WEBVTT - Dr Hutchins_Interscalene Brachial Plexus NB_PP-EX-US-7273 CC Transcript_09FEB22 1 00:06.500 --> 00:10.000 So I’m Jacob Hutchins, an anesthesiologist in Minneapolis 2 00:10.001 --> 00:14.499 Minnesota with a specialty and regional anesthesia and acute pain as well as 3 00:14.500 --> 00:19.499 ambulatory surgery. Recently at our ambulatory surgery center we've been 4 00:19.500 --> 00:24.499 using EXPAREL in the use in interscalene brachial plexus nerve 5 00:24.500 --> 00:30.000 blocks. Prior to that we had previously used short-acting either bupivacaine 6 00:30.001 --> 00:33.499 order ropivacaine nerve blocks and we found that often times those nerve 7 00:33.500 --> 00:38.000 blocks would wear off sometimes in the middle of the night which will result in 8 00:38.001 --> 00:43.000 patients calling their providers for additional uses of pain relief which 9 00:43.001 --> 00:48.499 often times included opioids or resulted in them going to the emergency room 10 00:48.500 --> 00:52.499 for additional pain relief or even being readmitted to the hospital for additional 11 00:52.500 --> 00:56.499 pain relief. So with the ability to use EXPAREL in an interscalene nerve 12 00:56.500 --> 01:01.000 block, we found that we’ve been able to provide a longer duration interscalene 13 01:01.001 --> 01:06.499 nerve block for our patients and that ability has allowed us to really improve 14 01:06.500 --> 01:11.000 our pain control in our patient population. Because of that we've been able to 15 01:11.001 --> 01:14.499 decrease the amount of opioids that our patients are using. Some patients even 16 01:14.500 --> 01:18.499 using no opioids after their shoulder surgeries. We’ve been able to allow our 17 01:18.500 --> 01:23.000 patients to have improved satisfaction, they've been more comfortable. 18 01:23.001 --> 01:27.499 Patients have less risk of calling in their providers in the middle of the night 19 01:28.000 --> 01:31.499 due to increased pain from a short-acting nerve block worn off. With the long-acting 20 01:31.500 --> 01:37.499 or block it decreases the amount of phone calls. But also with a goal of 21 01:37.500 --> 01:41.499 really trying to find ways to improve patient outcomes so less phone calls, 22 01:41.500 --> 01:45.499 less emergency room visits, less readmissions, but also trying to find 23 01:45.500 --> 01:50.000 ways to really overall improve their benefit and at the same time decrease 24 01:50.001 --> 01:52.000 the amount of opioids that they need after surgery. 25 01:52.001 --> 01:55.499 So when we use EXPAREL in our interscalene nerve blocks, a lot of it is 26 01:55.500 --> 01:59.499 managing patient expectations. A lot of times we’re combining EXPAREL with 27 01:59.500 --> 02:04.000 bupivacaine. And so we're talking to patients ahead of time about how this 28 02:04.001 --> 02:09.000 block is really going to work with them. Day 1, often times it's a dense block. 29 02:09.001 --> 02:13.499 Patients have minimal to no pain. Day 2, the initial bupivacaine that we 30 02:13.500 --> 02:16.499 combined with the EXPAREL slowly wearing off and they're starting to have 31 02:16.500 --> 02:21.000 some soreness that may occur. It's a low amount of pain but they do feel a 32 02:21.001 --> 02:24.000 difference from day 1 till day 2. So we talk to patients, say you're going to be 33 02:24.001 --> 02:27.000 sore. There’s is going to be some soreness there. That's normal. 34 02:27.001 --> 02:30.000 You have pain medication to take as needed. And we're very aggressive 35 02:30.001 --> 02:34.000 with non-opioid pain medication. So our patients are instructed to take 36 02:34.001 --> 02:38.499 acetaminophen, instructed to take NSAIDs to minimize their pain in the 37 02:38.500 --> 02:44.000 short, acute postoperative period. After day 2, patients are instructed that on 38 02:44.001 --> 02:47.000 3 is that's is when that block is going to wear off. So they're going to feel 39 02:47.001 --> 02:51.499 decrease numbness on that third day and they should be comfortable after that. 40 02:52.000 --> 02:55.000 Often times the motor block is disappearing in that first day. 41 02:55.001 --> 02:58.499 They'll have a sensory, they’ll have numbness on that second and third 42 02:58.500 --> 03:02.499 day, but their motor is back. And so we just really are instructing them to really 43 03:02.500 --> 03:06.499 be careful, but to ensure that this is all a normal progression of how the nerve 44 03:06.500 --> 03:10.499 block wears off and these are all normal expectations. Pain is normal, 45 03:10.500 --> 03:13.500 but we're going to aggressively treat it with as much non-opioids as possible. 46 03:14.000 --> 03:17.000 In order for us to bring EXPAREL to the ASC, we really had to look at what's the 47 03:17.001 --> 03:21.499 benefit to our patient population. Because using EXPAREL in 48 03:21.500 --> 03:25.499 interscalene nerve block at a surgery center isn't going to affect the length of 49 03:25.500 --> 03:29.499 stay of our patients. Some of the goals that we have for patients and 50 03:29.500 --> 03:33.499 out patients surgery are minimal pain. We want to have decreased opioids as 51 03:33.500 --> 03:39.000 much as possible. And we want to have minimal amounts of provider phone 52 03:39.001 --> 03:43.000 calls, readmissions to the emergency room, and readmissions to the hospital 53 03:43.001 --> 03:44.000 for pain control.   54 03:44.001 --> 03:47.000 So I have changed my injection technique since I started using 55 03:47.001 --> 03:51.000 EXPAREL. Initially, when I started using EXPAREL, I did 1 injection 56 03:51.001 --> 03:55.000 at the bottom part of the interscalene brachial plexus at the posterior border. 57 03:55.001 --> 03:59.499 But I found when I did 2 injections, I would have better coverage with the 58 03:59.500 --> 04:03.499 EXPAREL. Because EXPAREL doesn't spread as well as bupivacaine does. 59 04:03.500 --> 04:08.499 So now I inject half of bupivacaine in my EXPAREL mixture at the bottom 60 04:08.500 --> 04:12.000 part of the brachial plexus, the posterior border. And then the other half at the 61 04:12.001 --> 04:16.000 top part of the brachial plexus posterior border in the interscalene brachial 62 04:16.001 --> 04:20.000 plexus area. By doing it that way, I'm able to provide better coverage 63 04:20.001 --> 04:24.000 and more consistent interscalene nerve block for shoulder. 64 04:24.001 --> 04:29.499 I will use 10 mLs of half percent bupivacaine with 10 mLs of EXPAREL. 65 04:30.001 --> 04:32.000 Again half at the bottom and half at the top.   66 04:34.001 --> 04:38.000 In this video I will describe an interscalene brachial plexus block 67 04:38.001 --> 04:41.000 performed with liposome bupivacaine and bupivacaine. 68 04:42.500 --> 04:48.000 The patient was positioned supine with the head of the bed elevated 45 degrees and a head 69 04:48.001 --> 04:53.000 looking in the opposite direction. A high-frequency linear ultrasound probe 70 04:53.001 --> 04:58.499 was placed at the level of the clavicle to identify first, the supraclavicular 71 04:58.500 --> 05:00.000 brachial plexus.   72 05:00.500 --> 05:04.499 And then the probe was rotated cranially until the interscalene brachial 73 05:04.500 --> 05:09.499 plexus was found positioned between the middle and anterior scalene muscles. 74 05:11.000 --> 05:17.000 A 21 gauge, 50 mm echogenic blunt tip needle was 75 05:17.001 --> 05:23.000 advanced in plane until the tip of the needle reached past the middle scalene muscle 76 05:24.500 --> 05:29.000 and was positioned near the caudal border of the   77 05:29.001 --> 05:36.000 interscalene brachial plexus. Then 5 mLs of 0.5% bupivacaine plain and 78 05:36.001 --> 05:40.000 5 mLs of liposome bupivacaine were injected.   79 05:42.001 --> 05:44.000 Then the needle was repositioned   80 05:44.001 --> 05:47.000 to the cranial portion of the interscalene brachial plexus block 81 05:48.001 --> 05:52.000 to ensure adequate spread of both of the bupivacaine and the liposome 82 05:52.001 --> 05:54.000 bupivacaine around the brachial plexus.   83 05:55.500 --> 05:57.000 Again, at this level   84 05:57.500 --> 06:04.499 5 mLs of 0.5% bupivacaine plain and 5 mLs of 1.3% bupivacaine 85 06:06.000 --> 06:07.000 were injected.   86 06:07.500 --> 06:13.000 As the probe is moved up and down the brachial plexus, you're able to see nice 87 06:13.001 --> 06:18.000 spread of local anesthetic in the interscalene groove covering 88 06:19.001 --> 06:24.000 the entire interscalene brachial plexus with local anesthetic to ensure that the end 89 06:24.001 --> 06:28.000 brachial plexus is surrounded by the liposome bupivacaine. 90 06:32.001 --> 06:37.499 Once finished, the needle was removed and the patient proceeded to surgery. 91 06:39.499 --> 06:43.000 So, we have found that we have been able to use EXPAREL in a wide range 92 06:43.001 --> 06:48.000 of patient ages. It’s helpful in the young patients. 18, 19, 20 year old patients 93 06:48.001 --> 06:52.499 that are young athletes, never maybe been exposed to opioids before. But it's 94 06:52.500 --> 06:56.499 also helpful in the elderly patients to really minimize the opioids and really 95 06:56.500 --> 07:00.000 hopefully minimize any of those opiate-related adverse events that can occur 96 07:00.001 --> 07:04.000 in that patient population. So we use it in our young patients 97 07:04.001 --> 07:05.499 but also in our old patients.