Needle Insertion Site Research Articles

Skin blood perfusion and cellular response to insertion of insulin pen needles with different diameters.

Today most research on pen needle design revolves around pain perception statements through clinical trials, but these are both costly, timely, and require high sample sizes. The purpose of this study was to test if tissue damage, caused by different types of needles, can be assessed by evaluating skin blood perfusion response around needle insertion sites. Three common sized pen needles of 28G, 30G, and 32G as well as hooked 32G needles, were inserted into the neck skin of pigs and then removed. Laser Speckle Contrast Analysis was used to measure skin blood perfusion for 20 minutes after the insertions. Seven pigs were included in the study and a total of 118 randomized needle insertions were conducted. Histology was made of tissue samples inserted with 18G, 28G, and 32G needles, and stained to quantify red and white blood cell response. Based on area under curve, calculated for each individual blood perfusion recording and grouped according to needle type, skin blood perfusion response relates to needle diameter. The response was significantly higher after insertions with 28G and hooked 32G needles than with 30G (P < .05) and 32G (P < .01) needles. Histology results were not significant, but there was a trend of an increased response with increasing needle diameter. Skin blood perfusion response to pen needle insertions rank according to needle diameter, and the tissue response caused by hooked 32G needles corresponds to that of 28G needles. The relation between needle diameter and trauma when analyzing histology was also suggested.

Ultrasound for Routine Lumbar Puncture

The objective was to determine if use of ultrasound (US) by emergency physicians (EPs) to localize spinal landmarks improves the performance of lumbar puncture (LP). This was a prospective, randomized, controlled study conducted in a county teaching hospital. Subjects, adults 18years of age or older who were to receive LPs for routine clinical care in the emergency department (ED), were randomized either to undergo US localization of the puncture site or to have the puncture site determined by palpation of spinal landmarks. Primary outcomes were the number of needle insertion attempts and success of the procedure. Secondary outcomes were pain associated with the procedure, time to perform the procedure, number of traumatic taps, and patient satisfaction with the procedure. One-hundred patients were enrolled in the study, with 50 in each study group. There were no significant differences between the two groups in terms of age, sex, body mass index (BMI), indication for LP, or ease of palpation of landmarks. For both primary outcomes and secondary outcomes there were no significant differences between those undergoing US localization and those with palpation alone. These data do not suggest any advantage to the routine use of US localization for LP insertion, although further study may be warranted to look for benefit in the difficult to palpate or obese patient subgroups.

Accuracy of botulinum toxin type A injection into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist: manual needle placement evaluated using ultrasonography.

To investigate the accuracy of manual needle placement for injection of botulinum toxin type A into the forearm muscles of adults with spastic flexed wrist and clenched fist as a consequence of stroke. Prospective clinical study. A total of 41 adults with chronic stroke who were scheduled to receive botulinum toxin type A injection into the following forearm muscles: flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and flexor digitorum profundus. According to Huber & Heck's atlas suggestions on treatment of spasticity with botulinum toxin, surface identification of muscles to inject was performed by means of palpation and anatomical landmarks. Accuracy of needle placement and muscle thickness at the site of needle insertion were assessed using ultrasonography. Overall accuracy of manual needle placement evaluated using ultrasonography was 51.2%. Accuracy was significantly higher for the finger flexors than for the wrist flexors (63.4% vs 39.0%). The finger flexors were significantly thicker than the wrist flexors (mean 1.58 vs 0.49 cm). Instrumental guidance should be used in order to achieve an acceptable accuracy of needle placement when performing botulinum toxin type A injections into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist.

Development of an ultrasound image processing approach to enable automated needle localisation for epidural anesthesia

In this paper, ultrasound imaging is utilised to detect the anatomical structure of lumbar spine, in order to automatically search for a proper epidural needle insertion site. Induced by random speckle noise, ultrasound images are generally obscure and have low resolution, which decrease the readability of the image content. In order to improve the interpretability of ultrasound images, local normalisation modified with difference of Gaussian (DoG) algorithm is used for pre-processing. The pre-processing procedure successfully filters the noise and extracts the main anatomical structures; meanwhile it removes the local means induced by non-uniform wave reflection rate. Then, template matching algorithm, augmented with a position correlator, is utilised to automatically identify the features of interest. Based on the result of feature matching, proper needle insertion site will be identified automatically. The approach has been tested on more than 200 ultrasound images with a 100% success rate. The proposed system allows the anesthetist to use the approach efficiently without the burden of interpreting real time ultrasound images.

Real‐time length measurement of epidural Tuohy needle during insertion

This study presents a novel technique for the measurement of insertion depth of an epidural Tuohy needle in real-time. A wireless camera is used which transmits video images during insertion to a host computer. The computer contains the image processing algorithm to detect the visible needle in the image and measures the length. The measurement is done by HSV background removal, colour comparison and using RGB intensity profile to locate 10 mm markings on the Tuohy needle shaft. The visible length is then subtracted from the known length of the needle to calculate the depth of the needle tip. The camera can be placed in the operating theatre between 50 and 100 cm away from the needle insertion site. Wireless camera is beneficial since it minimises disturbance to the anaesthetist and the patient and avoids ethical and sterility concerns which would be caused by bringing additional equipment into the hospital room. The speed of the image processing technique is 10 frames per second with a maximum error of ±3 mm. The image processing failure rate was 3 frames out of 150 which gave an overall reliability of 97.8% during insertion. Also this enables continuous needle depth monitoring during insertion by storing measurements into a data file. The purpose of measuring needle depth in real time is to precisely place the needle in the epidural space.

Simplicity, skills, and pitfalls of ascending aortic cannulation for type A aortic dissection

BackgroundAscending aortic cannulation for an antegrade central perfusion during surgery for type A aortic dissection is simple and can be performed within median sternotomy. This cannulation is performed routinely without problems in our hospital. Using our experience, the skills and pitfalls were clarified to make this challenging procedure successful.Methods29 cases of ascending aortic cannulation using the Seldinger technique for insertion were studied. All insertions were performed with the guidance of transesophageal echocardiography alone. The cannulas were inserted after decompressing the aorta by initiating cardiopulmonary bypass with femoral artery cannulation. From our experience, the skills required for this procedure are the abilities to carefully assess the needle insertion site preoperatively, sense resistance to needle insertion twice, and ensure the guide wire is in the descending aorta and distal arch. The pitfalls are entrance of the guide wire into the false lumen and dilatation of the false lumen during the insertion procedure.ResultsThere were no complications associated with ascending aortic cannulation. Regarding morbidity, 2 cases of brain infarction occurred. There were 3 hospital deaths unrelated to the procedure.ConclusionsIn surgery for type A aortic dissection, ascending aortic cannulation using the Seldinger technique is simple to perform. We found that some practical skills and precautions were required to make this procedure successful.

Ultrasound Guidance Decreases Complications and Improves the Cost of Care Among Patients Undergoing Thoracentesis and Paracentesis

Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P &lt; .001) and LOS by 1.5 days (P &lt; .001). Bleeding complications increased cost by $19,066 (P &lt; .0001) and LOS by 4.3 days (P &lt; .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.

A novel and effective acupuncture modality as a complementary therapy to acute pain relief in inpatients with rib fractures.

Pain control has been emphasized as a priority for both practitioners and inpatients with rib fractures, since analgesia could only offer limited relief from severe pain. A prospective and randomized controlled trial was conducted to analyze the efficacy and efficiency of acupuncture in acute pain relief for inpatients with rib fractures. A total of 58 inpatients were recruited and allocated to two groups, receiving identical doses of conventional oral analgesics as well as filiform needles as treatment and thumbtack intradermal (TI) needles placed upon the skin surface as a control, respectively, via novel acupuncture modality once daily for three consecutive days. The effect of pain relief was evaluated during activities that induce pain, and sustained maximal inspiration (SMI) lung volumes and sleep quality were assessed. The patients treated with filiform needles had more effective pain relief than those in the TI needle group during deep breathing, coughing, and turning over the body (p < 0.05), and the effect persisted for at least 6 h in most patients. Sustained maximal inspiration lung volumes and sleep quality did not show improvement through every acupuncture intervention, and they could not respond accurately to pain relief via acupuncture. The active evaluation could provide a more adaptive model for assessing pain intensity due to rib fractures. This novel acupuncture modality in which the needle insertion sites are corresponding to the pain spots can be a safe and viable therapy for relieving pain in inpatients with rib fractures.

Revisiting the anatomy of the ilio‐inguinal/iliohypogastric nerve block

The ilio-inguinal/iliohypogastric nerve block (INB) is one of the most common peripheral nerve block techniques in pediatric anesthesia, which is largely due to the introduction of ultrasound (US) guidance. Despite the benefits of US guidance, the absence of an US machine should not deter the provider from performing INB, considering that many institutions, especially in developing countries, cannot afford to provide ultrasound machines in their anesthesiology departments. The aim of this study was to revisit the anatomical position of the ilio-inguinal and iliohypogastric nerves in relation to the anterior superior iliac spine (ASIS), in a large sample of neonatal cadavers, and compare the results with a similar group in a previously published US-guided study. With Ethics Committee approval, the ilio-inguinal and iliohypogastric nerves were carefully dissected in 54 neonatal cadavers. In the total sample, the ilio-inguinal nerve was found to be 2.2±1.2mm from the ASIS, on a line connecting the ASIS to the umbilicus. The iliohypogastric nerve was on average 3.8±1.3mm from the ASIS. For the entire sample, the optimal needle insertion site was 3.00mm from the ASIS. Although there is a strong correlation between the needle insertion point and the weight of the neonate, this will only 'fit' for 60% of the population. The linear regression formula; needle insertion distance (mm)=0.6×weight+1.8 can be used as a guideline for the position of the ilio-inguinal and iliohypogastric nerves.

Artifact-reduced simultaneous MRI of multiple rats with liver cancer using PROPELLER

To explore simultaneous magnetic resonance imaging (MRI) for multiple hepatoma-bearing rats in a single session suppressing motion- and flow-related artifacts to conduct preclinical cancer research efficiently. Our institutional Animal Experimental Committee approved this study. We acquired PROPELLER (periodically rotated overlapping parallel lines with enhanced reconstruction) T2 - and diffusion-weighted images of the liver in one healthy and 11 N1-S1 hepatoma-bearing rats in three sessions using a 3-T clinical scanner and dedicated multiarray coil. We compared tumor volumes on MR images and those on specimens, evaluated apparent diffusion coefficients (ADC) of the tumor, and compared them to previously reported values. Each MRI session took 39-50 minutes from anesthesia induction to the end of scans for four rats (10-13 minutes per rat). PROPELLER provided artifact-reduced T2 - and diffusion-weighted images of the rat livers. Tumor volumes on MR images ranged from 0.04-1.81 cm(3) and were highly correlated with those on specimens. The ADC was 1.57 ± 0.37 × 10(-3) mm(2) /s (average ± SD), comparable to previously reported values. PROPELLER allowed simultaneous acquisition of artifact-reduced T2 - and diffusion-weighted images of multiple hepatoma-bearing rats. This technique can promote high-throughput preclinical MR research for liver cancer.

"Severe Neurological Deficit" a Rare Complication Following Spinal Anesthesia

Severe neurological deficit following spinal anesthesia is an uncommon incident. Here we report a 24-year-old female who was given spinal anesthesia for lower segment caesarean section developed transient severe pain at the site of needle insertion radiating to right lower limb during the procedure followed by weakness predominantly involving the right lower limb and areflexia. Her magnetic resonance imaging of spine revealed signal intensity alteration in the spinal cord from 5th thoracic segment to the conus suggestive of extensive myelitis along with involvement of nerve roots following the procedure. doi: http://dx.doi.org/10.4021/jnr140w

A 45° Set Square Method for Accurate Needle Insertion in Ultrasound-guided Internal Jugular Venous Catheterization

Until now, there was no standardized method for insertion of introducer needle in ultrasound-guided internal jugular venous catheterization (IJVC). The needle insertion site and angle have been determined on the basis of the performer's experience. We designed a new standardized approach (called 45° set square method) that determines the site and the angle of needle insertion during ultrasound-guided IJVC to improve first-attempt success rate and reduce complications. The purpose of this study was to investigate the clinical usefulness of the novel 45° set square method for IJVC by ultrasound guidance in the Emergency Department (ED).

Percutaneous Endoscopic Cecostomy (PEC) Tube Placement: A Case Series

Purpose: Percutaneous cecostomy (PEC) placement has been used to treat recurrent colonic pseudobstruction, colonic atony or obstipation in children since it was first described in the 1980s. However, its role in the adult patient population for similar indications or palliation has yet to be defined. There have only been a few published case reports of successful PEC placement in adults. We report our experience with PEC placement in two adult patients at our institution with colonic atony and dilated colons (Figure A). Methods: With the patient in the supine position, a site was identified in the ascending colon with external transillumination and corresponding indentation on endoscopy in the right lower quandrant. The abdominal wall was marked and prepped in a sterile manner. After a local anesthetic (1% lidocaine) was injected a 22 Gauge needle was advanced under endoscopic visualization into the colon lumen followed by advancement of the trocar needle directly adjacent to the 22 Gauge needle. A snare was introduced through the endoscope and opened in the colonic lumen. The guide wire was passed through the trocar and into the open snare (Figure B). The snare was closed around the guide wire. The endoscope and snare were removed, pulling the wire out through the anus. A skin incision was made at the site of needle insertion. The externally removable Kimberly Clark 20 Fr gastrostomy tube was lubricated and tied to the guide wire and subsequently pulled through the anus and into the colon. The trocar needle was removed, and the colostomy tube was pulled out from the colon through the skin. The external bumper was attached to the colostomy tube, and the tube was cut to remove the guide wire. The final position of the cecostomy tube was confirmed endoscopically (Figure C) and subsequently with an abdominal X-ray (Figure D). The tube was capped and sutured into place externally with 2 vicryl 2.0 sutures, and the tube site was cleaned and dressed. Results: In the cases described above, a colonoscopy was performed without difficulty and successful PEC placement was achieved using the modified PEG pull technique with relative ease. Our patients did well post procedure with complete resolution of their symptoms and were discharged with no active issues secondary to PEC placement. This illustrates how PEC tube placement can be used to safely manage adult patients with colonic atony in day to day practice. Conclusion: PEC is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. Further study in a prospective fashion needs to be performed to further outline its clinical indications, therapeutic possibilities, and potential complications.

Intravitreal injections using a novel conjunctival mould: a comparison with a conventional technique

AimsThe aims were to compare a novel conjunctival mould used to assist the delivery of intravitreal drugs to a conventional technique with respect to patient, surgeon and cost benefit.MethodsA prospective...

310 Comparison of Ideal Needle Insertion Location for Internal Jugular Central Venous Access: Anatomic Landmarks versus Ultrasonography Guidance Method

Study Objectives: Ultrasonography-guided central venous access of the internal jugular vein is considered superior to landmark-guided line placement. The use of ultrasonography has resulted in fewer attempts at line placement, shorter time for line placement and fewer complications. Current practice almost excludes using the landmark approach, except for patients in extremis undergoing emergent line placement. Complications of central lines are not uncommon and can be significant. Preliminary studies have shown conflicting data regarding the utility of US-guided access when compared to the “blind” or landmark approach to access. We were interested in determining whether or not there is a significant difference in the ideal needle insertion sites for the 2 methods of line placement. Methods: Our aim was to measure the distance between landmark and ultrasonography-guided needle insertion sites for internal jugular central line placement in a convenience sample of patients in our Level II urban academic emergency department (ED). Actual central line placement was not required. A convenience sample of 45 patients seen in the emergency department at Christus Spohn Memorial Hospital and were enrolled in this study from June to August 2011. Eligible participants include ED patients between the ages of 18 and 65 who were medically stable and able to be placed in Trendelenburg position without risks or complications. A study investigator, using anatomic landmarks in accordance with standard practice, drew an × on the skin with an invisible marker representing the location where the needle would be placed. Next, the second investigator, blinded to the first investigator's placement location, used bedside ultrasonography to identify the most ideal location for anterior approach for initial needle puncture by placing an ink mark in the exact location the initial needle puncture would have been placed in an actual line placement. The invisible pen marks were then illuminated with a black light and the distance between the “invisible” × and the ink was measured. The second investigator then also made note of the anatomical relationship of the carotid artery as compared to the internal jugular vein as well as any other anatomic variations. Results: Of the 45 sampled patients, 45% were found to reflect “normal” anatomy where the internal jugular lies lateral as compared to the carotid artery, 0% demonstrated the carotid artery superficial to the internal jugular, 55% demonstrated the carotid artery immediately deep compared to the internal jugular, and finally 0% were found to have a carotid artery more lateral when compared to the internal jugular. Measurements taken were found to have a range from 2.0 mm to as much as 150.0 mm with an arithmetic mean of 23.2mm and a standard deviation of 23.9. Seven of the 45 (15.5%) samples fell within the 5mm margin while the other 38 (84.5%) were greater than the acceptable 5mm margin for ideal initial needle insertion. Test value of 5.1 with a 95% confidence interval (10.8 to 25.2) and a significance level of P<0.0001. Conclusion: Ultrasonography guidance continues to be proven as a safer, more reliable, and more accurate means of placing central lines. This study reinforces the benefits of direct visualization to recognize the structural arrangement of the anatomy of the neck specifically that of the carotid artery and internal jugular vein, as well as identifying the most desirable location for initial needle insertion.

43 The Usefulness of New Triangle Approach for Needle Insertion in Ultrasonography Guided Internal Jugular Venous Catheterization

Study Objectives: Catheterization of the internal jugular vein by ultrasonography guidance is an essential procedure in emergency department. Most performers have been usually catheterized by identifying catheter tip after determination of needle insertion site on the basis of their experiences. For decreasing the number of needle insertion trial, we mathematically designed new standardized approach (called triangle approach) which determines the site and the angle of a needle insertion during ultrasonography guided internal jugular venous catheterization.

In Response

The repetition of medical illustrations is not only a useful learning aid, but a common practice among many major medical texts. In fact, this practice was introduced nearly a century ago in one of the earliest regional anesthesia textbooks published in the United States.1 Each chapter of our textbook2 was specifically designed to function as a stand-alone chapter so that readers would not have to page back-and-forth to other sections of the atlas to view relevant images. Thus, although a limited number of images could have been eliminated, this would have significantly reduced the utility (and intent) of each chapter to provide a comprehensive overview of the anatomy, patient–provider orientation, needle insertion site, and technique for each individual block. Also, Dr. Liu3 is simply inaccurate with his claim that “nearly half” of the illustrations are repeated within the text. To be precise, the atlas contains 221 unique illustrations of which only 31 (14%) are repeated in the text without modification. Furthermore, many (if not most) of these repeated illustrations do not occupy an entire page of the atlas as suggested by Dr. Liu. In contrast to Dr. Liu's comments that the repetition of a limited number of anatomically useful illustrations is distracting, we believe quite firmly in the classic Latin teaching: “repetitio est mater studiorum”—repetition is the mother of all studies and learning. James R. Hebl, MD Robert L. Lennon, DO Adam K. Jacob, MD Hugh M. Smith, MD, PhD Department of Anesthesiology Mayo Clinic Rochester, MN [email protected]

Solid Pleural Lesions

T he pleural space is the cavity between the lungs and chest wall. It consists of a serous membrane, which folds back onto itself to form a two-layered structure. The inner visceral cover the lungs, blood vessels, bronchi, and nerves. The outer parietal pleura are attached to the chest wall. The pleural cavity normally contains up to 5 mL of pleural fluid. When assessing pleural lesions, one should consider morphologic criteria: whether the abnormality is solitary or multiple, unilateral or bilateral, calcified or noncalcified. The most common solid pleural lesions (Table 1) include benign, malignant, and borderline processes. The most common solid pleural lesion-mass is pleural thickening, which can be localized or diffuse, unilateral or bilateral, and calcified or noncalcified. Among pleural neoplasms, malignant tumors (particularly metastases) are more common than benign tumors. Metastases to the pleura develop from hematogenous spread of cancer cells through the bloodstream, lymphangitic spread, or direct contact by malignant neoplasms in the lung. Malignant lesions are accompanied by pleural effusion, which is often bloody. A pleural tap with removal of a small amount of fluid for histologic analysis can provide accurate diagnostic information, and drainage of large amounts of pleural fluid offers symptomatic relief (Table 2). Pleural effusion is probably the most common and clinically important secondary finding caused by pleural lesions. They may be unilateral or bilateral depending on the underlying cause. Histologically, pleural effusion can represent either exudate or transudate. Transudative effusions, often caused by chronic heart failure, uremia, or hypoalbuminemia due to an imbalance of hydrostatic and oncotic forces, are characterized by their low protein content and specific gravity. In contrast, exudates are frequently caused by infection, infarction, or malignancy and have high levels of protein and lactate dehydrogenase and elevated specific gravity. Chest radiography does not permit the differentiation between exudate and transudate. Even when using attenuation measurements, the ability of CT to make this distinction is limited. Consequently, pleural tapping is often required to establish a final diagnosis. Transthoracic ultrasound may be of value in determining the appropriate site of needle insertion.

SI joint injection - a novel approach

As one of several differential diagnoses for chronic low back or lower extremity pain, sacroiliac (SI) joint dysfunction can involve a biochemical abnormality (e.g., infectious, inflammatory, metabolic) and/or mechanical disturbance (e.g., degenerative joint disease, trauma) of the joint. A common treatment modality is intra-articular sacroiliac joint injection of local anesthetic and/or corticosteroid under fluoroscopic, ultrasound or computed tomographic guidance. The standard fluoroscopic guided method for this injection involves insertion of a single needle into the posteroinferior aspect of the joint space, which localizes the drug into the synovial portion of the joint. However, as several studies have demonstrated, SI joint dysfunction can often involve not only the intra-articular space, but also the SI joint capsule and/or surrounding ligaments. In this paper, we describe a modified technique to the traditional SI joint injection method, which calls for two separate points of needle insertion under fluoroscopic guidance: the commonly performed injection into the posteroinferior intra-articular space and an additional injection into the joint capsule just medial to the posterosuperior margin of the SI joint. Our technique is a combination of the traditional fluoro-guided inferior intra-articular joint injection and the ultrasound-guided technique which targets the superior posterior aspect of the joint, performed simultaneously under fluoroscopy. Specifically, the site of needle insertion superiorly in our two- needle technique is just medial to the superior aspect of the joint at the level of the first posterior sacral foramen (S1). Both needles can be inserted at the same angle of fluoroscopy, not requiring any additional fluoroscopic adjustments compared to the standard technique. We believe this dual injection of the SI joint is easy to perform and can notably additionally decrease the degree of pain by targeting injury pathology in the intra-articular space and the surrounding joint capsule.

The management of malignant ascites in Palliative care: An audit of clinical practice and development of standards and guidelines

BackgroundMalignancy is the underlying cause in approximately 10% of all cases of ascites. About 15–50% of patients with malignancy will develop ascites. Cancers commonly associated with the development of ascites...