A stab in the dark

Q3 Medicine
Gillian Whalley
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Ultrasound has been established as a helpful addition to inserting intravenous lines, taking biopsies and draining free fluid, to name but a few.</p><p>If one assumes that the person inserting a needle has absolutely no knowledge of underlying anatomy and is simply taking a stab whilst hoping it will hit its spot then it is easy to perceive the massive benefit of ultrasound-guided procedures. But that simply isn't true. Medical students spend many hours learning about surface anatomy and how it relates to the underlying layers of tissue, muscle and bone below the skin. Doctors have a great understanding of anatomy and use their hands to palpate for certain underlying structures such as bony processes, tendons and veins, in order to piece together an image in their mind about the underlying anatomy. Anyone who has had blood taken knows that those technicians who do this are adept at feeling the anatomy on the inside of the elbow to find a vein to puncture and drain blood from no matter how deep it is. It is a well-honed skill.</p><p>But taking blood is one thing, injecting substances is quite another. Intra-articular injections for the treatment of joint osteoarthritis have been popular for some time and are safely performed using anatomical landmarks only. But increasingly, practitioners are using ultrasound to guide needle placement. In this issue of AJUM, Oo <i>et al</i>.<span><sup>1</sup></span> have performed a systematic review of ultrasound-guided injections and concluded that clinical outcomes are superior compared with landmark-guided injections. As a potential patient, I can see how this may build confidence in the procedure, but the added benefit of improved clinical outcomes makes ultrasound guidance even more compelling.</p><p>All new approaches come with a learning curve however and potentially some questions about who should do these procedures. Those with extensive landmark-guided experience may find the ultrasound hinders the process at first. And conversely, those with ultrasound experience may not have the confidence with landmark-guided procedures. Having two professionals (one an ultrasound expert) working side by side may seem attractive but it would be cost-prohibitive as the number of ultrasound-guided procedures increases. 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In this issue of AJUM, Akahoshi <i>et al</i>.<span><sup>2</sup></span> present a small study where they evaluated the efficacy of ultrasound-guided fine needle biopsy of hypoechoic lesions during endoscopic examinations.</p><p>And to aid the training of practitioners in ultrasound-guided needle insertion, McKinley <i>et al</i>.<span><sup>3</sup></span> provide a description of a do-it-yourself ultrasound phantom for needle guidance. 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引用次数: 0

Abstract

Procedural guidance with ultrasound is challenging traditional medicine. And for good reason – precision is an ally whenever you are inserting a needle into a human body. With some imagination, I am able to conjure up a gruesome Hollywood-esque image of someone gripping a syringe in a gloved fist and thrusting it towards a body with the intention of hitting a target under the skin. In my mind, there is an element of chance as to whether the needle hits the intended anatomical target. It's a stab in the dark. In a more nuanced and stable clinical scenario, the insertion point is carefully considered and the odds of missing may be relatively low. But no matter how low, it seems intuitively sensible to use any imaging guidance available. And increasingly, that guidance is provided by ultrasound. Ultrasound has been established as a helpful addition to inserting intravenous lines, taking biopsies and draining free fluid, to name but a few.

If one assumes that the person inserting a needle has absolutely no knowledge of underlying anatomy and is simply taking a stab whilst hoping it will hit its spot then it is easy to perceive the massive benefit of ultrasound-guided procedures. But that simply isn't true. Medical students spend many hours learning about surface anatomy and how it relates to the underlying layers of tissue, muscle and bone below the skin. Doctors have a great understanding of anatomy and use their hands to palpate for certain underlying structures such as bony processes, tendons and veins, in order to piece together an image in their mind about the underlying anatomy. Anyone who has had blood taken knows that those technicians who do this are adept at feeling the anatomy on the inside of the elbow to find a vein to puncture and drain blood from no matter how deep it is. It is a well-honed skill.

But taking blood is one thing, injecting substances is quite another. Intra-articular injections for the treatment of joint osteoarthritis have been popular for some time and are safely performed using anatomical landmarks only. But increasingly, practitioners are using ultrasound to guide needle placement. In this issue of AJUM, Oo et al.1 have performed a systematic review of ultrasound-guided injections and concluded that clinical outcomes are superior compared with landmark-guided injections. As a potential patient, I can see how this may build confidence in the procedure, but the added benefit of improved clinical outcomes makes ultrasound guidance even more compelling.

All new approaches come with a learning curve however and potentially some questions about who should do these procedures. Those with extensive landmark-guided experience may find the ultrasound hinders the process at first. And conversely, those with ultrasound experience may not have the confidence with landmark-guided procedures. Having two professionals (one an ultrasound expert) working side by side may seem attractive but it would be cost-prohibitive as the number of ultrasound-guided procedures increases. Furthermore, I have heard concerns from some practitioners that less experienced practitioners will become too reliant on ultrasound for their procedures; and that they will lose the art of the traditional landmark-guided techniques but if ultrasound is better for patients is this a problem?

Just as injecting substances into joints requires precision, so too does the removal of cells from the body. Because needle aspiration requires precise anatomical alignment, in order to ensure the correct cells are sampled, ultrasound is potentially very useful for refining this technique. In this issue of AJUM, Akahoshi et al.2 present a small study where they evaluated the efficacy of ultrasound-guided fine needle biopsy of hypoechoic lesions during endoscopic examinations.

And to aid the training of practitioners in ultrasound-guided needle insertion, McKinley et al.3 provide a description of a do-it-yourself ultrasound phantom for needle guidance. It provides novices a way to practice their needle insertion and through a series of wires and LED lights gives direct and real-time feedback (in the much the same way as the ubiquitous game of ‘Operation’ but without the loud buzzer!).

I'm firmly of the opinion that ultrasound guidance is becoming standard care and the added expense (if there is any) will result in better outcomes for patients, as well as increasing the confidence of practitioners (and patients) with their procedures.

一针见血
超声波手术引导正在挑战传统医学。这是有道理的--只要将针头插入人体,精确度就是盟友。只要稍加想象,我就能勾勒出一幅好莱坞式的可怕画面:戴着手套的人握紧注射器,将其推向人体,意图击中皮下目标。在我看来,针头是否击中预定的解剖目标存在偶然因素。这是在黑暗中摸索。在更细微、更稳定的临床情况下,插入点是经过仔细考虑的,失误的几率可能相对较低。但无论几率有多低,直觉上使用任何可用的成像引导似乎都是明智的。而这种引导越来越多地由超声提供。如果我们假设插针者完全不了解潜在的解剖结构,只是简单地一针刺入,并希望能刺中目标,那么我们就不难发现超声引导手术的巨大优势。但事实并非如此。医科学生花费大量时间学习表面解剖学,以及它与皮下组织、肌肉和骨骼的关系。医生对解剖学非常了解,他们会用手触摸某些底层结构,如骨突、肌腱和静脉,以便在脑海中拼凑出底层解剖的图像。抽过血的人都知道,从事这项工作的技术人员善于感受肘部内侧的解剖结构,无论静脉有多深,都能找到静脉进行穿刺放血。但抽血是一回事,注射药物又是另一回事。用于治疗关节骨关节炎的关节内注射已经流行了一段时间,只需使用解剖标记即可安全进行。但越来越多的医生开始使用超声波引导针头放置。在本期《AJUM》杂志上,Oo 等人1 对超声引导注射进行了系统回顾,并得出结论认为,与地标引导注射相比,超声引导注射的临床效果更佳。作为一名潜在患者,我可以理解这将如何建立起对手术的信心,但临床疗效改善的额外好处让超声引导变得更有说服力。那些拥有丰富地标引导经验的人可能会发现,超声波一开始会阻碍手术的进行。反之,有超声波经验的人可能对地标引导手术没有信心。让两名专业人员(其中一名是超声波专家)并肩工作看似很有吸引力,但随着超声波引导手术数量的增加,成本会很高。此外,我还听到一些从业者担心,经验不足的从业者会过于依赖超声波进行手术;他们会失去传统地标引导技术的艺术,但如果超声波对患者更好,这又是否是个问题呢?由于针吸术需要精确的解剖对准,以确保采集到正确的细胞样本,因此超声波在完善这项技术方面可能非常有用。在本期的《AJUM》杂志中,Akahoshi 等人2 介绍了一项小型研究,他们评估了内窥镜检查中超声引导细针活检低回声病变的效果。它为新手提供了一种练习插针的方法,并通过一系列导线和 LED 灯提供直接和实时的反馈(与无处不在的 "操作 "游戏的方式基本相同,但没有响亮的蜂鸣器!)。我坚信,超声引导正逐渐成为标准护理,增加的费用(如果有的话)将为患者带来更好的治疗效果,并增强从业人员(和患者)对手术的信心。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Australasian Journal of Ultrasound in Medicine
Australasian Journal of Ultrasound in Medicine Medicine-Radiology, Nuclear Medicine and Imaging
CiteScore
1.90
自引率
0.00%
发文量
40
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