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Supplemental video on subparaneural upper trunk block

Video Author: Hongye Zhang
Published on: 05.20.2022
Associated with: Anesthesia & Analgesia. 134(6):1308-1317, June 2022

The subparaneural upper trunk block is performed in the supraclavicular fossa, at the site where the upper trunk has trifurcated into anterior and posterior divisions and the suprascapular nerve. Local anesthetic is injected inside the paraneural sheath between either anterior and posterior divisions or posterior division and the suprascapular nerve.

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The subparaneural upper trunk block is performed in the supraclavicular fossa, at the site where the upper trunk has trifurcated into anterior and posterior divisions and the suprascapular nerve. Local anesthetic is injected inside the paraneural sheath between either anterior and posterior divisions or posterior division and the suprascapular nerve.
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Play Video |
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Play Video |
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Duration: 00:43
The subparaneural upper trunk block is performed in the supraclavicular fossa, at the site where the upper trunk has trifurcated into anterior and posterior divisions and the suprascapular nerve. Local anesthetic is injected inside the paraneural sheath between either anterior and posterior divisions or posterior division and the suprascapular nerve.
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The ME four chamber view is analyzed using the Automated Function Imaging (AFI) software package. The LV long axis strain model is applied to the RV to allow correct labeling of septal segments. Tracking quality is automatically assessed for each segment (green: good or red: poor). Parametric display provides measurements for each of the six RV and global strain. The latter is normal at – 22.3% with regional peak variability with basal segments below normal limits. RV myocardial region of interest is redefined and the septum de-selected to obtain RV free wall strain that is measured at approximately -22%
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Identify the right jugular vein and carotid artery at the level of the thyroid cartilage on the short-axis view. Then, the probe is moved caudally following the internal jugular vein in the center of the monitor. Once the probe has reached the clavicle, it is inclined following the internal jugular vein to identify where it merges with the right subclavian vein and the underlying pleura on the long-axis view. The puncture needle is inserted using the long-axis view and advanced while identifying the needle point in real-time, until it reaches the right brachiocephalic vein.
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First part: The ME view, obtained by slightly withdrawing the probe from the modified ME 5-chamber view in video clip 1, demonstrates two cardiac masses (“proximal” and “distal”), with the RCA penetrating the left side of the distal mass. Second part: Color flow Doppler reveals laminar blood flow in the RCA. Third part: Simultaneous orthogonal planes to the RCA based on the ME aortic valve short axis view. Fourth part: Simultaneous orthogonal planes to the tricuspid valve based on the modified trans-gastric RV inflow-outflow view.
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Creator: Dr. Josh Zimmerman, MD, FASE
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A brief, screen-in-screen review of the techniques required to perform bedside cardiac ultrasound at the parasternal, apical, and subcostal windows.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
The right ventricle is under the transducer. There is normal excursion and coaptation of the aortic and mitral valves. The chambers are normal in size. There is brisk excursion of the aortic root, brisk opening of the mitral valve, a normal descent of the base of the MV, and normal thickening of the left ventricular segments.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:06
The aortic valve is heavily calcified and does not open well. The degree of stenosis cannot be quantified from this view, but with excursion this limited the assumption should be that the patient has severe stenosis until it is proven otherwise. In addition to aortic valve calcification, the mitral annulus is heavily calcified, there is left ventricular hypertrophy, and the left atrium is enlarged.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
The RVOT, LA, and LV are all dilated and appear proportionally large compared to the aortic annulus and root. Compare the relative sizes with Video 1 (normal PLAX.) There is evidence of decreased LV systolic function, with decreased motion of the aortic root, decreased excursion of the anterior mitral leaflet, decreased mitral annular excursion, and decreased thickening of the left ventricular segments. There is also a left pleural effusion.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:05
Left ventricular and aortic valve function appear normal. There is thickening of the tips of the mitral leaflets, with diastolic bowing seen particularly in the anterior mitral leaflet (the “hockey stick” appearance). The left atrium appears enlarged as well, consistent with elevated left atrial pressure from mitral stenosis.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:07
Multiple beats are shown in this clip and the image does not remain still because the patient was severely dyspneic. The patient has significant hypertrophy of the anterioseptal wall of the left ventricle. In multiple cardiac cycles the anterior mitral leaflet can be seen to impinge on the left ventricular outflow tract.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:05
The descending thoracic aorta is outside the pericardium, and a pericardial effusion will be seen extending between the heart and the aorta in this view while a pleural effusion will be seen deep and lateral to the aorta.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:06
The thinning of this segment suggests a scar consistent with previous myocardial infarction.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:07
A pericardial effusion around the heart, hyperdynamic left ventricular systolic function, and decreased LV filling in diastole.
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Creator: Dr. Josh Zimmerman, MD, FASE
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:08
The apex of the left ventricle is directly under the ultrasound transducer. All four chambers can be visualized. There is normal global and regional biventricular systolic function, normal excursion and coaptation of the mitral and tricuspid valves, and normal chamber sizes.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:11
A large portion of the myocardium at the LV apex is not thickening. There is decreased global LV systolic function and left atrial enlargement as well.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:09
Prolapse of both anterior and posterior mitral leaflets with left atrial enlargement.
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Abnormal mitral valve opening in a patient with rheumatic heart disease. The tips of the mitral leaflets are thickened. The left atrium appears qualitatively enlarged compared with the size of the left ventricle.
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Enlarged right ventricle with decreased RV systolic function in a patient with a history of chronic severe pulmonary hypertension.
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Duration: 0:11
Apical four chamber zoomed in on the tricuspid valve. This valve does not coapt well in systole, suggesting the presence of significant tricuspid regurgitation.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:10
Subcostal four chamber with right ventricular dilation and hypertrophy. The free wall of the RV appears as thick as the left ventricle. The RV appears larger than the LV, suggesting significant enlargement.
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Subcostal four chamber in a patient with pericardial effusion and tamponade. The effusion is seen as a large echolucent space around the heart. The right atrium appears collapsed in ventricular systole and the right ventricle appears compressed in ventricular diastole. These findings are both consistent with tamponade physiology.
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Creator: Dr. Josh Zimmerman, MD, FASE
Duration: 0:19
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Duration: 0:10
Subcostal IVC in a patient with cardiac tamponade. The IVC appears dilated and does not collapse as the patient sniffs.
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