Now this is the next thing I wanna talk about. So, you talked about the cervical plexus or superficial cervical plexus as a as an entity, you know, that thing behind the poster the midpoint of the poster board of sternocleidomastoid when we do it with landmark, which can visualize this gumpf out the back of the sternocleidomastoid on ultrasound. Here's that word again, gumpf. Okay. 

Love that. I gotta use that more often. But, you know, one of the things I learned from Twitter many years ago is doing isolated supraclavicular nerve blocks. So that's actually getting the medial, intermediate, and lateral supraclavicular nerve branches as they come off the superficial cervical plexus. That's kind of neck level scanning, but I have used this for clavicular fractures. 

And actually now I use this to augment my superior trunk block. So actually, what do you think about that? Do you use the nerves? Not the supraclavicular brachial plexus, but the supraclavicular nerves as individual things. Do you use that technique? 

So I I haven't I haven't been I haven't personally are you talking about going and scanning the supraclavicular nerves in in the subcutaneous Yeah. Tissue layer? Yeah. Yeah. Yeah. 

Yeah. Yeah. That's pretty that's some pretty fine scanning you're doing there. Well, there's a Canadian dude that told me that. Chris Probarker, taught me how to do that via Twitter with another chap from The UK called James Stimson. 

The two of those guys were sharing these videos, you know, early days, old time videos, and I kind of thought, well, listen. I'm gonna do that. And that's now become my favorite thing to find in there. That's really cool. And I think as ultrasound machines get better and better, we're able to see these little tiny cutaneous nerves and and then pick them off. 

But so I haven't I haven't personally I'd I'll usually just do a cervical plexus block proper, which, of course, most of that is supraclavicular nerves. But that's really cool. But the reason I like it is, I mean, we're talking about one or two cc's. Yeah. That that that's what it takes. 

Yeah. I mean so, anyway, that was that was my academic interest. But, guys, there's a great video by Vicente Roques on YouTube that shows a really cool way of finding those nerve blocks. But the key is actually to trace up the neck till you see the c four nerve root disappear into the transverse processes and then trace it down, and you'll then start to see the super nerves come off it, but I definitely recommend checking that out. Alright, Jeff. 

Before we take a little break, I wanted to ask you about three blocks that I've heard of that I have not used for shoulder surgery, but I wanna ask your opinion on using for shoulder surgery. One of them is the subscapularis plane block. Never done this. The other is ESP, and the third is PEX. Although I lie, I have I have done PEX for for shoulder surgery in some cases. 

But tell me about your thought about that. Is there an episode that we will have where ESP does not rear its ugly head? I'm gonna try my best to get in every single episode. I shouldn't say ugly head. I I I I'm not I'm not against the ESP. 

ESP, yep, people have done that for shoulder surgery for sure. Cervical ESP, people have done that. It seems like a lot for me, though. It's like a it's a big thing to do for for something that's a bit more remote. I I didn't I didn't get it. 

I'm guessing it's an attempt to, again, to provide a phrenic sparing approach to and it reminds me a little bit of Andre Beauzaert's technique where he would come from behind, from posterior, and come and hit the transverse process and then sort of walk off to get the cervical perivatibral for for shoulder surgery. That's not the same as the poster approach of PIPA, is it? That's is that different from PIPA? Very I think I think it's the same. Yeah. 

I think it's very similar. Yeah. PEX, I I have used for in cases where, PEX two or well, what's a new new nomenclature? Do you mean pex two? Do you mean you do do you mean pector serratus or interpetral? 

Pector serratus. Oh, okay. For for the axilla. Oh, yeah. Yeah. 

In cases where there's either a lot of axillary work or for some reason biceps tenodesis, so that's part of the shoulder procedure. They end up with this axillary pain that the PEX block seems to seems to relieve. I have not done a subscapularis plane block, so I can't can't comment. Yeah. Nor nor have I. 

So I I wanna hear from folks that have. I mean, you know, I I I don't know that. Listen. We're gonna we're gonna take a little break here just to to mix it up a bit. You know I love my dad jokes. 

I know you love your dad jokes. And and and bearing in mind, we sort of started off the episode with a bit of a wrap flavor. I've got some suitably okay, appropriate jokes. So how do you follow Will Smith in the snow? Boom. 

Don't know. You follow the fresh prince. That's like okay. Okay. I got one more. 

That's good one. That's good one. Right? Okay. I got one more. 

Yeah. Yeah. What is it called when a flatbread sings? A flatbread. No. 

No. No. A pita rap. Pita rap. Peter rap. 

I know. I can hear people at home, like, rolling on the floor, laughing, or ROFL. Alright. Have you got anything for me? Well, yeah. 

No. I'm gonna I'm gonna stick with the theme here. So I know you're a Star Wars fan. Yep. Who is Han Solo's favorite rapper? 

Who is Han Solo's you got me. Tupacca. Oh, that is brilliant. This is the perfect time when we need to get somebody to put that chew back a noise in in the background. That would be brilliant. 

There we go. There we go. That's that's brilliant. Okay. Okay. 

I love that. Anything more? Why didn't the fisherman make it as a big rap artist? Okay. No idea. 

His lines were okay, but his hooks were debatable. Debates. The bait fishing bait. That is the Literally from the bottom of the bait bucket. Lines, hooks, and bait in the punch line there. 

Just just to just to point that out. Oh my god. Okay. Listen. I think I think that I think that people have felt enough pain. 

Let's get let's get back into it. We want to take pain away, remember. That's the goal of regional needs. That's right. So so, Jeff, you know, we we've talked about these the the hardcore, interscaling, superior trunk, Then we talked about break it down to fragments, suprascapular, axillary, infraclavicular, maybe even supraclavicular nerves. 

What's the ideal length of the block? I remember the old days when people would do a block and they check the patient in PACU or recovery and if they take it out the whole hand and the patient couldn't move the hand or the whole arm, they'd be like, yes. That block's amazing. And then they leave the patient and then forget that the patient has to deal with that for like twenty four hours. So what's the ideal length of the block? 

How do we tie the block to the trajectory of pain related to the surgery? I have not had shoulder surgery, but I had friends that have, and it's not short. And nor is it nor is it mild pain. Rotator cuff surgery, for example, is very painful and lasts for several days. So I want to I do want to extend that block as long as humanly possible. 

Unlike the lower limb, like for total knees and hips and stuff, where we have that concern about, well, how are we gonna block them and allow them to walk out of the hospital? I don't care about that with shoulder. Okay. They're gonna be in a sling anyway. The shoulder the surgeon does not want them to move and disrupt the repair. 

Yeah. So they're they're cool if I, you know, block that shoulder out to, you know, three, four days. But I guess it depends on the type of surgery. Right? So if you're having a subacromial decompression versus a revision rotator cuff replacement, those are very two different beasts. 

Right? So True. True. Yes. Absolutely. 

So it, and the pain trajectories will be slightly different there. So you have to be a bit thoughtful about about that. But But for really painful surgery, you wanna cover as much of the pain as you can. Yep. And and make it last as long as I can, for sure. 

So so that that takes us nicely into the role of adjuvant. So I'm a I'm gonna say it upfront before I hand it over. I'm an intravenous dexamethasone user. I don't use any other adjuvants. Do you? 

So you just to be clear, you use IV dexamethasone and not perineural dexamethasone. Okay. Yeah. Correct. Correct. 

And I won't say I use as in not on myself, but for my patients. Yeah. I I I do like dexamethasone. It's What do you guys call it? Decadron? 

Decadron is a brand name, but dexamethasone is, I think, is an excellent drug for all kinds of reasons. Nausea, just making patients feel good. Uh-huh. Stereoids make you feel good. Yeah. 

But and and there's you know, we have good data to show if you use it irrespective of the route, it probably helps prolong analgesia in a in a couple different ways. But so I I'll use it as as sort of my go to adjuvant. Getting back to that duration issue, we have done tons of interscaling catheters for shoulder surgery. I'm a big catheter fan. I think that's a remarkable way to deliver long acting local anesthetic effect. 

It's titratable. You can turn it up, turn it down, which is sometimes important for inner shoulder surgery interscaling blocks because you can end up with unwanted side effects from that block. So if the block is a little bit too much, then they start to get a Horner syndrome or a recurrent laryngeal nerve palsy and their voice starts to change or they just feel like, oh my god, my my hand is my hand is too numb. I don't want this. You can turn it down and that sort of thing. 

You see a lot of catheters. We don't do as many anymore. The downside to interscaling catheters Yeah. It's just so close to the surface, that target zone, and the neck is so mobile that as the patient goes home and they're sort of moving their head around, we found the displacement rates were significant. Makes sense. 

Yeah. They get home and then the patient will call you back. Am I supposed to be seeing the blue tip, you know, on the skin? I'm like, no. Okay. 

That was that sorry. That got pulled out. We've transitioned to using a lot of liposomal bupivacaine, which is here in The US, it's it's one of the indications for that drug is the interscaling brachial plexus block. So that seems to get us between sixty to seventy two hours. Wow. 

But I will say we are using twenty mils of that medication and then five mils of half percent bupivacaine. So twenty five mils total and getting back to our earlier conversation about volume that seems to be it feels like a lot of volume. I feel a little bit like, ugh. I'm I'm using more than I need to, but that's the recipe that gets us at 60 to 72. Well, you know, it's interesting because, it's interesting because recently, you know, I hadn't had a chance to use the drug, but I have used it recently. 

And and, actually, I didn't use as much volume as that, but I certainly use more than I than I used to. And, yeah, I had to make the effort to inject the volume. But, of course, the thing I had to get my head around was of that larger volume of local and state you're using, only the active component that you're admixing it with is the bit that's gonna be causing the blocks. Although the volume is large, you're only putting in, say, example, five cc's of active drug. So, actually, they're not gonna get 15 or 25 cc's of active drug happening all at the same time. 

So once I kinda got my head around that, and accepted that I'm just delivering in a larger volume, I was a bit more relaxed. And I have to be honest, I was, yeah. My my first couple of uses, there is no doubt that in in my hands and that those limited experiences that actually it caused a definite prolongation of of sensory blocks. You know, definitely lots to to look at, watch that space. But I think the key for me is if I can spare the hand and finger function as much as possible, because I I think a lot of my patients don't like the fact that the whole arm feels like a piece of meat. 

So if I can give some retain some finger movement, it makes them feel that the hand has still got some hope. Yeah. And then it reassures them that the hand's gonna come back to life. Yeah. Yeah. 

For sure. I think it's important. So and to me, that's that's part of the reason I do favor the inner scaling over a more distal approach like supraclavicular. It just it seems a bit more targeted to just the shoulder. Any substantial volume in that in that space is gonna get a lot of nerves, not just c five and c six. 

Absolutely. Now listen. We're kind of getting to the climax of the episode or what I consider to be the climax of the episode. And that's something that I don't do lots of, or very much of regularly, and that is awake shoulder surgery. I do lots of other type of awake surgery. 

And if I had if you could see my hands, I'm doing awake in inverted commas here because there's a spectrum from being completely awake to being sedated. I would be really interested to get your take on this, and to cover things such as the use of cerebral oximetry, sedation. Yeah. We, I I agree. There's there's awaken as awaken. 

So we I have done awake shoulder surgery with patients talking to me and, and making sparkling conversation, but most of the time, they're getting some background propofol infusion to keep them from moving and and from being aware of things. But, it's an excellent technique, and our surgeons use it as a selling point now. So they they'll tell their patients in clinic, hey. Come get your shoulder surgery with me because you can have your shoulder surgery, quote unquote, awake. Well, guess then at least you're preselecting patients who are keen. 

You're not having to convince them they're coming to you because they want to, so there's a degree of motivation built into that process. Yeah. They're primed already by the surgeon in their clinic to know that this is what they're going to get when they come. Yeah, not a lot of salesmanship that has to be done on the day of surgery, which is always nice. So I think one of the big concerns and considerations is the beach chair position and having patients with prior history stroke or carotid stenosis or that sort of thing where you're concerned about cerebral perfusion. 

So you mentioned cerebral oximetry. We don't do a lot of that. If there's a patient that I think is particularly at risk, I've done arterial lines and then put the transducer at the level of the circle of Willis. So I have a a beat to beat measurement of what that brain is getting perfusion wise. Oh, that's clever. 

But there's been some good work out of HSS to show that probably that concern is more theoretical than we give it credit for. Well, well, I have heard some people getting unstuck when they were using blood pressure monitoring not at the correct level. Because every now and then, somebody will say, I'll do calf blood pressure readings because I don't wanna interrupt my total intravenous anesthesia, and that's an area of concern. And then you've gotta appreciate that measuring blood pressure at calf isn't the same as what's happening in the brain. Exactly. 

If I was doing your shoulder surgery, I I wouldn't be as concerned, but if it's that person that's got multiple vasculopathic sort of comorbidities that I'd I'd be more likely to add an extra monitor. Okay, Jeff. Let's imagine that we've got Henry, and Henry needs to have awake shoulder surgery. I really, really wanna know what you do for this. Okay. 

I'm imagining it. Henry, awake shoulder surgery. Got it. Well, so I think the first question is, is Henry fit from a pulmonary point of view to get our plan a block, which would be interscalene? So Okay. 

Let's let's say he is. And and and maybe we can do a second version where Henry's not. But assuming Henry's, able to get an interscalene block from a front end nerve point of view, we're gonna do an interscalene brachial plexus block. And so typically, we will use a formula I mentioned a few minutes ago with the twenty mils of liposomal and five mils of half percent bupivacaine. And this is a periplexus block coming in in plane from lateral aiming to just push the plexus away and and layer it out beside c five and c six. 

So can I just stop you there for a second? I just gotta get my head around this. So your the total volume that you're administering in this case is 25 mils, 25 ccs. Right? That's right. 

Yeah. But you're only using five mils of admixed, bupivacaine. Correct. And that's enough. And that's enough. 

I know. It's it's a question we we ask ourselves too, and it's like, is this gonna be enough? And but there are people that do awake shoulder surgery with very low volumes of plain local anesthetics. And so if you think about the the, like, a little bit of free fraction of vivacaine that's floating around in the liposomal bottle, somehow it's enough to set things up in about twenty minutes. So you do need a little bit of time for it to cook, but then then you're good. 

Now the other thing that we'll do with an awake technique is do either a cervical plexus block or specifically get those supraclavicular nerves by the clavicle so that that skin is is, by the acromion and where the where they're gonna put the ports or the upper part of the incision is gonna be covered. Depending on the volume and where you're putting your local for the interscaling brachial plexus, you may not get the cervical plexus in the same way that we did with my old 50 back in the day. And and when you're doing your supraclavicular, nerve technique, if you're not doing the cervical plexus, are you just doing that with infiltration around the clavicle, or are doing a targeted supraclavicular nerve block? So I just I'm a I'm a simpleton man. So I just I just take my ultrasound probe and sort of look at the subcutaneous layer in the supraclavicular fossa and and layer some local out there. 

Sometimes you see a little thing, you're like, oh, I think that's a nerve. But, but I I I I just it's more like a image guided infiltration. Okay. Okay. And and why do you think you need to do that? 

Just so just so we can all understand. So depending on if if it's arthroscopic surgery versus open surgery, either way, there's a likelihood that the surgeon's gonna need to put his or her knife or port through some skin that's supplied by the cervical plexus over top of the Right. Sort of cape area of the shoulder. So we've failed that way. When I was a resident, thought, oh, great. 

Interscaling block. That's all they need. And then patient goes, ow. And so, oof. Okay. 

I need to need to cover that skin on top. Nice. And so since you've added that little tweak in, you've managed to to reduce the chance of you having a, you know, a block that's not complete, doesn't cover that whole area. Yeah. Exactly. 

That's right. So then we'll head back to the Operating Room. And by this time, I've already coached Henry that, hey, we're you're gonna be awake. You're gonna be in a sitting position in the beach chair. We're gonna have your head kind of held in place by this this fancy, foam and strap apparatus. 

So you're gonna be looking straight ahead, we'll be talking to you and because that's what you wanted. And then, this is usually patient preference. Right? Like, they they come in they come and say, hey. I I was told I could get a awake shoulder surgery and so this is what I want. 

That's that's cool. There's awake and there's awake, we talked about this a bit earlier, but there we can do just a bit of midazolam and a hint of fentanyl and and have them quite responsive or run sort of low dose propofol. But we're not talking about GAWA because, you know, Power doesn't like GAWA. Power no like GAWA. No. 

No. No. I we, know, and we talked about the you having to put LMAs in and, you know, the beach chair position, which is, you know, not it's okay, but it's not not a great, great default plan. But if I am running propofol, what I tend to do is put the blood pressure cuff on the calf. And that way they're not, you know, every three or five minutes, the purple ball is backing up on the hand, and they start to move their arm because it's painful. 

That's a big deal. Right? Yeah. Yeah. And then, of course, you know, oxygen, capnography, some all the monitors, and, away we go. 

You mentioned that you change things possibly if the patient has got some pulmonary issues. So I'm really curious to know how you can deliver a wake shoulder surgery for somebody who's got respiratory impairment. Yeah. And it's a it's a little trickier, but, so what we'll do, and we talked about this, how important the suprascapular nerve block is for this, and so that's that's the first one we'll do behind, by the scapula. Then I'll do an infraclavicular brachial plexus block, and that will get most of the rest of everything else. 

And then we'll do a very careful cervical plexus block, and when I say that, or or the supraclavicular nerves, when I say that, again, I'm cognizant of the risk of any local anesthetic spreading from where my cervical plexus block is to the phrenic because they're kinda close. And so there's the we'll talk about it in another episode about cervical plexus blocks and deep and intermediate and superficial and what those all mean, but Uh-huh. I will this is a case where I'll do a very superficial one. I'm basically doing subcutaneous infiltration. So I I reduce the risk of getting to the phrenic. 

And that combination, closest we can get to reconstituting your your c five, c six, and cervical plexus block scenario for the healthy Henry. So it's a bit like knees. Right? We're breaking it down into those small component areas. Yeah. 

Exactly. Same themes. Upper limb, lower limb. Listen. I'm really blown away by that. 

It's really interesting, and I think it may take me a bit of time to get my confidence up in doing a wig surgery using that. But what's key for me and my my biggest learning point is you don't just do the posterior cord component of the infra brachial plexus when you're doing the phrenics bearing stuff. You do an an infraclavicular plexus block to kinda take everything out, and that probably makes a big difference. Yeah. And it and it ends up with a different dynamic. 

Right? So the patient with the inner scaling, the patient can usually move their hand and use their fingers a little bit. They may be a bit tingly, but they can use their hand, is a satisfier for those patients. In this other technique that I've just described, their arm won't be out for some time. So they just have to, you know, talk about talk to the patient about that. 

And the only thing I wanted to get your, your thoughts on before we finish up this really exciting kind of awake, surgery component is the volumes of local ants that you're using for the phrenic sparing technique. So for the suprascapular at the back and for your infraclavicular, what volumes are you using? Typically, suprascap, I tend to put 15 mils back there. Just, it's probably more than you need, but I it's what I've always used, and it seem it seems to give you the the right duration and, and onset as well. So and then in for clavicular, I tend to use about 20. 

And so that's now you got 35, but in two different spots. And cervical plexus, you know, that's a that's a couple of mils, really. Amazing, Jeff. Thank you so much for sharing your, your awake recipe for Henry. I'm sure Henry's gonna be very happy, and it sounds like one of the things that's key is making sure that patients are fully informed as to kind of the dynamic and how it's gonna it's gonna go with their head and their strap and everything. 

So listen. I think I think we're done, man. We're gonna wrap up this episode? Yeah. Yeah. 

I think that's it. That was this is fun. Enjoyed this. Well, listen, man. Why don't we wrap up episode 10? 

Listen, guys. Thank you so much for taking the time to follow in and listen to what we're talking about. You know the deal. Please like, subscribe, rate our podcast from your usual podcast provider wherever you get it from, and let us know what you wanna talk about next. And you know what? 

We've got a few various means of social media you can follow us on. What have we got, Jeff? Got, Twitter at block it underscore hot underscore pod at YouTube at block it like it's hot. And And yes. I'll I'll do it. 

I'll do this time. Okay. Okay. You just the Insta Instagram block it under block underscore it underscore like underscore its underscore. We gotta change this hot. 

And don't forget our hashtag hashtag block it like it's hot. Yeah. Let us know what you guys are doing for shoulder surgery and and if you're doing anything cool, innovative, you know, we wanna hear your thoughts. Absolutely. Until next time. 

We hope you all block it like it's hot.