Nerve blocks at the wrist for painful injections of the palm.

PURPOSE: Injections into the palmar hand for trigger finger, palmar flexor tenosynovitis, and Dupuytren contracture can be very painful. This randomized, controlled study evaluated nerve block anesthesia at the wrist for prevention of procedural pain associated with painful injection of the palmar hand. METHODS: Forty-seven corticosteroid injections for trigger fingers in 19 individuals were randomized to (1) anesthesia consisting of median and ulnar nerve block with 1% lidocaine anesthesia followed by standard injection or (2) standard injection alone using the 1-needle 2-syringe technique consisting of transthecal dilation of the synovial sheath with 0.5 mL 1% lidocaine with a mechanical syringe, the reciprocating procedure device, followed by injection with 20 mg triamcinolone acetonide. Baseline pain, needle insertion/sheath dilation pain, corticosteroid injection pain, resolution of trigger finger, and pain at outcome (2 weeks) were determined. RESULTS: Standard injection for trigger finger was associated with significant pain in 100% of subjects. Nerve blocks at the wrist provided effective anesthesia, resulting in a 56% reduction in injection pain compared with direct injection (P < 0.01). There was 100% resolution of trigger finger in both treatment groups. Pain at the 2-week outcome, reduction in pain from baseline, responders, and nonresponders were not statistically different (P > 0.3 for all). Eighty-eight percent of subjects preferred nerve block anesthesia to direct injection (P < 0.0001). CONCLUSIONS: Nerve block anesthesia at the wrist before palmar injection is preferred by patients and is highly effective in preventing pain associated with injection of the palmar hand for trigger finger and other painful hand procedures.

Syringe and needle size, syringe type, vacuum generation, and needle control in aspiration procedures.

PURPOSE: Syringes are used for diagnostic fluid aspiration and fine-needle aspiration biopsy in interventional procedures. We determined the benefits, disadvantages, and patient safety implications of syringe and needle size on vacuum generation, hand force requirements, biopsy/fluid yield, and needle control during aspiration procedures. MATERIALS AND METHODS: Different sizes (1, 3, 5, 10, and 20 ml) of the conventional syringe and aspirating mechanical safety syringe, the reciprocating procedure device, were studied. Twenty operators performed aspiration procedures with the following outcomes measured: (1) vacuum (torr), (2) time to vacuum (s), (3) hand force to generate vacuum (torr-cm2), (4) operator difficulty during aspiration, (5) biopsy yield (mg), and (6) operator control of the needle tip position (mm). RESULTS: Vacuum increased tissue biopsy yield at all needle diameters (P<0.002). Twenty-milliliter syringes achieved a vacuum of -517 torr but required far more strength to aspirate, and resulted in significant loss of needle control (P<0.002). The 10-ml syringe generated only 15% less vacuum (-435 torr) than the 20-ml device and required much less hand strength. The mechanical syringe generated identical vacuum at all syringe sizes with less hand force (P<0.002) and provided significantly enhanced needle control (P<0.002). CONCLUSIONS: To optimize patient safety and control of the needle, and to maximize fluid and tissue yield during aspiration procedures, a two-handed technique and the smallest syringe size adequate for the procedure should be used. If precise needle control or one-handed operation is required, a mechanical safety syringe should be considered.

Does sonographic needle guidance affect the clinical outcome of intraarticular injections?

OBJECTIVE: This randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular (IA) joint injections. METHODS: In total, 148 painful joints were randomized to IA triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating device). A one-needle, 2-syringe technique was used, where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the IA space with lidocaine. After IA placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks), and changes in pain scores were measured with a 0-10 cm visual analog pain scale (VAS). RESULTS: Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p < 0.001), 58.5% reduction in absolute pain scores at the 2 week outcome (p < 0.001), 75% reduction in significant pain (VAS pain score > or = 5 cm; p < 0.001), 25.6% increase in the responder rate (reduction in VAS score > or = 50% from baseline; p < 0.01), and 62.0% reduction in the nonresponder rate (reduction in VAS score < 50% from baseline; p < 0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%. CONCLUSION: Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinically significant manner.

Syringe size: does it matter in physician-performed procedures?

PURPOSE: We hypothesized that the size of syringe influenced needle control in physician-performed procedures. MATERIALS AND METHODS: Operators were tested for their ability to control a 1-, 3-, 5-, 10-, and 20-mL syringe and equivalent sizes of the new safety device, the reciprocating procedure device (RPD), using the quantitative needle-based displacement method. Three hundred twenty clinical syringe procedures were then randomized to either a 3- or 10-mL conventional syringe or to a 3- or 10-mL RPD. Patient pain was measured with the Visual Analog Pain Scale (VAPS). RESULTS: Increasing syringe size was associated with the undesirable characteristic of unintended forward penetration (loss of control of the needle in the forward direction) (r(2) = 0.97, slope = 2.14, 95% CI: 1.54-2.76, P < 0.002), and unintended retraction (loss of control of the needle in the reverse direction) (r(2) = 0.97, slope 2.15, 95% CI: 1.54-2.76, P < 0.002). In addition, 2-handed operation of a syringe resulted in greater control than 1-handed operation of a syringe (P < 0.001). When 1-handed operation was required, the RPD control syringe reduced unintended penetration by 52.3% (P >or= 0.001), unintended retraction by 56.8% (P >or= 0.001), and patient pain by 54.7% (P >or= 0.001) at each device size. CONCLUSIONS: For greater safety and control when operating the conventional syringe, smaller syringe sizes and 2 hands instead of 1 hand should be used whenever possible. If 1-handed operation of a syringe is necessary, a safety technology like the RPD control syringe should be used.

Integration of safety technologies into rheumatology and orthopedics practices: a randomized, controlled trial.

OBJECTIVE: To identify and integrate new safety technologies into outpatient musculoskeletal procedures and measure the effect on outcome, including pain. METHODS: Using national resources for patient safety and literature review, the following safety technologies were identified: a safety needle to reduce inadvertent needlesticks to heath care workers, and the reciprocating procedure device (RPD) to improve patient safety and reduce pain. Five hundred sixty-six musculoskeletal procedures involving syringes and needles were randomized to either an RPD group or a conventional syringe group, and pain, quality, safety, and physician acceptance were measured. RESULTS: During 566 procedures, no accidental needlesticks occurred with safety needles. Use of the RPD resulted in a 35.4% reduction (95% confidence interval [95% CI] 24-46%) in patient-assessed pain (mean +/- SD scores on a visual analog pain scale [VAPS] 3.12 +/- 2.23 for the RPD and 4.83 +/- 3.22 for the conventional syringe; P < 0.001) and a 49.5% reduction (95% CI 34-64%) in patient-assessed significant pain (VAPS score > or =5) (P < 0.001). Physician acceptance of the RPD combined with a safety needle was excellent. CONCLUSION: As mandated by the Joint Commission and the Occupational Safety and Health Administration, safety technologies and the use of pain scales can be successfully integrated into rheumatologic and orthopedic procedures. The combination of a safety needle to reduce needlestick injuries to health care workers and the RPD to improve safety and outcome of patients is effective and well accepted by physicians.

Patient pain and tissue trauma during syringe procedures: a randomized controlled trial.

OBJECTIVE: To investigate the relationship of needle control to tissue trauma and hemorrhage during syringe procedures. METHODS: Forty-seven subjects with a palpable knee effusion underwent needle and syringe aspiration. Subjects were randomized to the conventional syringe or a safety technology, the reciprocating procedure device (RPD). This trial was registered at clinicaltrials.gov. Pain was measured with the Visual Analog Pain Scale (VAPS). Cell count, crystal examination, culture, and aspirated fluid volume were determined. Red blood cell (RBC) counts were used to measure blood in aspirated fluid. RESULTS: Patient pain during the syringe procedure significantly predicted blood (RBC) in aspirated fluid (r = 0. 53, p = 0.001). When compared to the conventional syringe, the RPD safety device reduced blood in aspirated fluid by 66.7% (RBC, 10(3)/ml: RPD 8.9 +/- 11.4; syringe 26.7 +/- 90.2; p 0.01), reduced patient pain by 73.9% (VAPS: RPD 1.68 +/- 2.34; syringe 6.44 +/- 2.86; p < 0.01), and improved fluid aspirate yield by 132% (aspirate volume: RPD 20.9 +/- 19.7 ml; syringe 9.00 +/- 6.58 ml; p < 0.01). CONCLUSION: Inadequate control of needle and syringe during physician-performed syringe procedures is an important cause of trauma to patient tissues resulting in hemorrhage, increased patient pain, and decreased aspirate yield. The RPD -- a safety device that improves needle control and decreases needle trauma to tissues -- reduces hemorrhage and improves the safety, outcome, and aspirate yield of physician-performed syringe procedures.

Physician control of needle and syringe during aspiration-injection procedures with the new reciprocating syringe.

OBJECTIVE: To evaluate physician control of needle and syringe during aspiration-injection syringe procedures by comparing the new reciprocating procedure syringe to a traditional conventional syringe. METHODS: Twenty-six physicians were tested for their individual ability to control the reciprocating and conventional syringes in typical aspiration-injection procedures using a novel quantitative needle-based displacement procedure model. Subsequently, the physicians performed 48 clinical aspiration-injection (arthrocentesis) procedures on 32 subjects randomized to the reciprocating or conventional syringes. Clinical outcomes included procedure time, patient pain, and operator satisfaction. Multivariate modeling methods were used to determine the experimental variables in the syringe control model most predictive of clinical outcome measures. RESULTS: In the model system, the reciprocating syringe significantly improved physician control of the syringe and needle, with a 66% reduction in unintended forward penetration (p < 0.001) and a 68% reduction in unintended retraction (p < 0.001). In clinical arthrocentesis, improvements were also noted: 30% reduction in procedure time (p < 0.03), 57% reduction in patient pain (p < 0.001), and a 79% increase in physician satisfaction (p < 0.001). The variables in the experimental system--unintended forward penetration, unintended retraction, and operator satisfaction--independently predicted the outcomes of procedure time, patient pain, and physician satisfaction in the clinical study (p < or = 0.001). CONCLUSION: The reciprocating syringe reduces procedure time and patient pain and improves operator satisfaction with the procedure syringe. The reciprocating syringe improves physician performance in both the validated quantitative needle-based displacement model and in real aspiration-injection syringe procedures, including arthrocentesis.