June 2014 - Donna Magid, M.D., M.Ed.
JOINT PROCEDURES: 3 general categories, all (mis)posted as 'ARTHROGRAMS"; slight modifications of set-up:
- ASPIRATION (r/o infection)
- PAIN STUDIES
- GADOLINIUM for MRI or CONTRAST for CT
REFER to separate HIP and SHOULDER documents for positioning tips, etc. MSK Radiology coverage (Faculty, Fellow) listed on weekly MSK Schedule, Sharepoint.
BASIC SET-UP: ALL 3 start with:
Handwashing in front of pt., introduce yourself.
Informed and witnessed consent, documented 'Time Out" to confirm patient ID and side (pt. states name and birthday to match wristband and paperwork, points to joint/side of interest
Basic Tray (includes labels, cups, sponge sticks, drape)
Iodine/Betadine (skin prep) (alternatives available for Iodine-allergic)
- 20 G spinal needle (yellow)
- 1.5” 25 G needle (pale blue--NOT the provided 5/8")
- 1.5” 22 G needle (yellow)- comes on tray
- 1.5" 16 G needle (purple—for drawing fluids into syringe)
Syringes: 5, 10, and (except aspirations which instead need 2nd 5 cc), 20 ml —5 cc for Lidocaine 2% (can be 10 cc for bigger person), 10 ml for contrast-- put tubing on contrast-filled syringe immediately and run fluid to tip to clarify identity of clear fluids, or written labels! (Labels and pen sometimes included on sterile tray; label syringes as load them)—BE CONSISTANT every time to reduce possibility of grabbing/injecting wrong clear fluid.
Contrast (don't always use—if for example joint fluid backflows out of hub when spinal stylet removed from spinal, just go ahead and collect it without adding contrast)
Mammo-spot type metal dot marker for localization
Waterproof 'Sharpie' pen (non-sterile fine)
ASPIRATIONS to R/O INFECTION
Goal: extract joint fluid to test for infections. You are done when LABELLED samples successfully reach correct labs in correct containers in correct format and lab tech confirms "Yes you are in right place, this is fine". We do any non-Neuro joint, most often hips, SI, knees, shoulders, elbows, ankles, wrists. Shoulder cultures: “R/O P. Acnes” all over paperwork (finicky bug, requires extra week of growth). DO NOT STOP if 'dry'; insert 5 - 10 cc nonbacteriostatic saline x2 (if tolerated) and try again. Document this step in report even if no fluid obtained.
PAIN STUDY: seeks to inject long-acting anesthetics and steroids, to test both immediate and long-term response; no samples taken (unless, of course, pus comes rolling out at you--then culture it!). Most common requests are for hips or shoulders (supine) or SI joints (prone, towel roll under contralateral hip for slight obliquity).
GADOLINIUM INJECTION: for MR to follow; 1:200 (Gad:sterile saline or saline/Bupivacaine)
CONTRAST injection: for CT to follow; 1:1 (radiographic contrast:sterile saline)
ASPIRATION needs intra-articular fluid samples, so to Basic set-up add:
- 2nd 5 cc syringe on tray to use when attempting to extract fluid
- Green Port-a-Cult vial (ie make sure available in room before samples drawn) 1 ml = preferred minimal volume
- Purple OR green vacutainer (ditto, in room)
- Red vacutainer (ditto, in room)
- Small vial NONBACTERIOSTATIC saline --if tap ‘dry’ inject 5-8 cc NONBACTERIOSTATIC saline and re-try aspirating, hips, etc. Shoulder docs INSIST on up to ‘10-20 cc saline’ (I can’t get 20 cc into most shoulders) and re-try.
Capture image of small amount of radiographic contrast in joint to prove you were in the joint; don’t use too much or dilutes cultures and cell counts.
Lab sheets-- Pathology 5, Path 2, forms. PRINTED LABEL EACH VIAL, TEST TUBE; one tube per bag!!!
Path 5, green port-a-cult --standard requests are “C&S, Gram, anaerobic/aerobic" and if shoulder R/O P.acnes (must hand-write BIG on form); may need TB, fungal, prn. Tell HO to send correct lab forms if bizarre requests MICROBIOLOGY LAB.
Path 2, purple or green top - body fluid cell count and differential. Pink stat lab sheet, goes to CORE LAB.
Red top--"DidJa" tube, put extra fluid here in case you missed something ("DidJa sent the extraterrestrial DNA test sample, DidJa get the SpongeBob titres...")
Clear plastic sample envelopes: actual labeled sample goes to deep main pocket, paperwork to shallow pouch on side. Give Lab no excuse to toss sample!
SAMPLES must have machine-stamp label on tube or they get tossed at lab. Must be hand-delivered to relevant labs, by you or trusted tech/accomplice to whom you gave custody--do NOT leave on counter assuming 'someone' will take them. "Someone" doesn't exist.
REPEAT: Specimen tubes into main body of bag. One tube per bag, one paper; papers go into side pouch, or get tossed by lab.
PAIN TEST additions to basic set-up:
During consent, explain test may ‘make them better, may lead to no change, or even make you slightly more sore later today. These are all normal and possible outcomes and help your physician separate out possible causes of your pain. It’s a great test because there are NO wrong answers”. If lower extremity, explain will subtly lose proprioception ‘as if your foot were asleep’ and that care must be exercised walking, going over door sills, on steps, etc. “If you feel better you *aren’t* better, no activities you wouldn’t have been allowed to do yesterday’. Chondrolysis—risk of marcaine-triggered accelerated cartilage damage has only been associated with post-op constant intraarticular infusions but mention remote possibility (and cut Marcaine lower for pediatrics). Ditto risk of cardiotoxicity (arrythmia , seizure, arrest), only associated with high IV boluses—but many of out pts. Cardiac, and theoretic possibility of hitting femoral vein).
- 10 cc syringe to fill with radiographic contrast, put tubing on immediately to ID it.
- 20 cc syringe:Lots of chit-chat to relax pt .Good-vibe endorphins block those ‘I’m so scared needleneedleNEEDLE!’ thoughts.
- Bupivacaine (aka Marcaine, Sensorcaine) .5%, draw up 9 cc
- Kenalog 40, 1-2 1 cc (40 mg) vial—shake well (cloudy)—draw all (as best possible)
- Sterile water 5 cc (Make note of what you drew up; final dictation will be "7 cc of (9 cc Marcaine .5, 1 cc Kenalog 40, 5 cc sterile water) were injected…."
Post-injection, assist pt. upright, hold on table a moment to re-orient (check pulse; is pt. grey, clammy, teary-eyed? reassure!); help to upright and ask to ‘test-drive’ result by ambulating in room. One needs to ask the pt. to assess any immediate change in pain or ROM (ambulate in room, get up/down from chair, whatever), and to then keep track over next few days/hrs to note (and then report to referring doc) when pt. returned to pre-injection baseline (“How you felt yesterday”) (anesthesia good for 3-4 hrs, steroids may kick in and go days/weeks).
REMIND PATIENT that joint may be numb for hours/days but is NOT ‘better’; no activities that would not have been allowed/comfortable yesterday - no sports, push-ups, weight-lifting, high heels, ladder-climbing, ambitious activities. If hip injection, warn of subtle leg numbness ‘as if asleep’ that could make them clumsy (it distorts proprioception), making them stumble on steps, sidewalk, in house in the dark, or uneven ground - ‘Be very careful next few days”.
GADOLINIUM INJECTIONS: for MR which must follow immediately. Call MR and make sure they are aware of pt; give them estimate as to when they can expect pt. (make sure you ascertain which building/ scanners!)
Basic set up plus:
- Smallest container Gad (may need to get from MR)
- Tiny (1cc) TB type syringe marked in .1cc increments
- ~10 cc or slightly less sterile saline (need not be non-bacteriostatic)
- 20 cc syringe
Procedure: ~.3 cc Gad into tiny syringe; and draw ~19.5 cc saline (HIPS: 5 cc Marcaine, 10 cc sterile water) into 20 cc syringe; pull back 20 cc plunger a mm or two to make space at tip as hold upright. Inject ~.1 cc from TB syringe into nipple of 20 cc syringe; put finger over nipple tip and invert 1ce or 2ce to mix. This creates the necessary dilution (1:200 seems to work well, there is pre-exisiting joint fluid plus 2-3 cc of radiographic contrast injected first to confirm intra-articular position, which further dilute it. Literature says “1:200” but outcomes vary since additional fluid already in joint varies).
Use conventional radiographic contrast for test injections through spinal needle to confirm intra-articular position under fluoroscopy; capture image for records.
Once confirmed intra-articular, remove the tubing from the radiographic contrast, put it on 20 cc Gd/saline syringe, and gently push ~2-3 cc Gd/saline solution through tubing over tray (to replace tubing contents with Gd/saline mix); note volume left in syringe; re-attach to intra-articular needle, and inject Gd/saline as tolerated (?7-10 cc shoulder or hip; watch pt’s face, ask how feel—previous effusions leave joint space distended, surgery/prior procedures may scar it down tighter). Flick fluoro on intermittently to confirm radiographic contrast being displaced/diluted intra-articularly by radiolucent Gd/saline injection. Document with image, and make note of total volume injected.
Help pt. off table minimizing joint motion (ie stay in hospital gown, don’t change back to street cloths, use wheelchair to move to MR area, so as to not pump precious injection back *out* of capsule—“it’s a distended water balloon under pressure, with a small hole in it”), ESCORT (wheelchair probably) to MR via trusted technologist or yourself if no one else can. DO NOT CALL ESCORT, minutes matter once the contrast is in.
Donna Magid MD, M.Ed
Questions: call (410) 428-5530