Large-volume IM injections: A review of best practices If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. The revised standards became effective in 2001 (2). Document the procedure in the patients record. Monitor the patient for adverse and allergic reactions to the medication. Cookies are used by this site. Intramuscular Injection: Definition and Patient Education - Healthline 17. Bicillin L-A (penicillin G benzathine injectable suspension) Patient displays adverse reaction to the medication, with signs of urticaria, eczema, pruritus, wheezing, or dyspnea. Additional information about implementation and enforcement of these regulations is available from OSHA. 4. Syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) but unused should be discarded at the end of the clinic day. Compare Mar to the patients wristband and use two patient identifiers to confirm patient. WebRecommended available dose formulations include 50 mg/ml strength, in 3 ml multiple dose vials or 100 mg/ml strength, in 5 ml multiple dose vials. Children can be very anxious or fearful of needles. If the deltoid mass is large enough, give up to 2 injections into each deltoid muscle (separated by 2.5 cm). The IM site is used for medications that require a quick absorption rate but also a reasonably prolonged action (Rodgers & King, 2000). Evidence does not support use of antipyretics before or at the time of vaccination; however, they can be used for the treatment of fever and local discomfort that might occur following vaccination. The needle length is based on patient weight and body mass index. Deltoid Intramuscular Injections: A Systematic Review of Chapter 8: Routes & Formulations Variation from the recommended route and site can result in inadequate protection. Patient explains purpose, dosage, and effects of medication. The deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. If the gluteal muscle must be used, care should be taken to define the anatomic landmarks. Use a 22- to 25-gauge needle. (d) Some experts recommend a 5/8-inch needle for men and women who weigh <60 kg, if used, skin must be stretched tightly (do not bunch subcutaneous tissue). However, there is sufficient evidence that the ventrogluteal IM site is the preferred site whenever possible, and is an acceptable site for oily and irritating medications. 20. Even if the person coughs or sneezes immediately after administration or the dose is expelled any other way, the vaccine dose need not be repeated (5). Place safety shield on needle and discard syringe in appropriate sharps container. Explain the procedure for an IM injection, including the purpose of the injection and the reason for using the IM route. Older adult patients may have decreased muscle mass, which reduces drug absorption from IM injections. The deltoid muscle can be used if the muscle mass is adequate. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients (3). Hold syringe between thumb and forefinger on dominant hand as if holding a dart. 10. Older adults may have loss of muscle tone and strength that impairs mobility, placing them at high risk for falls as a result of guarding an injection site. Nakajima, Y. and others. Immune responses generated by jet injectors against both attenuated and non-live viral and bacterial antigens are usually equivalent to, and occasionally greater than, immune responses induced by needle injection. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Only give injections that are less than 0.5 mL into the deltoid. If the patient receives frequent injections, rotate sites. Label all medications, medication containers, and other solutions. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Always wear gloves to administer injections. 4. Begin by having the patient relax the arm. Perform hand hygiene before patient contact. Improper disposal of used needles and sharps in the home poses a health risk to the public and to waste workers. Rotavirus, adenovirus, cholera vaccine, and oral typhoid vaccines are the only vaccines administered orally in the United States. Review medication reference information pertinent to the medications action, purpose, onset of action and peak action, normal dose, and common side effects and implications. 13. These cookies may also be used for advertising purposes by these third parties. For injection into the anterolateral thigh, most adolescents will require a 1-1.5-inch needle to ensure intramuscular administration (27). Use of a topical refrigerant (vapocoolant) spray immediately before vaccination can reduce the short-term pain associated with injections and can be as effective as lidocaine-prilocaine cream (51). Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for infants aged <12 months and in the upper-outer triceps area of persons aged 12 months. Hands should be cleansed with an alcohol-based waterless antiseptic hand rub or washed with soap and water before preparing vaccines for administration and between each patient contact (1). katkonk, BSN, RN 400 Posts Specializes in Occupational health, Corrections, PACU. Instruct the patient and a family member to observe for effectiveness of the medication and adverse reactions and to report ineffectiveness of the medication and adverse reactions to the practitioner. 8. For women under 60 kg (130 lbs), a 16 mm (5/8 inch) needle is sufficient, In order to accurately determine the amount of medication to administer, the nurse must first calculate the total daily dose. They help us to know which pages are the most and least popular and see how visitors move around the site. Factors to look for include circulatory shock, surgery, or muscle atrophy. Then release the skin. Deltoid muscle: Locate the central and thickest portion of the deltoid muscle above the level of the The deltoid muscle is located by fully exposing the patients upper arm and shoulder and asking the patient to relax the arm at the side or by supporting the patients arm and flexing the elbow. How many ml 23. Distraction, such as blowing bubbles and applying pressure at the injection site before giving the injection, may help alleviate the childs anxiety. Discard the uncapped needle (or needle enclosed in a safety shield) and the attached syringe into a puncture-proof and leakproof receptacle. The vastus lateralis is commonly used for immunizations in children from infants through to toddlers. In certain circumstances in which a single vaccine type is being used (e.g., in preparation for a community influenza vaccination campaign), filling a small number (10 or fewer) of syringes may be considered (5). inject If less than a full recommended dose of a vaccine is administered because of syringe, applicator, or needle leakage, the dose should be repeated (5). Live attenuated influenza vaccine is approved for healthy nonpregnant persons aged 2-49 years and is the only vaccine administered by the intranasal route. 3. 16. Smoothly, quickly, and steadily withdraw the needle. with your non-dominant hand. Once medication is completely injected, remove the needle using a smooth, steady motion. With IMs, there is an increased risk of injecting the medication directly into the patients bloodstream. Web2 mL How many mL can be injected into the deltoid muscle 2.5 mL How many mL can be injected into the ventrogluteal muscle 20-30 minutes After receiving an allergy test, how long should a patient stay in the office? Although policy may vary (for example, if you are in an acute setting compared to a community setting), the CDC recommends wearing gloves if there is potential for contact with blood and body fluids. The needle is inserted at a 90-degree angle perpendicular to the patients body, or at as close to a 90-degree angle as possible. Vaccine recommendations and guidelines of the ACIP: General best practice guidelines for immunization. After the needle pierces the skin, use the thumb and forefinger of the nondominant hand to hold the syringe barrel while still pulling on the skin. Alternate sides should be used for subsequent injections. WebThe deltoid muscle is the preferred injection site in children aged 3-18 years when muscle mass is more developed. For non-live vaccines, manufacturers typically recommend use within the same day that a vaccine is withdrawn or reconstituted. In this case the needle length should be 1 inch to 1.25 inches. Administering a vaccine containing an adjuvant either subcutaneously or intradermally can cause local irritation, induration, skin discoloration, inflammation, and granuloma formation. Assess the patients knowledge regarding the medication to be received. Prepare medication from an ampule or a vial as per hospital policy. Place the heel or palm of your hand on the greater trochanter, with the thumb pointed toward the belly button. Any factor that interferes with local tissue blood flow affects the rate and extent of drug absorption. After the needle pierces the skin, use the thumb and forefinger of the non-dominant hand to hold the syringe. This prevents medication errors by providing an additional check. WebDo not inject this medication into a. Intramuscular Injection: To avoid the danger of subcutaneous fat atrophy, it is important to ensure that deep intramuscular injection is given into the gluteal site. Wodi, A.P., Shimabukuro, T. (2021). Learn how BCcampus supports open education and how you can access Pressbooks. Preparing and Administering Intramuscular Injections - JoVE For vaccinations in adults, this is usually a 2225-gauge needle which is 1 Dosage Calculation Practice_Part 3 1. A health care provider Use the correct needle length based on the patients gender and weight. Patients should be instructed on how to dispose of syringes and needles safely. Centers for Disease Control and Prevention (CDC). Deltoid muscle: Locate the central and thickest portion of the deltoid muscle above the level of the armpit and approximately 2" below the acromion process (see diagram at right). Oral typhoid capsules should be administered as directed by the manufacturer. As announced in the March 2023 PharmaCare Newsletter, Pendopharm (pdp) amlodipine 1 mg/mL oral solution (DIN 02484706) is a Limited Coverage benefit as of February 28, 2023. The tip should be inserted slightly into the naris before administration. Injectable immunobiologics should be administered where local, neural, vascular, or tissue injury is unlikely. Pretreatment (30-60 minutes before injection) with a 5% topical lidocaine-prilocaine emulsion might decrease the pain of vaccination by causing superficial anesthesia (43-44). It can only receive small volumes of medication, usually 1 milliliter or less. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them. The barrel holds the medicine and has markings on it like a ruler. WebA single injection can be given into each deltoid muscle in children, adolescents and adults. Response to vaccines recommended by the subcutaneous route is unlikely to be affected if the vaccines are administered by the intramuscular rather than subcutaneous route. Retrieved February 11, 2023, https://www.ismp.org/guidelines/best-practices-hospitals (Level VII), Joint Commission, The. The injection site is found in the center of the triangle (Figure 5A). Providers should consult package inserts for details. CDC twenty four seven. To locate the ventrogluteal site, place the patient in a supine or lateral position (on their side). There may be exceptions for specific medications. particles up to a hundred times smaller than those in suspensions that are however likewise suspended in a solution. Checklist 59 outlines the steps to perform a Z-track IM injection. Children and infants will require shorter needles. Ketorolac (Oral Route, Injection Route) Proper Use Chapter 20: Pediatric nursing interventions and skills. For example, varicella vaccine should be discarded if not used within 30 minutes after reconstitution, whereas MMR vaccine, once reconstituted, must be kept in a dark place at 36F to 46F (2C to 8C) and should be discarded within 8 hours if not used. A vapocoolant spray (e.g., ethyl chloride) may also be used just before injection to decrease pain. Intramuscular (IM) injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort. Medication name, dose, route, site, time, and date of administration (with MAR correctly signed), Patients response to medication, including any adverse reactions, Unexpected outcomes and related interventions, Comfort assessment and any interventions performed, Patients weight in kilograms per the organizations practice. 21. 7.4 Intramuscular Injections Clinical Procedures for Safer To decline or learn more, visit our cookies page. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. If worn, gloves should be changed between patients. (version 3, peer review, 2 approved). Intramuscular injections must be done carefully to avoid complications. 30 In pivotal clinical studies of Literature shows inconsistency in the selection of sites for deep muscular injections: selection may be based on familiarity and confidence rather than on best practice (Ogston-Tuck, 2014a). The deltoid muscle is the site most typically used for vaccines. Topical lidocaine-prilocaine emulsion should not be used on infants aged <12 months who are receiving treatment with methemoglobin-inducing agents (e.g., acetaminophen, amyl nitrate, nitroprusside, dapsone) because of the possible development of methemoglobinemia (50). The deltoid muscle is preferred for adolescents 11-18 years of age. To prevent inadvertent needlestick injury or reuse, safety mechanisms should be deployed after use and needles and syringes should be discarded immediately in labeled, puncture-proof containers located in the same room where the vaccine is administered (5). Different single-components of combination vaccines should never be mixed in the same syringe by an end-user unless specifically licensed for such use (4). The marking at 100 is the same as 1 If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.5 The rectus femoris is no longer considered a safe injection site because of the risk of damage to the descending branch of the lateral circumflex femoral artery and the muscle branch of the femoral nerve to the vastus lateralis.6. Intramuscular injections are administered at a 90-degree angle to the skin, preferably into the anterolateral aspect of the thigh or the deltoid muscle of the upper arm, depending on the age of the patient (Table 6-2). People self The overlying skin and subcutaneous tissues are pulled to the side with the ulnar side of the nondominant hand. Hepatitis B administered intradermally might result in a lower seroconversion rate and final titer of hepatitis B surface antibody than when administered by the deltoid intramuscular route (53-54). Administration of vaccines | The Australian Immunisation Handbook The anterolateral thigh can also be used. injection How many mL can be injected into the gluteus maximus? 23. Assess baseline vital signs and the patients medical and medication history. WebHow many mL can be injected into the deltoid and thigh muscles? Upon injection, if a patient complains of radiating pain, burning, or a tingling sensation, remove the needle and discard. Aspiration refers to the action of pulling back on the plunger for 5 seconds prior to injecting medication (Ipp, Sam, & Parkin, 2006). Data source: Centers for Disease Control, 2013, 2015; Perry et al., 2014. When giving an IM injection, how can you avoid injury to a patient who is very thin. Thanks. Intramuscular injections are It is suitable for small volume injections. Similarly, doses of rabies vaccine administered in the gluteal site should not be counted as valid doses and should be repeated (54). Remove needle cap by pulling it straight off the needle. Injection Other serious complications of Care should be taken to avoid intravenous or 21. Evidence indicates that this cream does not interfere with the immune response to MMR (45). Always wear gloves to administer injections. Hepatitis A vaccine and meningococcal conjugate vaccine do not need to be repeated if administered by the subcutaneous route (55-56). The location of underlying bones, nerves, and blood vessels and the volume of medication to be administered are also considered. The site provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat. Sep Applying a colorful adhesive bandage or sticker to the injection site should be considered. In general, for an adult male weighing 60 to 118 kg (130 to 260 lbs), a 25 mm (1 inch) needle is sufficient. ). (2023). Other adverse effects occur: hematoma or abscess; infection; fibrosis of the muscle, tissue damage because of patient movement during injection; glass particles injected into muscle as a result of not using a filter needle; permanent damage to sciatic nerve resulting in paralysis, fibrosis, or abscess. The maximum amount of medication for a single injection is generally 1 ml. This technique, pulling the skin laterally before injection, prevents medication leakage into subcutaneous tissue, seals medication in the muscle, and minimizes irritation.5 To use the Z-track method in an adult, the appropriate-size needle is attached to the syringe, and an IM site is selected. Rodgers, D. Wilson (Eds. The nurse or doctor will advise which needle size is appropriate for your child. Needles and syringes used for vaccine injections must be sterile and disposable. Although the deltoid site is easily accessible, the muscle is not well developed in many adults. If a child needs 3 or 4 intramuscular vaccines at the same visit, the options will depend on the childs deltoid muscle mass. This confirms the correct identity of the patient. The total daily dose is 750 mg every four hours, or 3,000 mg per day. WebAugmentin (amoxicillin/clavulanic acid) is an antibiotic that is available as a 150 mg/mL strength injection. Smallpox vaccine is accessed by dipping a bifurcated needle directly into the vaccine vial. WebIn the elderly population, the mean daily volume was 1340 mL (range 6981708 mL) or a bolus of 500 mL over 26 hour) for a mean total of 5 days (.2521 days). 19. I was personally taught to use no more than 0.5 in a child and 1 mL in a well developed adult deltoid. The needle gauge for intramuscular injection is 22-25 gauge. 14. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. The maximum amount of medication for a single injection is 3 ml. Thank you for taking the time to confirm your preferences. Take all necessary steps to avoid interruptions and distractions when preparing and administering medications. Ensure the patients position for injection is not contraindicated by a medical condition (e.g., circulatory shock, surgery). The Needlestick Safety and Prevention Act (2) was enacted in 2000 to reduce the incidence of needlestick injury and the consequent risk for bloodborne diseases acquired from patients. If a medication is discoloured or cloudy, always check manufacturers specification for the medication. (2023). Because of the adverse and documented effects of pain associated with IM injections, always use this route of administration as a last alternative; consider other methods first (Perry et al., 2014). With skin held to one side, quickly insert needle at a 90-degree angle. Injection technique is the most important parameter to ensure efficient intramuscular vaccine delivery. Explain the procedure and the medication, and give the patient time to ask questions. Anderson, C.E., Herring, R.A. (2022). Colloids. This step prevents the spread of microorganisms. WebLocate the deltoid injection site, as described above. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. Complications with IM include muscle atrophy, injury to bone, cellulitis, sterile abscesses, pain, and nerve injury (Hunter, 2008; Ogston-Tuck, 2014a). Assess for factors such as muscle atrophy, reduced blood flow, skin condition, and circulatory shock. Aspiration before injection of vaccines or toxoids (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary because no large blood vessels are present at the recommended injection sites, and a process that includes aspiration might be more painful for infants (22). Can 2 ml of fluid be administered in deltoid muscle? Changing needles between drawing vaccine from a vial and injecting it into a recipient is not necessary unless the needle has been damaged or contaminated (11). To prevent contamination of the vial, make sure the patient area is clean and free of potentially contaminated equipment. The anterolateral thigh also can be used. Glynda Rees Doyle and Jodie Anita McCutcheon, Clinical Procedures for Safer Patient Care, LandmarkingVentrogluteal Administering an IM InjectionUsing Z-track, Landmarking Vastus Lateralus Administering IM InjectionUsing Z-track, Insertion of an Indwelling Subcutaneous Device aka subcutaneous butterfly, Next: 7.5 Intravenous Medications by Direct IV Route, Creative Commons Attribution 4.0 International License. Keep a sheet or gown draped over body parts not requiring exposure.