What is the recommended approach for a cortisone (corticosteroid) injection consult?

Recommended Approach for Cortisone Injection Consultation

For optimal patient outcomes, a cortisone injection consultation should include proper patient selection, appropriate dosing based on joint size, sterile technique, and thorough post-injection monitoring to minimize complications while maximizing therapeutic benefit.

Pre-Injection Assessment

• Evaluate the specific condition requiring injection (joint inflammation, tendinopathy, bursitis)
• Review patient's medical history for:
  • Previous response to corticosteroid injections
  • Contraindications (active infection, fracture, prosthetic joint) 1
  • Risk factors (diabetes, hypertension, osteoporosis)
  • Current medications (especially anticoagulants)

Injection Protocol

Dosing Guidelines

• Small joints (fingers, toes): 2.5-5 mg triamcinolone acetonide 2
• Medium joints (wrist, elbow, ankle): 5-10 mg triamcinolone acetonide 2
• Large joints (knee, shoulder, hip): 10-40 mg triamcinolone acetonide 2

Administration Technique

1. Strict aseptic technique is mandatory 2
2. Shake vial before use to ensure uniform suspension
3. Inspect suspension for clumping or granular appearance (agglomeration)
4. After withdrawal, inject without delay to prevent settling in syringe
5. For joint injections:
   • Follow standard intra-articular injection technique
   • Consider aspirating synovial fluid if excessive amount present
   • Consider local anesthetic use prior to injection
   • Avoid injecting directly into tendon substance 2, 3

Post-Injection Care

• Monitor patient for 15-30 minutes after injection for immediate reactions 4
• Provide education on:
  • Expected timeline for symptom relief
  • Potential side effects and when to seek medical attention
  • Activity modification (relative rest for 24-48 hours)
  • Use of ice for post-injection pain

Managing Potential Reactions

Mild/Moderate Reactions

• Stop injection immediately if reaction occurs
• Switch IV line to normal saline to keep vein open
• Monitor vital signs
• Consider hydrocortisone 200 mg IV for moderate reactions 4
• Treat specific symptoms as needed:
  • Nausea: ondansetron 4-8 mg IV
  • Urticaria: second-generation antihistamine (loratadine 10 mg)
  • Mild hypotension: IV hydration 4

Severe Reactions

• Call emergency services immediately
• Administer epinephrine 0.3 mg IM for anaphylaxis
• Provide supportive care based on symptoms 4

Follow-Up Recommendations

• Schedule follow-up evaluation 2-4 weeks after injection
• Assess response to treatment
• Consider additional treatment options if inadequate response
• Limit frequency of injections (generally no more than 3-4 injections per year in the same location) 1

Potential Complications to Discuss with Patients

• Local complications:

  • Post-injection flare (temporary pain increase)
  • Skin hypopigmentation and atrophy
  • Tendon rupture (avoid direct tendon injection)
  • Accelerated osteoarthritis progression with repeated injections 1

• Systemic complications:

  • Adrenal suppression (with multiple or frequent injections)
  • Facial flushing
  • Temporary hyperglycemia (particularly in diabetic patients)
  • Potential osteoporosis with long-term use 1, 5

Special Considerations

• Diabetic patients: Monitor blood glucose levels for 1-2 weeks post-injection
• Athletes: Advise about potential tendon weakening and need for activity modification
• Immunocompromised patients: Higher risk of infection; consider alternative treatments
• Patients on anticoagulants: Increased risk of bleeding; apply pressure after injection

By following this structured approach, clinicians can optimize the safety and efficacy of cortisone injections while minimizing potential complications.