Dr. Thomas Cornwell, Executive Chairman of the Home Center Care Institute. Today I will demonstrate how to aspirate and inject the knee joint. Please note that I am not wearing PPE for this video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective equipment during your visit. This of course applies to the current COVID-19 pandemic. You'll want to first gather your equipment and supplies for the procedure as listed in the course materials. I will now walk you through the procedure step-by-step. Before starting, counsel the patient and caregivers on the risks and benefits of the procedure. A consistent and thorough way of doing this is by having the patient read HCCI's pre- and post-steroid injection instructions or by going over it with them. This useful HCCI patient resource describes the procedure, the risks and the benefits, the contraindications, and the post-procedure instructions. It can also serve as the written consent by having the patient sign it. Verbal or written patient consent needs to be documented in the medical record. A patient safety check should be done prior to any procedure to verify patient identity, the correct injection point, and the medication being used. I always have someone verify any injection I give, whether it be a steroid shot or a flu shot. This is often done by my medical assistant, but if alone, I will have the patient or caregiver read the label to verify. Now let's wash our hands and get started. Injections can be given lateral or medial and superior, mid patella with the leg straight, or inferior with the knee bent at a 90 degree angle. We are going to demonstrate the most commonly used superolateral approach. It is preferred because, as you can see in the diagram, it provides easy access under the quadriceps tendon and patella. It is good for both aspiration and injection, and there are no other structures in the area to be concerned about. For the superolateral approach, the patient should be in the supine position with the knee in a slightly flexed position at about 15 degrees. You can use a roll-up towel under the knee and cover with a disposable under pad to prevent stains. After putting your gloves on, mark the injection site one centimeter above and one centimeter lateral to the patella. You can do this by imprinting the pen in the area. Clean the injection site with three povidine iodine or chlorhexidine swabs, applying each swab in a circular manner, starting at the injection site and circling out. Wait a minimum of two minutes. Wipe the medication vials, diaphragms with alcohol. Drop a syringe of corticosteroid and four to six mLs of an anesthetic agent. If local anesthetic is desired, you can apply three to four mLs of an anesthetic agent to the injection site and along the anticipated needle trajectory. Alternatively, ethyl chloride spray can be applied from six inches away for five to six seconds. For aspiration, use a 10 mL empty syringe with an 18 or 20 gauge 1.5 inch needle. A 20 or 30 mL syringe can be used for larger effusions. Insert the needle, bevel up at a 45 degree angle distally and inferiorly under the patella and aspirate effusion if present. Compression of the opposite side of the joint may aid arthrocentesis. Once the syringe is filled, a hemostat can be placed on the hub of the needle to disconnect the aspiration syringe, then connect the corticosteroid syringe and inject into the synovial space. If no effusion is present that needs aspiration, the corticosteroid-filled syringe with a 25 gauge 1.5 inch needle using the same technique can be done. When the aspiration injection is complete, withdraw the needle and apply pressure to the site with a 2x2 gauze. Clean the prep area with alcohol wipes and cover the site with an adhesive bandage. I now have my fluid in here. You have to check with your lab. You have to check with your lab, but you want to send the fluid for gram stain and culture, RBC and WBC and differential and for crystals. You need to check with your lab which tubes they like. They usually want a sodium heparin green or a lavender tube for doing the test. And you can use either a urine cup for the gram stain and culture or you can actually just send them the syringe without the needle on it. Depending on the cause of the knee pain, the local anesthetic should provide immediate pain relief, which confirms the steroid was placed in the correct area. Prior to performing a knee aspiration or injection, you need to determine if there are any contraindications. Contraindications include infections such as bacteremia, if a septic effusion is suspected, overlying cellulitis or osteomyelitis. A severe coagulopathy is a contraindication, but being on warfarin with a therapeutic INR is not a contraindication. Injections also appear to be safe for patients taking direct acting oral anticoagulants. A retrospective study of 1,050 joint injections at Mayo Clinic with patients on direct acting oral anticoagulants did not have one bleeding complication. Other contraindications include having an osteochondral fracture, impending joint replacement surgery scheduled within days, a prosthetic joint, or poorly controlled diabetes. Patients should also not have more than three injections per year. Potential complications include rare iatrogenic infections occurring in only 1 in 14 to 77,000 injections. Hyperglycemia can occur especially with patients on insulin and patients should be told to monitor their sugars closely for one week. Steroid flare occurs in 2 to 10% of injections and affects women more than men. It is caused by a steroid crystal-induced inflammatory synovitis. To treat, the patient can apply ice for 15 minutes every 3 to 4 hours and take acetaminophen or ibuprofen for pain. The steroid flare typically resolves within 1 to 2 days. Patients should call if not better in 2 days. Finally, facial flushing has been reported in 1 to 30% of patients. One of the things that I really like about this model is the needle is connected to a box here so that when I go in it tells me, and this way I can have you do it 10, 20, 30 times if you'd like so that you really know when you're in the right spot so then you feel comfortable when you actually do it on your first patient. I hope your participation in this video simulation will help you gain confidence on how to safely perform a knee aspiration and injection in the home. When the injection is successful at reducing pain, not only does it improve quality of life, it also helps the patient be more functional while also improving the quality of life of the patient. at reducing pain, not only does it improve quality of life, it also helps the patient be more functional while also being a blessing for the caregivers. Thank you for watching.

knee joint

aspiration

injection

infection control guidelines

personal protective equipment