Appropriate equipment, technique ensure accurate placement of joint injections

CLEVELAND — Use of appropriate equipment and technique may ensure the comfort of patients who receive joint aspiration and injections in rheumatology practices, said a presenter at the Rheumatology Nurses Annual Conference.

“Using appropriate equipment and technique will ensure accurate placement and a comfortable procedure for patients and you,” Jon Giles, MD, MPH, assistant professor of medicine, Division of Rheumatology, Columbia University, College of Physicians and Surgeons, said.

Giles said not much equipment is needed for joint aspiration and injections. Antiseptic preparation materials, anesthetic material, the choice of needle, syringe and injectant, as well as tubes, labels, biohazard bag and dressing, are all that are needed. In general, smaller needles are more comfortable for patients and are easier to fit in smaller spaces.

Jon Giles

“You want to have a comfortable procedure, and you do not want your patients to get [post-traumatic stress disorder] PTSD after this” he said.

For most injections done in a rheumatology office, at least 1.5 inches of length of needle are needed for all but small joints of the hands and feet. The largest gauge should be an 18-gauge needle, with the smallest being either a 25-guage or 27-gauge needle, he said. As for syringes, Giles said a 60-mL syringe is hard to pull back under vacuum conditions. Although it can remove a lot of volume, it could accidently collapse the synovium down back on the needle.

Giles said there are no comparative studies on the need for sterile gloves and gowns when doing joint aspirations and injections, and the risks of post-procedure septic arthritis and skin and soft tissue infections are so low that complete sterile procedures are not needed. However, the exception is for patients who have histories of skin or soft tissue infections after previous injections. He also cautioned to not put a needle into a joint through cellulitis, erysipelas, abscesses or psoriatic plaques.

He said there is no need for the skin and subcutaneous tissue to be anesthetized with lidocaine, as there are no studies regarding benefits of this practice. However, the rule is to always anesthetize unless a second needle will be more uncomfortable than doing the procedure without the local anesthetic. Topical anesthetics are rarely used due to limited deep coverage and the length of time it takes to act, he said.

As to whether one should inject local anesthetic mixed with the corticosteroid, Giles said there are no comparative studies on this practice. Although this practice may provide some immediate pain relief, the effect is temporary and should be used in a large joint or bursa only. – by Kristine Houck, MA, ELS

Reference:

Giles J. Joint injections: The how, where and why. Presented at: Rheumatology Nurses Society Annual Conference; Aug. 3-6, 2016; Cleveland.

Disclosure: Giles reports no relevant financial disclosures.