We have run our ultrasound guided injection training courses for several years and wanted to provide some top ultrasound guided injection training tips on how to perform these techniques. It is a tough skill to develop, so practical experience is key. We have plenty of other resources regarding guided injections here. There are however some things you can do to try and help yourself.

 Ensure optimal ergonomic set up

• Appropriate height of the plinth ensures that prior to the injection the patient or region to inject is close to the injector. 

• Ensure that the ultrasound screen is in the same field of view as the body part that is being injected. 

Needle visualisation

• Aim to maintain continuous real time visualisation of the needle tip in relation to the target and the surrounding structures. 
• To prevent movement of the transducer relative to the needle trajectory, anchor the hand holding the transducer. (Figure 1)
• Transducer control can be improved by supporting the elbows or forearms on the table (Figure 2) 

• Make sure to visualise the short end of the transducer (Figure 3) so that the needle is easily seen when inserted. 
• Take a bird’s eye view of the transducer with the needle in the plane of the transducer to make sure that the needle is advanced along the entire footprint of the transducer. This will help to minimise cross cut artefact.

Specific techniques to optimise visualisation

Fishtailing

• To make sure that the entire needle is visible before advancing the needle further keep the transducer still when the needle is visible then intermittently rotate the other end of the probe from left to right. Stop when the entire needle is completely visualised. 

Heel to toe manoeuvre

• With a steep needle trajectory consider improving the angle by pushing one end of the transducer (the part of the transducer that is furthest away from the needle) into the soft tissue in order for the transducer to be more parallel to the needle improving visualisation of the needle. See Video 1 below.

Ultrasound gel used as standoff

• Sterile Ultrasound gel can be used to visualise the needle trajectory even before entering the skin. Sometimes the target structure is so superficial or at such a steep angle that it is difficult to adequately visualise the needle.  
• Method:  One end of the probe has a mound of gel whilst the other end of the probe is anchored on the skin. The needle is now introduced either through the gel or just proximal to it (Figure 4).

Injecting away from the probe

• When injecting it is possible to get a more parallel needle position by inserting the needle at a distance away from the probe but in plane with the probe. This makes it possible to inject deeper located structures with good needle visualisation.  You do however need to ensure you understand the anatomy adjacent to the probe as your needle will pass through tissue that is not visualised on ultrasound.