Joint Aspirations Flashcards
Indications for joint aspiration
- Evaluate for infection/systemic rheumatic disorder
- Evaluate effusions of unknown origin
- Relieve pain caused by a tense effusion
Indications for bursa aspiration
- Painful persistent swelling that does not respond to conservative treatment
- Olecranon bursitis aggravated by normal activities
Contraindications for joint/bursa aspiration
- Burns, cellulitis, impetigo
- When risks for introducing bacteria outweigh the benefits
- After joint arthroplasty
- Hemophiliacs or patients on anticoag w/ a hemarthrosis
Complications of joint aspiration
- Infection
- Bleeding
- Intra-articular injury
- Damage to underlying vascular or neuro structures
- Pain
- Reaccumulation of fluids
- Allergic reaction
Complications of bursal aspiration
- Infection
- Pain
- Chronic recurrence
- Chronic drainage via sinus tract
- Acute recurrent swelling
- Baker’s cysts or popliteal bursae (herniations of the joint capsule)
What is the MC joint/bursa that get aspirations?
Knee MC joint
Olecranona and pre-patellar MC bursae
Procedure prior to joint/bursa aspiration
- Informed consent
- Use standard precautions
- Prep and scrub to minimize introduction of bacteria
Is joint/bursa aspiration a sterile or clean procedure?
Sterile
What needles/syringes are required for joint aspirations?
- For anesthetic: sterile 1 inch 25 gauge needle and 5/10 mL syringe
- For aspiration: sterile 1.5 inch 18/19 gauge needle w/three 30 mL or two 60 mL syringes
What tubes are needed for aspiration?
- Red/green top containing Na heparin for crystals, total protein, glucose, RA latex
- Purple top w/EDTA for cell count and differential
- Yellow top for cultures
What do red/green top tubes contain and what do they test from aspirations?
- Contains Na heparin
- Tests for crystals, total protein, glucose, RA latex
What do purple top tubes contain and what do they test from aspirations?
- Contains EDTA
- Cell count and differential
What do yellow top tubes test from aspirations?
Cultures
Joint aspiration technique
- Attach 18 gauge to 30/60 mL syringe
- Insert needle at same point as anesthetic tract and advance toward joint
- Apply gentle pressure on opposite side to milk fluid toward needle
- Begin to withdraw fluid by pulling back on plunger of syringe
What do you do if flow of fluid stops in a joint aspiration?
Reposition needle and attempt to withdraw fluid
Describe normal aspirate
Clear
Slightly thick
Yellow
Describe infected aspirate
Thick, cloudy, purulent
WBCs over 50,000
Positive culture
Describe inflammatory aspirate
Cloudy
Less viscous
Elevated WBC 20-50,000
Describe gout/pseudogout aspirate
Positive for crystals
What could cause bloody joint aspirate?
Fracture (fat globules)
Patellar dislocation
ACL/PCL rupture
Coagulopathy
Follow up care of joint aspiration
- Avoid use of joint for 1 day
- If infection suspected, broad spectrum abx for S. aureus and MRSA
- Call if signs of infections
When should admission be considered after joint aspiration?
For all suspected joint infections
Olecranon bursal aspiration technique
- Administer anesthetic on superior-lateral aspect of distended olecranon bursa
- Flex elbow 90 degrees
- Enter on a 90 degree angle superiorly/inferiorly and aspirate slowly until bursa sac is flat
Why shouldn’t an olecranon bursa be aspirated laterally or medially?
Ulnar and radius nerves run pretty superficially in the grooves
When should a bursa be aspirated until?
Until the bursa sac is flat
Follow up care of bursal aspiration
- Apply direct pressure at site and apply bandage w/ACE wrap
- Do not overuse joint for at least 2 days
- Call if signs of infection
Indications for joint injection
- Relieve inflammation/pain
- Tendonitis/bursitis
- OA and inflamm arthritis
- Gout/pseudogout
- Neuritis (carpal tunnel syndrome)
Contraindications of joint injection
- Cellulitis
- Bacteremia/septic effusion
- Coagulopathy/uncontrolled INR
- Joint prosthesis
- Acute fracture
- Inaccessible joints
- History of allergy to the injectables
- Lack of response after 3-4 injections
- Incompetent provider/uncooperative patient
Complications of joint infection
- Infection, bleeding, damage to underlying structures
- Pain, allergic reaction
- Intravascular injection
- PTX
- Need for further treatment
- Steroid flare
- Tendon rupture
Define steroid flare
Usually due to precipitate forming from preservative in multi-dose vial of lidocaine injected with the steroid
Treatment of steroid flare
Ice and NSAIDs
Use of single dose vials
Joint injections and tendons
- Avoid injecting directly into tendon
- Avoid in or near high load tendons (achilles, patellar, plantar fascia)
- Avoid concomitant quinolones
- Can cause tendon rupture
Precautions of joint injections
- Rest joint for 1-2 wks after
- Avoid trauma to articular cartilage (know anatomy and go slow)
- Wash povidone-iodine prep off bc it can burn the skin
What steroid has the highest proportion of anti-inflamm effect with lowest proportion of mineralcorticoid effect?
Triamcinolone (Kenalog)
What joints can Triamcinolone (Kenalog) be used in?
Any joint
Does Triamcinolone (Kenalog) precipitate with lidocaine?
No
What joints can methylprednisolone be used in?
Any joint
Describe methylprednisolone use in joint injections
- Causes less skin atrophy/hypopigmentation
- Avoid short or long acting
What is Hyaluronan mostly used for?
OA of the knees (may delay the need for TKA)
When is Hyaluronan used?
After steroid injections have failed
*Most insurances will not pay for this
How does Hyaluronan work?
May decrease inflammation and stimulate endogenous hyaluranon synthesis
Side effects of Hyaluronan
- Local inflamm reaction
- Pain
- Anaphylaxis
What is Synvisc?
- Hyalouranon made from birds beaks
- 1 to 3 injections
What is Hyalgan?
- Hyalouranon made from birds beaks
- 5 injections
What is Supartz?
- Hyalouranon made from birds beaks
- 5 injections
Which Hyalouranon agents are non-avian derived?
Orthovisc
Euflexxa
What is Orthovisc?
- Non-avian Hyalouranon
- 3 injections
What is Euflexxa?
- Non-avian Hyalouranon
- 3 injections
Where are common locations for steroid injections?
-Greater trochanteric bursa
-Knee joint
-Carpal tunnel
-DeQuervain’s
-Trigger finger
-Subacromial space
etc etc
Define hematoma block
Analgesic technique used to allow painless manipulation of fractures w/o use of general anesthesia
When are hematoma blocks typically used?
Wrist and ankle fractures
Contraindications of hematoma blocks
- Pts at risk of bleeding
- Open fractures or contaminated injuries
- Very young children
Equipment for hematoma block
- Sterile OR non-sterile gloves
- Cleansing solution
- 12 cc syringe
- Large bore needle to draw meds (blunt tip or 18-22 gauge)
- Large bore needle for injection (18-22 gauge)
- 8-12 cc 1 or 2% lidocaine
How does a hematoma block compare to conscious sedation with IV propofol?
Equally efficacious in terms of both quality of reduction and pain control
Advantages of hematoma block
-Faster time to reduction
-Faster time to leave post-procedure
compared to conscious sedation
Purpose of LP
To obtain info about CSF
R/o potential life threatening conditions
What should always be performed prior to LP?
Neuro exam and/or any potentially life saving interventions (e.g. abx and steroids for suspected bacterial meningitis)
Indications for LP
- Suspect meningitis
- Suspect subarachnoid hemorrhage
- Suspect CNS diseases (Guillan-Barre)
- Therapeutic relief of pseudotumor cerebri
Absolute contraindications of LP
- Infected skin over needle entry site
- Presence of unequal pressures between supratentorial and infratentorial compartments
Relative contraindications of LP
- Increased ICP
- Coagulopathy
- Brain abscess
- Anticoag use
Indications for performing CT prior to LP
- Over 60 yo
- Immune compromised
- Known CNS lesions
- Seizure within 1 wk of presentation
- Abnormal LOC
- Focal findings on neuro exam
- Pts with papilledema, clinical suspicion of increased ICP
Prior to LP, ensure that patients are ____. Why?
Hydrated to avoid a dry tap
How to lower risk of post-LP headache?
Smaller needle used
LP tray should include:
- Sterile dressing, gloves, drape
- Antiseptic solution
- Lidocaine 1%
- Syringe 3 mL
- Needles, 20 and 25 gauge
- Spinal needles, 20 and 22 gauge
- Three way stopcock
- Manometer
- Four plastic test tubes numbered 1-4 with caps
- Syringe, 10 mL (optional)
What position is the patient put in for LP? Why?
Left lateral recumbent position (hips, knees, chin flexed toward chest to open inter-laminar spaces)
Location of LP
L3-L4 interspace
- Locate by palpating R and L posterior superior iliac crests
- Move fingers medially
- Mark entry site w/thumbnail or marker
How should needle be inserted for LP?
All the way to the hub
How should the needle bevel be oriented in an LP? Why?
- Parallel to the longitudinal dural fibers (up in lateral recumbent position, to one side in the sitting position)
- Increases chance that needle will separate the fibers rather than cut them
Needle bevel faces ___ in lateral recumbent position for LP
Up
Needle bevel faces ___ in sitting position for LP
To one side
How is the needle inserted during an LP?
Slightly cephalad angle (direct it toward umbilicus)
What does it mean when a “pop” is felt during an LP?
When needle penetrates the dura
When should stylet be withdrawn in an LP?
Either after the pop of the dura or approx 4-5 cm (and observe for fluid return)
If no fluid is returned during an LP, what should be done?
Replace stylet, advance or withdraw needle a few mm, recheck for fluid return
How should opening pressure be measured in an LP?
- With patient in lateral recumbent position
- Attach manometer through stopcock and measure height of fluid
- Patient legs must be straight to avoid a falsely elevated pressure
What could happen if a patient’s legs are not STRAIGHT during opening pressure measurement with an LP?
Falsely elevated pressure
How should CSF be collected in the test tubes of an LP?
- At least 10 drops in each of the 4 plastic tubes starting with tube 1
- Tube 1 CSF should come from manometer
What do you do if CSF flow is too slow?
- Ask pt to cough or bear down
- Ask an assistant to press intermittently on pt’s abdomen
- Rotate needle 90 degrees so bevel faces cephalad
Describe which tubes test for what in CSF analysis?
- Tube 1: cell count and diff
- Tube 2: gluc and protein
- Tube 3: gram stain, culture and sensitivity
- Tube 4: cell count and diff
What does elevated WBC in CSF indicate?
Infection or leukemia
Inflammation
Traumatic tap
What does a traumatic tap introduce into the CSF?
WBCs and RBCs
Protein
High protein levels in CSF can indicate what?
- Demyelinating polyneuropathies or postinfectious states
- Traumatic tap
Normal glucose level in CSF approximates ___ of the peripheral blood glucose level at the time of tap
60%
What is recommended when evaluating glucose level in CSF?
Simultaneous measurement of blood glucose (especially if CSF glucose is low)
Low CSF glucose level indicates:
Bacterial infection (usually) Tumor infiltration (meningeal carcinomatosis)
High CSF glucose level indicates:
No specific diagnostic significance (usually spillover from an elevated blood glucose)
What is the best way to distinguish RBCs related to intracranial bleeding?
Examine the centrifuged supernatant CSF for xanthochromia (yellow color)
What is xanthrochromia?
- Yellow color of centrifuged supernatant CSF
- Can distinguish RBCs related to intracranial bleeding
- Can be produced by spillover from a very high serum bilirubin level (over 15 mg/dL)
What is xanthrochromia in a freshly spun CSF sample evidence of?
Preexistent blood in subarachnoid space
How long does xanthrochromia last?
As long as several weeks after a subarachnoid hemorrhage (greater diagnostic sensitivity than CT w/o contrast)
Complications of LP
- Post puncture headache
- Bloody or dry tap
- Infection
- Hemorrhage
- Dysesthesia (irritation of nerves or nerve roots by spinal needle)
- Post puncture cerebral herniation
How to avoid dysesthesia from LP?
Don’t withdraw spinal needle without replacing stylet!
can cause aspiration of a nerve or arachnoid tissue into epidural space
