June 2014 - Donna Magid, M.D., M.Ed.
SHOULDER PROCEDURES include 4 different studies:
- ASPIRATION to R/O Infection (most likely to be encountered overnight)
- PAIN STUDY: Bupivacaine and Kenalog injection to test response
- MRI or CT: gadolinium (immediately pre-MRI) or contrast (pre-CT)
ASPIRATION for Possible Infection:
“R/O P. Acnes” must be handwritten BIG on all forms—fastidious ‘bug’, special handling/10 day culture necessary.
- 1.5" 25 gg needle (NOT the standard 5/8")
- Basic Tray
- 20 gg spinal needle (yellow)
- 50 cm tubing
- Lidocaine 2 % (drawn into 5 cc syringe—10 cc if huge patient)
- 10 cc Omni or Hypaque w/ tubing attached and contrast run through to tube tip (tube = de facto ‘label’, distinguishing between clear fluids on table)
- Betadyne in one of the two prep cups on standard tray
- 16 gg purple needle to draw up meds and contrast
- (2nd 5 cc syringe and yellow (20) gg needle-- to use if aspirate fluid obtained for culture)
- IF PAIN STUDY ADD: Bupivacaine (~9 cc), Kenalogue 40 (one 1-cc bottle, ie 40 mg, shaken well), sterile water
IF MRI or CT STUDY ADD:
- 20 cc syringe
- Gd: smallest size vial Magnevist/Gadolinium; CT: Omnipaque/water, 1:1
- TB ( one cc) syringe, marked in .1 increments
- 0.3 mm Gd: 18 or so cc sterile water
- NEVER mix Gad with steroids (even if req erroneously requests)--precipitates
WASH YOUR HANDS in front of patient while introducing self.
- INDICATION : “sample joint fluid to test for infection” OR “inject special MR contrast to better see non-bony shoulder” OR “inject anesthesia and steroids to test response, possibly give temporary relief”
- 'Time Out': to confirm side of interest" (L, or R) “and patient ID" (check wrist bracelet, ask pt to state name, DOB, and to point to joint, explaining it is safety precaution).
- RISKS: Pain, Bleeding, Allergy to Materials, Infection, Retained Materials, Non-diagnostic test; if marcaine used add chondrotoxicity (“cartilage loss”), cardiac side effects (see JOINT document for more info), ‘numb arm’ .
- ALTERNATIVES: “Do nothing, Operate”
Tech to provide one copy of signed and witnessed document for pt, or pt. chart if Emergency/Inpatient
LOCALIZE: It's Position Position Position. Extra time here pays off BIG.
Put on nonsterile gloves. Make sure pt. is lying flat in anatomic position, no more than one pillow. Stand behind pt's head, assess for scoliosis or guarding or asymmetry. Gently encourage pt to drop shoulders back towards tabletop (with anxiety or pain, pts. tend to hunch). Externally rotate hand and arm, so pt is palm-up, if tolerated; use rolled sheet or towel under hand/wrist to help them stay supinated, and put lead glove over hand to stabilize --moves labrum and biceps tendon out of way.
Use metal dot marker to localize junction of middle and inferior thirds of the glenohumeral joint space. Be meticulous, w/ tube collimated and centered right over the GH space. Mark site w/ (nonsterile) waterproof marking pen.
Markedly obese pts, and/or very large breasts: try to smooth tissue away from field as best possible.
Encourage patient to look straight ahead or close eyes; tendency is either to turn head to watch, or to see needles from peripheral vision and get jumpy. Therefore also put your curled (nondominant) hand as visual shield between patient’s face and your needle as work near face, to block peripheral vision. DOUBLE GLOVE OVER the nonsterile gloves.
- Use sponge stick and iodine prep in concentric circles extending from the localizing mark. Wipe area x4, then leave wet iodine prep to 'work' while draw up materials. Stand between pt's eyes and needles/tray while drawing up, to keep catecholamines down!
- Draw up Lido 2% in 5 syringe.
- Draw up radiographic contrast in 10 cc syringe, promptly attach 50 cm tubing and run contrast to tip (=s identifying ‘label’).
- Extract spinal needle from packing tube and separate occluder stylet from hollow needle, to make sure it isn't stuck (rare but possible—black 22gg were notorious for a while).
- LABEL syringes w/ sterile labels/sterile marker if provided (tubing on middle-size syringe= de facto label)
- Spread sterile fenestrated sheet over cleaned work area, long side oblique transverse towards contra-lateral lower chest, folding or tucking at pt's chin so it doesn't tickle and make them move.
- Anesthesia: Use 1.5 " 25 gg blue needle. Warn ‘Bee sting and burning, you can curse but DON’T MOVE”. Raise small subQ wheal lidocaine at localizing dot, then promptly go straight down perpendicular to skin through localizing dot towards GH joint. Compress skin under needle to reach deeper than 1.5". As pull back, inject gently. Now switch to the spinal, go deep to bone (or until feel distinctive ‘pop’ through capsule) along same path. Stylet IN (or needle will clog).
- Fluoro to see if you are directly over joint space at desired target. IF YOU ARE: remove stylet, give tiny test-injection of lido. If strong resistance, pull back 0.5 mm (to free oblique tip and lumen from cartilage or bone) and try again. If test injection 'falls' in freely, switch to contrast and tubing and under fluoro inject a drop.
- If contrast drop hovers in blob at needle tip: not in. If it distributes in ‘fan’ infero-medially you are in pectoralis muscle. If it promptly squirts freely laterally and medially around anatomic neck and head, good. Remove tubing from spinal hub, and use clean/empty 5 cc syringe to try to aspirate fluid. Needle can be gently 'jiggled' up/down less than 1 mm, or 'walked' medial-lateral the same (down to bone gently, pull back gently while keeping negative pressure on syringe).
IF YOU DO NOT GET ANY FLUID: Surgeons insist we inject up to 10 cc NONBACTERIOSTATIC saline and try re-aspirating; do do as two 5-cc attempts. (NOTE same on lab form if fluid obtained since it is now diluted)
IF ANY FLUID OBTAINED: need 1 cc in culture bottle for culture and sensitivity, Gram, R/O P.Acnes, if fluid present PURPLE TOP TEST TUBE for Body Fluid Cell Count and Cell Diff. (note source on pink paperwork)
PAPERWORK for SAMPLES:
ALL bottles/vials must have machine-printed pt. labels. Bottles go into main compartment of transport bag, paperwork into side pouch of bag.One bag, one specimen. LAB WILL TOSS MIS-PACKAGED STUFF--CAVEAT!!!
HAND DELIVER or give direct custody only to intelligent trusted tech or helper who swears they know where labs are and will deliver immediately. Lab has low threshold to toss samples. Leaving on counter for 'someone'? "Someone" does not exist.
Path 5, Port-A-Cult--C&S, “R/O P acnes”!!! (hand-write on forms), Gram, anaerobic/aerobic; if TB, fungal,
requested, check that too but may need more fluid--to MICROBIOLOGY LAB
Path 2 (pink is stat), purple or green top tube - body fluid cell count and diff--to CORE LAB
Still got fluid? Red top ("Didja") tube, to a plastic bag, and call house officer-- in case he/she wants Ironman titres, X-Files DNA test, Katniss count, etc.
PAIN TEST: Slightly modified paperwork (Indication changes, add ‘numb arm’,‘chondrolysis’ and ‘cardiac side effects’), same pt. prep.
- Draw up 9 cc bupivacaine (Sensorcaine, Marcaine), 1-2 cc (bottle= 1 cc) of Kenalog 40 (shake well first),4- 5 cc sterile water.
- Once small radiographic contrast test injection proves intra-articular position,remove tubing and contrast syringe, start injecting bupivacaine/steroid slowly till pt. winces or if no problem (post effusion, joint capsule may be distended). Inject ~10 cc if tolerated.
- Clean up tray, take off sterile gloves, leave nonsterile gloves on, help pt. sit up and when ready, ask pt to 'test' shoulder (move gently) to assess if they feel better/worse/same. Tell them “anesthesia lasts ~4 hrs; if pain relieved could last hours or days longer than that”, and they need to keep track and let Orthopaedist know in a few days.
- REMIND them if they feel better, they are NUMB, NOT better and same activity restrictions in effect. DOCUMENT this warning in dictation.
MRI Gadolinium injection:
- Confirm that MR will be available and expecting pt. in about 30 minutes.
- Confirm that tiny 1 cc TB syringe and small vial Gadolinium in fluoro area (it's still occasionally a BYOB affair)
- Once pt signed and prepped and sterile (double) gloved:
- Draw .3 cc Gad up into TB (tiny) syringe (comes w/ attached needle, use and leave on).
- Draw ~19.5 cc sterile water/saline into 20 cc syringe , pull back slightly to make air pocket at tip of inverted syringe (nipple up)
- Use TB syringe to inject 0.1 cc Gad into tip of 20 cc saline syringe, holding latter tip-up. Put finger over tip and invert 20 cc syringe 1ce or 2ce to mix (again—this approximates ‘1:200” in literature but there will be native fluid, plus injected contrast, further diluting this mix) .
- Once small radiographic contrast injection confirms intra-articular position, remove tubing, drain into betadyne cup, and slowly run Gd/saline through tubing to replace. Slowly inject 5-8 cc saline/Gd as tolerated, brief fluoro checks to confirm positive contrast redistributing/diluting. Capture image to document/prove.
- Once done, sit pt. up gently, warn against excessive motion (do not allow to dress, don’t ‘test’ arm by moving it), and ESCORT directly to MR by wheelchair.
On-Call MSK Radiology on weekly MSK Rads Schedule, Sharepoint
Queries, comments, corrections: Donna Magid MD M.Ed 410 428 5530