This chapter summarizes best practices related to vaccine administration, a key factor in ensuring vaccination is as safe and effective as possible. Sebro R. Anatomical variations of the deltoid artery: relevance to the deltopectoral approach to the shoulder. Preparing and Administering Intramuscular Injections - JoVE Report of 3 cases. The remaining 14publicationswere the immunization guides issued by theIndian and international public health organizations and the data obtained from themwas used for comparison. Determination of deltoid fat pad thickness. Fujimoto E. Iatrogenic axillary neuropathy after intramuscular injection of the deltoid muscle. Cook IF. Feb; The patient can be positioned lying on their stomach or standing up. The deltoid site is preferred because it is easily accessible for clinicians and for patients to expose, Site is 13 fingerbreadths (5 cm) below the mid-acromion, and it is frequently used in clinical settings in Japan. The evidence table for this guideline can be accessed here. Two reviewers (SC and SS) worked separately to gather data from all of the studies that were included. Implications for needle length in adult immunization. Design Systematic review using the Preferred Reporting Items for Systematic Reviews and . Three dose regimens of fulvestrant in postmenopausal Japanese women with advanced breast cancer: results from a double-blind, phase II comparative study (FINDER1). However, up to 1 mL of any medication may be administrated to this muscle (the maximum volume should never exceed 2 mL). Australian Immunization Handbook, Australian Government Department of Health, Canberra. 1995;8(1):23-33. The authors received no specific funding for this study except for the journal publication charges. All the authors strictly adhered to a well-developed registered review protocol throughout the study and followed the risk of bias in systematic reviews (ROBIS)guidance tool. 2 ml is the standard for the deltoid muscle this answer is according to the NLN. The https:// ensures that you are connecting to the 2004;47(3):287-296. Apaydin N, Tubbs RS, Loukas M, Duparc F. Government of Canada. See, Advise patients to remain in the hospital/ on the ward for 1520 minutes following their injection. Land mark the injection site in the deltoid muscle: Two finger widths down from the acromion process; the bottom edge is at an imaginary line drawn from the axilla. shoulder. Three modifications should be urgently implemented in nursing training programs: Nursing students must be taught about structures at risk with IMIs. Trauma 18.6: Administering Intramuscular Medications - Medicine LibreTexts Palpate the acromion (outer edge of the scapula) and trace an imaginary inverted triangle below the J Psychiatr Ment Health Nurs. 6. Disagreements were settled by conversation. The deltoid muscle is preferred for children aged 3-10 years ; the needle length for deltoid site injections can range from to 1 inch on the basis of technique. Due to the solubility of the active drug, the maximum concentration formulated to date is 250 mg per 5 mL (50 mg/mL).30 In pivotal clinical studies of fulvestrant 250 mg/month, injection-site reactions occurred in 1% of treatment courses or 7% of patients treated with one 5-mL injection and in 4.6% of treatment courses or 27% of patients treated with two 2.5-mL injections.9,31 No sciatic nerve injuries have been reported in the literature for fulvestrant. Bancsi A, Houle SK, Grindrod KA. Shoulder injury related to vaccine administration and other injection site events. 10. Finally, we found that massaging the area during and after an IM injection helps to prevent and relieve pain. If the skin is stretched flat, a 1/2 inch needle is sufficient. The volume of the IM injection should not be more than 1 mL. If the volume is greater then 2 cc you must divide the dose and give 2 injections as the maximum volume in the Gluteal muscle is 2 cc. trochanter:A bony prominence at the top of the femur where the hip and thigh muscles are fixed. Whitehouse Station, NJ: Merck & Co, Inc; 2011. Eur J Oncol Nurs. Duplicate articles (n=19) were deleted, and two reviewers independently assessed 97 publications. 1. Upper limb nerve injuries caused by intramuscular injection or routine venipuncture. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. J Clin Oncol. Please remember to The zone between the halfway point of the a-AB line and the lower one-third of the b-AB line may be safe for IMIs. Intramuscular injection. EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 10th Floor, Southern House, Wellesley Grove, Croydon, CR0 1XG. The structural formula of haloperidol decanoate, USP, 4- (4-chlorophenyl)-1- [4- (4-fluorophenyl)-4-oxobutyl]-4 piperidinyl . Department of Orthopedics, All India Institute of Medical Sciences, Gorakhpur, IND. 2010;19(18):1170-1174. Accessed January 16, 2013. Further cadaveric and ultrasonographic studies are needed to study the neurovascular profile in relation to safer areas for IMI in the deltoid muscle. 30. 2000;31(3):574-582. Report of three cases, Frozen shoulder syndrome can be a severe manifestation of vaccination-related shoulder dysfunction, Teaching best evidence: Deltoid intramuscular injection technique, The axillary triangle method was proposed. SKILLS - INTRAMUSCULAR INJECTIONS | Nursing Times An official website of the United States government. One area for future research is to determine the optimal amount of time needed to administer large-volume injections, as medications in viscous solutions may take longer to inject. - And More, Close more info about Large-volume IM injections: A review of best practices, Una Hopkins, RN, FNP-BC, DNP; Claudia Y. Arias, RN, OCN, http://www.enotes.com/intramuscular-injection-reference/intramuscular-injection, http://www.cheshire.ie/docs/staff/policies/clinical/AdministrationofInjections/IntramusInjectAIG03.pdf, http://www.dtgp.cpft.nhs.uk/FileHandler.ashx?id=721, Should Vital Signs Be Routinely Obtained Prior to Intravenous Chemotherapy? Up to 1ml can be injected into this site in neonates, up to 3mls in children and up to 5mls in adults. Vaccine administration practices: Canadian immunization guide [Internet]. Except for a few points in Domain 2 of Phase 2, all other requirements were met. All vaccinators must be competent in intramuscular (IM) injection technique. Ann Oncol. Administration of vaccines | The Australian Immunisation Handbook The Australian Immunization Handbook: 10th edition Australia: Commonwealth of Australia. We chose and incorporated the articles that contained this information. and transmitted securely. Table 5summarizes the data extracted from these 12 articles regarding the sites, surface landmarks, techniques, and post-injection complications. Establishing a new appropriate intramuscular injection site in the deltoid muscle. Current practice among general practitioners and practice nurses, Injury to structures underneath the deltoid muscle can be avoided using appropriate needle lengths. Medication administration and IV therapy. 2011;67(5):1034-1040. Deltoid versus gluteal: which intramuscular injection site do mental health patients prefer? It has a markedly extended duration of effect. What volume of medication can be injected into the site? Two nurses administering fulvestrant simultaneously (ie, one nurse per injection per buttock) has been helpful for patient comfort in our experience. This technique is preferred in adult/ adolescent patients. Inclusion in an NLM database does not imply endorsement of, or agreement with, The following features of the study were gathered: (i) the research author; (ii) the study design; (iii) the country of publication; (iv) the number of participants; (v) the participants age group; (vi) the participants gender; and (vii) the participants ethnicity. 2010;123(2):453-461. Risk of bursitis and other injuries and dysfunctions of the shoulder following vaccinations. Reid CD, Taylor GI. 2006;17(2):205-210. (<60 kg) for IM injection in the deltoid muscle only, or 2) a 1" needle for administration in the thigh muscle for adults of any weight. 2010;64(11):1573-1579. Ottawa, ON: Government of Canada. The second, termed the acromial artery, runs deep to the anterior part of deltoid muscle, near the clavicle. Feb; Dosing of INVEGA SUSTENNA - Injection Volume - Janssen Science Intramuscular injections should not be used in people with myopathies or those with trouble clotting. The anterolateral aspect of the thigh, or vastus lateralis muscle, is the preferred IM site for neonates and infants. There was a restriction for the non-English language of publications. This guideline aims to facilitate the administration of intramuscular injections to maximise the therapeutic effect while minimising potential complications and patient discomfort. 2010;21(12):2342-2347. The site is shown in a self-generated image in Figure, A mid-deltoid site is proposed, with the acromion as the origin of the deltoid muscle and the deltoid tuberosity as the insertion of the deltoid muscle. The deltoid muscle is relatively easy to locate and access, making it an ideal site for intramuscular injections. The articles which satisfied the inclusion and exclusion criteria were eligible for review. Oncol Nurs Forum. The recommended volume is 1ml; however, up to 2mls can be administered. 2 Shatsky M. Evidence for the use of intramuscular injections in outpatient practice. If landmarked correctly however, it is safe to use. Limitations included the unavailability of free access to complete text in many articles resulting in exclusion. Intramuscular injections (IMIs) are among the most common medical procedures performed in any healthcare center [1]. Current IMI techniques at the deltoid site are deficient in many respects. Mishra P, Stringer MD. Administration of medications via the intramuscular route: an integrative review of the literature and research-based protocol for the procedure. 28. Medication fluid amounts up to 0.5-1 mL can be injected in one site in infants and children, whereas adults can tolerate 2-5 mL. The following sample policy and procedure incorporates current rationale for each . Globally, the deltoid is the preferred IMI site in clinical practice [1]. Poland GA, Borrud A, Jacobson RM, McDermott K, Wollan PC, Brakke D, Charboneau JW. Efficacy and safety in intramuscular injection techniques using ultrasonographic data. Displace the skin and subcutaneous tissue by pulling the skin laterally or downward from the injection site. What is maximum volume for subcutaneous injection? Topuz K, Kutlay M, Simsek H, et al. There were 174 published papers found after the initial search. Registration is free. Data were depicted by self-generated images. informed practice: Trauma-informed care is a way of approaching interactions with children and families in which providers remain cognizant of the impacts of trauma while also taking actions to prevent potentially traumatic experiences (Boles, 2017). The muscle is located in the upper outer quadrant of the buttock, approximately 5-8cm below the iliac crest. Based on the neurovascular network lying underneath the deltoid muscle and in relation to the upper end of the humerus, the proximal humerus is related to a network of arteries arising from the second part of the axillary artery. Administer these vaccines by IM injection: Haemophilus influenzae type b (Hib) Influenza vaccine, inactivated (IIV) Hepatitis A (HepA) Hepatitis B (HepB) Hepatitis A and hepatitis B Influenza vaccine, recombinant (RIV4) (HepA-HepB) Human papillomavirus (HPV Meningococcal conjugate (MenACWY) A needle gauge of 22-25 is recommended for IM injections, with a larger gauge (e.g., 22) required for more viscous or larger volume products1, and evidence to suggest using a smaller gauge needle (23 or smaller) for those with bleeding disorders. The initial search identified 174 articles. Overall, 5 mL has been cited for adults as the maximum volume for a single IM injection, with lower maximums proposed for adult patients with less-developed or small muscle mass.3,13,14. PDF Queensland Paediatric Emergency Care Skill Sheets Intramuscular Injection Best practice guidelines for the administration of intramuscular injections in the mental health setting. When IM has been prescribed Site selection and land marking Vastus Lateralis The anterolateral aspect of the thigh, or vastus lateralis muscle, is the preferred IM site for neonates and infants. The results section describes the images that were taken. Clin J Oncol Nurs. The review protocol can be accessed from https://www.crd.york.ac.uk/prospero/. ONA. The anterolateral thigh can also be used . Approximately 2-3 fingerbreadths (approximately 2 inches) below the acromion process, and sitting just above the level of the armpit, in the central part of the upper arm is the deltoid injection site Clinical judgement is required when selecting an injection site and needle length. Philadelphia, USA: Wolters Kluwer: Lippincott Williams & Wilkins; 2015. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PDF Administering Intramuscular Injections to Children: What Does the Clinical Guidelines (Nursing) : Intramuscular Injections The correct injection site for deltoid IM is 2.5 cm below this landmark, as seen above. The deltoid muscle is a rounded triangle shape. 17. Monitoring Editor: Alexander Muacevic and John R Adler. SKILLS - INTRAMUSCULAR INJECTIONS | Nursing Times. For the ventrogluteal muscle of an average adult, give up to 3 ml of medication. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. Eighteen papers were eligible forinclusion and exclusion based on the inclusion and exclusion criteria but were eliminated after reviewers screened them for irrelevant data that was outside the scope of the current review. Clifton Park, NY: Delmar Cengage Learning; 2005:405-434. Nursing students should measure their own fingers to decide a 4-cm range to use for landmarking the deltoid site. Your use of this website constitutes acceptance of Haymarket Medias Privacy Policy and Terms & Conditions. Among the 39 reviewed articles,only 12 articles focused specifically on the site of deltoid IMI. More than 12 billion IM injections are administered annually throughout the world (Jinet al., 2015). The first, termed the deltoid artery, runs in front of the deltoid muscle, near the deltopectoral line. Several small variances were also observed (8%). The deltoid branch of thoracoacromial artery accompanies the cephalic vein in deltopectoral groove and supplies the deltoid, The vascular territory of the acromio-thoracic axis, Two common variants of the deltoid artery were found. The authors have declared that no competing interests exist. Post-vaccination frozen shoulder syndrome. J Adv Nurs. Using 20 drops/mL tubing, what is the drip rate in drops/minute? This study analyzes the procedures of administering IMIs in the deltoid related to the neurovascular network underlying the muscle and proposes a preferred site with the least chance of injury. The same two independent reviewers independently examined 12 papers found through citation searches for eligibility against the pre-specified inclusion criteria. - Conference Coverage - Full-Length Features The PCHA, along with the AXN, is frequently found in the region between 5 and 9 cm below the lateral border of the mid-acromion process. Intramuscular Injection (IM) - OSCE Guide - Geeky Medics The gluteal site is commonly used to administer antibiotics, or any medication with a volume exceeding 2 mL but less than 3 mL for an adult. However, nurses who were older than 30 years, were diploma prepared, and had more than 4 years of nursing experience were more likely to choose the dorsogluteal site; whereas nurses who were age 20 to 24 years, were degree prepared, and had 1 to 4 years of nursing experience were more like to choose the ventrogluteal site.19 This finding supports the idea that the ventrogluteal site may be used more often by those who received specific guidance in administering at that site.

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