Arthrocentesis

INDICATIONS:

Diagnosis of septic joint or crystal-induced arthritis
Differentiation of traumatic effusion (blood in the joint) from inflammatory process
Diagnosis of intra-articular fracture (blood with fat globules in the joint)
Pain relief from acute hemarthrosis or tense effusion
Local instillation of medications (anti-inflammatory or local anesthetics)

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ABSOLUTE CONTRAINDICATIONS:

Infection in tissue overlying puncture site


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RELATIVE CONTRAINDICAIONS:

Bacteremia
Bleeding diatheses
Joint prosthesis


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MATERIALS:

Skin preparation solution (povidone-iodine and alcohol)
Sterile gloves and drapes
Local anesthetic
Syringes (2mL, 10mL, and 20mL)
Needles (18, 20, 22 and 25ga)
Sterile saline
Sterile gauze dressings
Hemostat
3-way stopcock
sterile basin, cup, and/or test tubes
green-top tube with liquid anticoagulant (to evaluate for crystals)
microscope slides and coverslips
culture media (if looking for infection)

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PRE-PROCEDURE PATIENT EDUCATION:

Explain indications for procedure, technique, and possible complications. Obtain written consent when appropriate. Answer any questions the patient may have.


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PROCEDURE/TECHNIQUE:

Carefully palpate joint to be aspirated to identify all landmarks

Select puncture site and approach to joint, taking care to avoid tendons, major vessels and nerves

Use only sterile equipment and ensure proper sterile technique

Thoroughly scrub the skin with a surgical scrub and then apply/paint on an antiseptic solution (Betadine) several times, allowing it to dry between applications

Remove betadine with alcohol to prevent transference of betadine into the joint space

Change gloves after skin prep.

Apply sterile towels/drape

Infiltrate skin with local anesthetic using 22 or 25 ga needle
Identify landmarks

Attach needle (18-22ga) to syringe and insert at desired landmark through the skin and subcutaneous tissue into the joint space.

Try not to bounce the needle off of the bony structures as a means of locating the joint to avoid damaging articular cartilage.

Use a larger syringe for larger joints and larger effusions
Consider using a 3-way stopcock to help to drain large effusions. This will help you to avoid having to change the syringe, which can cause the needle to move or become dislodged after you have already entered the joint space.

If the syringe must be changed during the procedure, grasp the needle hub with a hemostat and hold it tightly while the syringe is changed.

Intra-articular placement is confirmed by easy aspiration of synovial fluid (and/or blood, joint space contents)

Try to remove all joint space contents/fluid

If the fluid stops flowing, the joint space has been drained, or the needle tip has moved/become dislodged, or there is debris or clot obstructing the tip.

If you suspect the needle has moved, slightly advance or retract the needle, rotate the bevel, or try using less pressure to aspirate.

Remove the needle and apply a sterile dressing to the puncture site once aspiration is complete

Send synovial fluid for analysis in proper containers (check with lab) as indicated by clinical scenario.


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COMPLICATIONS, Prevention & Management:

· Infection can occur from introduction of skin bacteria into the joint space during the needle puncture. This complication can be limited by maintaining sterile technique and avoiding needle insertion through obviously infected skin.

· Bleeding is rarely a significant complication, but can occur in patients with bleeding disorders (such as hemophilia) or in patients who are taking anticoagulants. Arthrocentesis should be delayed until the clotting disorder has been reversed or enhanced with administration of specific clotting factors.

· Rarely, a local allergic reaction may occur from hypersensitivity to the local anesthetic. If it does occur, it is usually minor and can be treated with oral antihistamines. Monitor the patient for any signs of systemic allergic reaction or anaphylaxis. If there are signs of system reaction, this is an emergency and will require IV therapy, cardiac monitoring, and other treatments depending on the severity of the reaction.


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DOCUMENTATION FOR THE MEDICAL RECORD:

Write a procedure note describing the indications for the procedure, skin preparation, sterile technique used, equipment and needle size used, amount and type of local anesthetic, number of attempts required, appearance and quantity of joint contents aspirated, type of dressing/splinting applied, lab studies ordered, and patient tolerance of procedure as well as complications.


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ITEMS FOR EVALUATION:

· Understands indications/contraindications

· Educates/prepares patient

· Identifies proper landmarks

· Uses sterile technique

· Performs procedure correctly

· Understands potential complications and their management

· Adequate documentation performed