Tag Archives: ultrasound-guided

Threading the Needle at UltraCon

Posted on by
Reply

Ultrasound has many advantages when used for interventional procedures such as improved visualization of the anatomy in relation to the needle tip. But acquiring the skills to perform ultrasound‐guided procedures takes time and practice.

And that is why the AIUM has devoted a full-day symposium called “Threading the Needle” to this topic on March 27, 2023, at UltraCon. The symposium provides a comprehensive overview of ultrasound-guided procedures, including:

Instrumentation
The needles and associated instrumentation commonly used in ultrasound-guided procedures will be shared. Important features and variations in equipment will be introduced for all specialties.

Teaching Tools
How do you teach others at your institution to perform procedures? The facilitator will provide an overview of best practices with specific examples.

Skills Station
Needle guidance principles will be taught for clinical applications such as IV access, target practice, and more utilizing hands-on models and cutting-edge technologies.

Safety
What are the important safety considerations when performing ultrasound-guided procedures?

Threading the Needle is just one of eight in-depth symposia featured at UltraCon 2023. Check out the Full Schedule to get a sneak peek at everything you could learn.

Another helpful resource about these procedures is the AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures.

Therese Copper, BS, RDMS, is the Director of Accreditation, and Mark Macoit is the Marketing Manager at the American Institute of Ultrasound in Medicine (AIUM).

Ultrasound-Guided Obstetric and Gynecologic Procedures in the Pelvis

Posted on by
Reply

Ultrasound guidance can be a safe and effective technique in obstetric and gynecologic procedures. Before beginning such a procedure, consider which approach will you take, transabdominal, transgluteal, or transvaginal. The approach that uses the shortest distance to the area of interest without transversing other structures is usually the best tolerated by the patient and will rarely result in complications, which are uncommon and usually minor, such as pain or self-limited bleeding. To select the shortest and safest path for access, review prior cross-sectional imaging and determine it on a case-by-case basis.

In cases of fluid management, such as benign adnexal cyst or peritoneal inclusion cyst fluid collection, note that you may need a larger needle gauge (18+) in those instances in which the fluid is thick. If you intend to test for malignancy, also take into account that fluid is generally less likely than solid tissue to give up the cells needed for a diagnosis.

Fine-needle aspiration in a case with mixed cyst and solid mass.

Ultrasound guidance can also enable delivery of vascular acting medications directly where it is needed, as well as to guide direct gestation sac injection of potassium chloride (KCl) and/or methotrexate for cervical, interstitial, or C-section ectopic or heterotopic pregnancies in appropriate patients.

In conclusion, transvaginal or percutaneous ultrasound guidance can be used in the search for a diagnosis, in fluid collections, and to treat obstetric and gynecologic pathology, such as delivering medications to treat ectopic pregnancy or vascular conditions in select cases.

To learn more about this topic and see examples of its use, watch the full on-demand webinar, “Ultrasound-Guided Interventions to Treat Obstetric and Gynecologic Disease” presented by Tara A. Morgan, MD. Members of the American Institute of Ultrasound in Medicine can access it for free. Join today!

Read more from Tara A. Morgan, MD, on ultrasound guidance in the Journal of Ultrasound in Medicine:

Ultrasound in Central Vein Assessment – The Importance of Knowing

Posted on by
2

Thorough vascular assessment prior to any intravascular device insertion is of paramount importance – for both clinician and patient. It guides the clinician to evaluate the current state of vessel health, determining suitability of the veins, and to follow a pre-determined pathway that will lead to the best decision for the patient. The assessment phase alone in vascular access procedures highlights a number of important underlying anatomical structures, as there are frequently variances amongst many patient groups and it provides a platform to perform a thorough assessment of the vascular structures to evaluate vessel health, viability, size, and patency, including the location of other important and best-avoided anatomical structures – prior to performing any procedures. The success in complication-reduction alone drives the importance of patient safety and improved patient- and device-related outcomes, not to mention patient satisfaction and comfort.

Its use for assisting the proceduralist are many:

  • pre-procedural ultrasound assessment of the vascular anatomy provides a rational choice of the venous access most likely to be associated with an optimal clinical outcome;
  • real-time, ultrasound-guided puncture and cannulation of the vein reduces the risk of failure and/or damage to the surrounding structures;
  • ultrasound scan after the venipuncture allows an early/immediate detection of puncture-related complications such as pneumothorax or local hematoma;
  • ultrasound-based tip navigation verifies the proper direction of the guidewire and/or the catheter during its progression into the vasculature;
  • transthoracic echocardiography allows proper ultrasound-based tip location;
  • ultrasound is also useful for detection of late complications such as catheter-related venous thrombosis, tip migration, or fibroblastic sleeve.

A simple yet systematic approach to vessel assessment is the RaCeVA (Rapid Central Vein Assessment), a process manifested as a quick and highly effective process for performing vessel assessment in a compelling and methodical approach. It allows a systematic approach to exclude venous abnormalities such as thrombosis, stenosis, external compression, and anatomical variations of size and shapes; it also allows a full anatomic evaluation for optimum site selection and the best insertion approach for the patient. It also has many advantages: it takes only 30–40 seconds for each side, it is easy to teach, easy to learn, and it is a useful guide for a rational choice of the central vein to be accessed, in terms of patient safety and cost-effectiveness, since it helps the operator to choose the most favorable puncture site and the optimal insertion site, with an overall improvement of the clinical outcomes and patient satisfaction.

RaCeVA - table

The RaCeVA Steps

Important considerations include the following:

  1. size of the vein (internal diameter/caliber)
  2. depth of the vein (depth of target vessel from skin surface)
  3. respiratory variations (influence of respiratory cycle on vein diameter)
  4. compression by artery (influence of arterial pulsation on vein diameter)
  5. proximity to non-venous structures that must not be damaged (pleura, nerve, artery)
  6. exit site location – convenience/appropriateness in terms for best care and maintenance

Image 1

Overview of RaCeVA steps highlighting ultrasound transducer scanning points – courtesy of the author.

Utilization of the RaCeVA protocol throughout both pre- and post- device insertion stages offers multiple advantages: “before” (to define the anatomy and the best target vessel), “during” (with real-time techniques of ultrasound-guided venipuncture: short-axis in-plane, short-axis out-of-plane, long-axis in-plane), and “after” cannulation (to detect or rule out complications such as pneumothorax, malpositions, local hematoma).

 

As a tool, RaCeVA is designed (a) to teach the different ultrasound-guided approaches to the central veins, (b) to help the operator to scan systematically all possible venous options, and (c) to guide the operator in choosing the most appropriate vein to be accessed, on a rational and well-informed basis. Optimal training is mandatory, through formal programs and hands-on sessions that imply using vascular simulation phantoms – the latter being especially important for practitioners to perform repeated ultrasound-guided vascular cannulations without posing serious risks for patients and ultimately successfully transferring this practice to patients.

 

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

Connect_digital_graphics_E-NEWSLETTER

Timothy R. Spencer, RN, DipAppSc, BHSc, ICCert, APRN, VA-BC™, is Director of Global Vascular Access, LLC, in Scottsdale, Arizona.

 

Ultrasound-Guided Musculoskeletal Injections

Posted on by
2

I began using Musculoskeletal (MSK) ultrasound (US) in 2010. It has been incredibly exciting to observe the growth of applications of this amazing technology for both myself personally as well as for the entire MSK US practicing community. MSK US has become an integral part of my Sports Medicine practice and I certainly anticipate its’ role to continue to expand and be able to provide cutting-edge medical care to my patients.IMG_8265

There is great variability with which MSK US is used among practitioners. Some providers do complete diagnostic scans of the shoulder, for example, to evaluate the extent of a potential rotator cuff tear to guide with potential surgical decision making, while others perform selective nerve blocks and finally, some practitioners simply use it to assist with the accuracy of various MSK joint and soft tissue injections. I would like to illustrate to all of you the applications for which I most commonly use MSK US to improve patient care.

Probably the most common application for which I use MSK US is to assist with the accuracy of joint and soft tissue injections. It has been clearly documented that MSK US improves the accuracy of certain MSK injections. While I do not use MSK US for all injections, ie, simple knee intra-articular and shoulder sub-acromial injection, I routinely employ MSK US to assist with certain injections. Common joints and soft tissue areas for which I employ MSK US for either cortisone or pro-inflammatory injections like Platelet Rich Plasma (PRP) are:

Shoulder: Glenohumeral and acromioclavicular joint and long head biceps tendon sheath

Hip: Femoroacetabular, hamstring origin (tendon or bursa), mid-portion hamstring, pubic symphysis, gluteal tendons and bursa, iliopsoas bursa and tendon

Knee: Pes anserine and iliotibial bursae, patella and quadriceps tendons, Baker’s cyst aspiration

Wrist: Triangular fibro cartilage complex (TFCC), various wrist extensor and flexor tendons, aspirate ganglion cysts, numerous hand and wrist joints

Elbow: Lateral and medial epicondyle area, triceps insertion, olecranon bursitis, distal biceps and intra articular

Ankle: Achilles, tibialis posterior, peroneal tendons, numerous foot and ankle joints, plantar fascia

Back: Sacroiliac joint

I would also like to illustrate some interesting recent cases supporting the utility of MSK US in a Sports Medicine practice.

I am consulted numerous times a week by my orthopedic surgeon colleagues for diagnostic joint injections. Oftentimes, a patient’s hip pain may be multifactorial or difficult to specifically isolate. I will perform an intra-articular injection to see if it alleviates that patient’s pain, thus identifying that the area in which I placed the injection as the pain generating location. Correct identification of the pain generating source will help to assist with treatment considerations.

I also recently had a patient with greater than 1 year of hip pain. He had seen 8 different providers and had an extensive workup with imaging and injections only to have continued pain. He had hip joint and hamstring origin injections and felt no improvement. I was able to use the US to identify and isolate the obturator internus as the source of his pain by providing a diagnostic injection. This injection helped to make the appropriate diagnosis and ultimately influenced treatment.

Last month, an orthopedic surgeon asked me to evaluate a patient for refractory symptoms from a Baker’s cyst. The cyst persisted despite multiple intra articular-injections. I evaluated the cyst with US and noted that it was multilobulated. I was able to specifically aspirate each of the loculations and the patient has remained symptom-free.

I was also asked to see one of our varsity basketball players for refractory lateral knee pain. His athletic trainer was treating him with rehabilitation and multiple modalities but the pain persisted and was affecting the athletes’ ability to play. I was able to identify an inflamed Iliotibial band bursa with the US and subsequently inject it. He became pain-free and was able to play in that weeks’ game as well as the rest of the season.

Another exciting application of MSK US that has piqued my interest recently is the use of the US to assist with appropriately identifying the compartments of the lower extremity for chronic exertional compartment testing. I can employ the US to guarantee that I am in the appropriate anatomic compartment for testing.

With any new technology, the application and utility of MSK US can be user-dependent and it can be affected by a somewhat steep learning curve. MSK US curriculums are frequently being added to Sports Medicine fellowships to train some of the future leaders of medicine. I certainly anticipate that this technology with continue to evolve and its’ treatment applications will continue to expand.

How do you use MSK US? How has it improved your practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Bryant Walrod, MD, CAQSM, is Assistant Professor: Clinical at Ohio State University, is Team Physician for the Ohio State Athletics, and practices at The Ohio State University Wexner Medical Center.

Greater Trochanteric Pain Syndrome

Posted on by
Reply

In a study funded in part by AIUM’s Endowment for Education and Research, Jon Jacobson, MD, and his team from the University of Michigan set out to determine the effectiveness of percutaneous tendon eer_logo_textsidefor treatment of gluteal tendinosis. The full results of this study were recently published in the Journal of Ultrasound in Medicine.

Greater trochanteric pain syndrome is a condition that most commonly affects middle-aged and elderly women but can also affect younger, and more active, individuals. It has been shown that the underlying etiology for greater trochanteric pain syndrome is most commonly tendinosis or a tendon tear of the gluteus medius, gluteus minimus, or both at the greater trochanter and that tendon inflammation (or tendinitis) is not a major feature. This condition can be quite debilitating and often does not respond to conservative management.

Treatment of greater trochanteric pain syndrome should therefore include treatment of the underlying tendon condition. Ultrasound-guided percutaneous needle fenestration (or tenotomy) has been used to effectively treat underlying tendinosis and tendon tears, including tendons about the hip and pelvis. Similarly, autologous platelet-rich plasma (PRP), often combined with tendon fenestration, has been used throughout the body to treat tendinosis and tendon tears.

Although studies have shown patient improvement with PRP treatment, the true effectiveness of this treatment compared to other treatments remains uncertain. Although percutaneous ultrasound-guided tendon fenestration has been shown to be effective about the hip and pelvis, there are no data describing the use of PRP for treatment of gluteal tendons, and there is no study comparing the effectiveness of each treatment for gluteal tendinopathy. The purpose of this blinded prospective clinical trial was to compare ultrasound-guided tendon fenestration and PRP for treatment of gluteus tendinosis or partial-thickness tears in greater trochanteric pain syndrome.

We designed a study in which patients with symptoms of greater trochanteric pain syndrome and ultrasound findings of gluteal tendinosis or a partial tear (<50% depth) were blinded and treated with ultrasound-guided fenestration or autologous PRP injection of the abnormal tendon. Pain scores were recorded at baseline, week 1, and week 2 after treatment. Retrospective clinic record review assessed patient symptoms.

To break this down a little further, the study group consisted of 30 patients (24 female), of whom 50% were treated with fenestration and 50% were treated with PRP. The gluteus medius was treated in 73% and 67% in the fenestration and PRP groups, respectively. Tendinosis was present in all patients. In the fenestration group, mean pain scores were 32.4 at baseline, 16.8 at time point 1, and 15.2 at time point 2. In the PRP group, mean pain scores were 31.4 at baseline, 25.5 at time point 1, and 19.4 at time point 2. Retrospective follow-up showed significant pain score improvement from baseline to time points 1 and 2 (P < .0001) but no difference between treatment groups (P = .1623). There was 71% and 79% improvement at 92 days (mean) in the fenestration and PRP groups, respectively, with no significant difference between the treatments (P >.99).

These results led us to conclude that both ultrasound-guided tendon fenestration and PRP injection are effective for treatment of gluteal tendinosis, showing symptom improvement in both treatment groups.

What is your experience with treating greater trochanteric pain syndrome? Are you familiar with the Endowment for Education and Research?  Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Jon A. Jacobson, MD, is Professor of Radiology, Director of the Division of Musculoskeletal Radiology, Assistant Medical Director of Northville Health Center, and Medical Director of Taubman Radiology within the University of Michigan Health System.