Needle Approach Research Articles

High volume and low concentration of anaesthetic solution in the perivascular interscalene sheath determines qualityof block and incidence of complications

In the perivascular sheath of the brachial plexus, the volume of anaesthetic solution determines the quality of anaesthetic cover. Fibrous septa may divide the perivascular space into compartments, leading to inadequate diffusion of the anaesthetic solution. The aim of our study was to obtain good anaesthesia and less complications using high volume of low concentration anaesthetic solution, overcoming the obstacle of the septa with a double approach to the scalene sheath. Sixty patients scheduled for shoulder capsuloplasty received both Winnie interscalene brachial plexus block and Pippa proximal cranial needle approach. The patients were randomly assigned to two groups. A constant dose of local anaesthetic was administered to each group: Group I (30 patients) received high volume (60 mL of anaesthetic solution) and Group II (30 patients) received low volume of solution (30 mL of anaesthetic solution). Sensory and motor block in the upper limb and complications were evaluated. In all the patients the quality of anaesthesia obtained at the surgical site was excellent. In Group I also the areas supplied by the medial cutaneous nerves of the arm and forearm, ulnar, median and radial nerves were blocked (P < 0.002). Complications were only observed in Group II and consisted of bradycardia and hypotension (66% of the patients) and phrenic nerve paresis (27% of the patients). The lower concentration of the anaesthetic solution avoids complications while increased volume provides good analgesic cover. The combination of the Winnie interscalene plexus block and the Pippa proximal cranial needle approach should contribute to fill up the scalene sheath overcoming the septa obstacles.

A modified needle-inside-needle technique for the ganglion impar block

The ganglion impar is the fused terminus of the paired sympathetic chain located at the level of the sacrococcygeal junction. It has been blocked using a bent and a curved spinal needle via the anococcygeal ligament. It has also been approached through the sacrococcygeal disc using a straight spinal needle. We describe a needle-inside-needle modification of the latter approach.Technical features: A 22-gauge (G), 1(1/2)-inch (38 mm) needle is introduced through the sacrococcygeal ligament under fluoroscopy via the sacrococcygeal disc. A 25-G, 2-inch (50 mm) needle is introduced through the 22-G needle. Placement is confirmed with injection of iopamidol 300, 0.2 mL in the retroperitoneal space with the comma sign. The bent and curved needle techniques are associated with significant discomfort, tissue trauma and risk of rectal perforation due to difficulty in obtaining a midline needle tip position. The straight spinal needle approach minimizes these problems, however there is increased risk of discitis and a longer spinal needle may help also raise incidence of needle breakage. The needle-inside-needle technique may reduce these risks.

Proposal of blood-collecting needle approach to semi-invasive method

Many diabetic patients carry a portable self-monitoring of blood glucose (SMBG)-analyzer in order to collect their own blood and examine their glucose levels; this allows them to determine such factors as insulin dose, diet and exercise to stay healthy. However, the test causes physical and mental stress for the subjects. The authors aim to develop a semi-invasive blood-collecting needle which does not need a power source for the pump mechanism. In this study, we fabricated a capillary action needle that can collect the blood sample automatically. A blood-collecting needle was fabricated from 25 gage sized medical needle (diameter of 0.5mm, stainless steel) by cutting process, and it had a half-opened crevice in the tip. In order to evaluate the physical characteristics of the blood-collecting needle, the relationship between the size and suction time and/or suction volume were measured using an isotonic sodium chloride solution, whole rabbit blood, and whole human blood with anticoagulant. Next, in order to evaluate the degree of invasion, the diameters of erythema in auricles of rabbits were observed for 2 days using a CCD camera-type microscope. The mean suction time of the isotonic sodium chloride solution and the whole rabbit blood were 1.5s (n = 10) and 9.0s (n = 5), respectively. Selection of a suitable size of the blood-collecting needle enabled the collection of 0.1μL of whole human blood in 10s. Moreover, it was shown, by comparing the observed diameter of the erythema, that the invasiveness of the blood-collecting needle was smaller than for commercial needles of the equal diameter. It became clear that this fulfils the fundamental functions of a semi-invasive blood-collecting needle.

Complications of percutaneous vertebroplasty and their prevention.

Complications due to vertebroplasty may be divided into two categories whether or not they are related to polymethylmethacrylate (PMMA) cement leakage from the compressed vertebral body. PMMA leakage is a very frequent occurrence in vertebroplasty is also the main source of complications. Neurological complications are due to cement leakage into the spinal canal and less exceptionally into the intervertebral foramen. The transpedicular needle approach reduces the risk of cement leakage into the foramen. Pulmonary embolism of PMMA may occur when there is a failure to recognize venous migration of cement early during the procedure. Cortical destruction, presence of an epidural soft-tissue mass, highly vascularized lesions, and severe vertebral collapse are factors which increase the rate of complications, which is therefore much higher in metastatic than in osteoporotic vertebral collapse. Prevention of PMMA leakage-related complications is a multifactorial issue including procedure preparation, needle approach and placement, and cement application. The technical refinements which may help reduce the risk of PMMA leakage are reviewed in this article. Experimental data have shown that systemic reactions may occur during vertebroplasty in the absence of cement leakage. These reactions may be partly related to vascular embolism of bone marrow fat. Another controversial issue is a possible increase in the risk of vertebral collapse of adjacent vertebrae following vertebroplasty. Prospective randomized studies are needed to resolve this issue.

Single needle approach for multiple medial branch blocks: a new technique.

Medial branch blocks are an important tool for the diagnosis of facet joint arthropathy. The most commonly used technique involves multiple needle placements, one for each nerve blocked. This multiple needle technique may require a large amount of local anesthetic for anesthetizing the skin, thereby increasing the rate of false-positive blocks. Diagnostic lumbar medial branch blocks are usually performed using multiple needles, one for each branch. The authors describe a different technique using a single needle for all levels. Initially, the needle is directed toward the medial branch located at the level of the affected facet joint in the antero-posterior view. After anesthetizing this nerve with local anesthetic, the same needle is withdrawn to the skin with the tip still in the subcutaneous tissue and repositioned to block the medial branch above, and thereafter below, while continuing to use only the antero-posterior view, thereby using only one entry site. When performed correctly, the single needle technique provides accuracy similar to the more conventional multiple needle approach during the performance of diagnostic facet joint nerve blocks. Because only one skin entry point is needed, however, this technique may afford several advantages over the multiple needle approach. These may include less patient discomfort, less time required and less radiation exposure since only one C-arm position is used, a smaller volume of local anesthetic, and possibly a lower incidence of false-positive blocks.

Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection.

We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 x 10(9)/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1-20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention. Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.

CT-guided superior hypogastric plexus block.

This study reports our experience with CT-guided block in the superior hypogastric plexus, using a single needle and anterior approach, in patients with pelvic cancer. Ten patients with pelvic malignancy underwent CT-guided hypogastric neurolytic block with alcohol via an anterior approach. A solution of 10, 15, or 20 ml of alcohol, 4 ml of bupivacaine HCl, and 2 ml of contrast medium was injected. The results were evaluated based on pain relief, using a four-grade analogue scale. CT images always showed spread of solution around the iliac vessels. Pain relief was complete in four cases, moderate in two, mild in three, and none in one. Best results were observed with the largest amounts of alcohol. CT-guided percutaneous superior hypogastric block is a safe, relatively easy, and effective procedure in patients with severe pain from pelvic malignancies.

An Automatic Blood-Collecting Needle Approach to Semi-invasive Method

An Automatic Blood-Collecting Needle Approach to Semi-invasive Method

RETROPERITONEAL LAPAROSCOPY FOR RENAL BIOPSY IN CHILDREN

Purpose: We report our experience with the retroperitoneal laparoscopic approach for treating pediatric patients and when the percutaneous needle approach is not possible due to uncontrolled hypertension, bleeding disorders, anti-clotting medications and anatomical abnormalities.Materials and Methods: Retroperitoneal laparoscopic renal biopsy was performed in 20 patients 2 to 18 years old (mean age 9.7) during a 16-month period. At the same time 53 percutaneous needle biopsies and 1 open biopsy were performed. The child is in a flank position, and 2 trocars are used via a direct vision approach. The first trocar is 12 mm. in diameter and positioned on the posterior axillary line, and the second trocar is 5 mm. in diameter and is entered 4 cm. anteriorly. Gentle dissection is done to free the lower pole of the selected kidney, biopsy forceps are used to grasp the specimen under direct vision and the biopsy site is fulgurated using bipolar electrocautery.Results: Biopsy was performed successfully in all cas...

Retroperitoneal laparoscopy for renal biopsy in children.

We report our experience with the retroperitoneal laparoscopic approach for treating pediatric patients and when the percutaneous needle approach is not possible due to uncontrolled hypertension, bleeding disorders, anti-clotting medications and anatomical abnormalities. Retroperitoneal laparoscopic renal biopsy was performed in 20 patients 2 to 18 years old (mean age 9.7) during a 16-month period. At the same time 53 percutaneous needle biopsies and 1 open biopsy were performed. The child is in a flank position, and 2 trocars are used via a direct vision approach. The first trocar is 12 mm. in diameter and positioned on the posterior axillary line, and the second trocar is 5 mm. in diameter and is entered 4 cm. anteriorly. Gentle dissection is done to free the lower pole of the selected kidney, biopsy forceps are used to grasp the specimen under direct vision and the biopsy site is fulgurated using bipolar electrocautery. Biopsy was performed successfully in all cases except 1, which was converted to an open procedure. Mean operative time was 40 minutes, blood loss was minimal and mean hospital stay was 1.2 days postoperatively. No pain medication was required postoperatively, and all patients returned to their usual activities within 3 to 5 days. A minor intraoperative complication, which was a peritoneal tear with no postoperative sequelae, occurred in 1 case. The retroperitoneal laparoscopic technique is simple and safe, and does not require extensive laparoscopic experience. We believe that this approach is reliable, and has less morbidity and several advantages compared to open surgery. It should be selected as the first choice for treating pediatric patients when percutaneous needle renal biopsy is contraindicated.

Brachial plexus block using a new subclavian perivascular technique: the proximal cranial needle approach

We describe the proximal cranial needle approach for brachial plexus blockade; clear surface markings and cranial direction of the needle lead to satisfactory results with a low incidence of complications.

Supraclavicular brachial plexus anesthesia using the plumb bob method

The plumb bob technique is a recently described, innovative approach to supraclavicular brachial plexus blockade. Validated by computerized tomographic analysis in volunteers, the method uses the reliable relationship of the brachial plexus to easily identified anatomic landmarks. Brachial plexus location is greatly simplified by a true vertical, or plumb bob, needle approach at the junction of the clavicle and the lateral head of the sternocleidomastoid muscle. The needle is passed through successive steps in a parasgittal plane until the plexus is contacted. Large or muscular patients often require a slight caudad angulation from the plumb bob in the parasagittal plane to achieve plexus contact; thin patients often require a slight cephalad angulation from the plumb bob. Ease of plexus location and the high degree of complete plexus blockade associated with the supraclavicular approach result in a technqiue optimally suited for a busy upper extremity surgery pratice. Needle adjustments required to stimulate the different elements of the brachial plexus are readily apparent, greatly facilitating the teaching of the technique to residents-in-training. Risk of pneumothorax remains a concern, and adjustments in the orginally described plumb bob approach are presented as a method to eliminate this complication.

Direct cannula entry for laparoscopy

The common blind puncture technique for inserting a cannula to establish pneumoperitoneum was first described by Veress in 1938 and carries several significant and specific complications such as gas embolism, subcutaneous inflation, failed pneumoperitoneum, and bowel or visceral insufflation. Direct cannula insertion is both safe and effective. No major complications using this technique occurred in a series of 550 consecutive laparoscopies. It would seem that the patient who is served safely by a Veress needle approach is equally served by direct cannula entry.

Magnetic resonance imaging guided breast biopsy using a frameless stereotactic technique

The high sensitivity but poor specificity of contrast enhanced magnetic resonance (MR) imaging for delineating malignant breast lesions is increasing the demand for MR guide breast biopsy. However, the poor patient access offered by conventional MR systems makes such procedures extremely difficult. We describe a method of performing breast biopsy outside the bore of the magnet using the 3-D MR imaging data. This involves a frameless stereotactic technique using an ultrasonic localizer. The position in space of the tip of a pointer with a handle which incorporates two ultrasound emitters can be tracked using an array of ultrasound detectors. MR visible marker beads (fiducials) placed on the breast and imaged at the same time are identified to the computer in relation to images of the breast. The ultrasonic localizer is used to register the position in space of the fiducials by touching them with the tip of the pointer. The image of the lesion within the breast can then be displayed in relation to the position of the tip of the pointer and the needle approach planned. Nine women with foci of enhancement on their dynamic contrast enhanced MR images underwent frameless stereotactic breast cytology. Needle placement within 2 mm of the lesion was achieved at first pass in eight out of nine (89%) cases: in one case the needle had to be re-positioned prior to sampling. This technique provides a means of targetting MR visible lesions using the MR imaging data whilst performing the procedure outside the magnet bore.

Emergency Bone Marrow Infusions-Reply

In Reply .—Dr Turkel has certainly contributed a great deal in the field of intraosseous infusions. 1,2 He refers to a study 3 of massive arsenotherapy delivered by bone marrow infusion in seven rabbits. Four rabbits developed asymptomatic pulmonary fat emboli and one died suddenly from fat embolism. A sharp, 18-gauge needle with fitted stylet was used in all the animals. It is unclear what role the infusion agent (massive arsenotherapy) had in the development of these fat emboli. Two studies in the mid-1940s described 70 intraosseous infusions in children using the Turkel trephine technique without evidence of pulmonary emboli. 1,4 Additionally, Heinild et al 5 utilized a standard bone marrow needle approach on 982 infusions in children without evidence of pulmonary emboli. Meola, 6 in children, and Valdes, 7 in adults, demonstrated the safety of 341 bone marrow infusions with simple hypodermic needles, again without evidence of pulmonary emboli.

Cholestatic liver disease.

The newer diagnostic techniques, such as ultrasonography and cholangiography by the thin needle or retrograde endoscopic approach, simplify differentiation of extra-from intrahepatic disease and open the way to more specific management.

Da Costa's Syndrome: Aetiology. Lecture III

<b>382</b> <h3><b>Objectives</b></h3> Preclinical Molecular Imaging technologies have an increasingly broader application base while at the same time are becoming more user friendly. To the best of our knowledge, to date no automated or semi-automated system has been developed that allows probe injections and blood sampling from a rodent9s tail. Tail vein injections are a routine but critical step in most imaging applications, while poor injections greatly affect the experimental results. We have devised a semi-automated vascular access system to facilitate injections and blood sampling from the mouse tail. We have eliminated the handheld needle approach by using a mechanically moving needle, controlled by machine vision. This approach reduces the operator skill requirements, allows the use of significantly smaller needles than those currently used by handheld means, and has the potential to provide improved control in time and location of the injected volumes and drawn samples. <h3><b>Methods</b></h3> We localize the superficial tail blood vessel with near infra-red live video imaging. The needle is aligned with the vessel, according to the image, by mechanical means. The needle is then inserted into the vessel by a linear actuator. The monitoring and feedback of the needle insertion is done with a pressure transducer connected to the needle. Once the needle is inserted, probe injection and/or blood sampling can be done either manually or controlled by microfluidic systems. <h3><b>Results</b></h3> We have constructed a prototype vascular access system with which we can reliably locate vessels in the tail of an anesthetized mouse and insert miniature, 34 gauge needles, into the vessel. Our feedback system provides us with information on the success of the needle insertion, which we have verified by PET imaging of the mouse, including the tail. <h3><b>Conclusions</b></h3> Our device will aid in preclinical molecular imaging of mice and other mouse handling techniques where access to the mouse tail vessels is necessary. We continue to work on our prototype device to make it more user friendly and robust