University of Wisconsin-Madison [37], also investigated the effect of Z track technique on injection pain in participants and measured the intensity of discomfort (burning, stinging, aching, being sore or hurting when touched or moving the leg) with a 4-point Likert scale. Step 4: Give the Injection 1. Copyright: © 2021 Ayinde et al. Studies using either parallel or crossover designs were combined in the meta-analysis. Acupressure techniques which mostly involved applying sustained pressure followed by intermittent pressure (tapping) to acupressure points local to the injection site reduced pain (4 studies: SMD = -1.62[-2.80,-0.44]), as did injections to the ventrogluteal site compared to the dorsogluteal site (2 studies, SMD = -0.43[-0.81,-0.06]). IM injection sites should be rotated to decrease the risk of hypertrophy. He is an NIHR Journals Editor and associate editor of Sexually Transmitted Infections journal. (2011, May 9). intramuscular injection injection into the substance of a muscle, usually the muscle of the upper arm, thigh, or buttock. However, there was very high unexplained heterogeneity between studies and risk of significant bias within small studies. Traditionally, the dorsogluteal area between the iliac crest and the greater trochanter is the preferred site for intramuscular injections .11 Some authors have also explored administering gluteal intramuscular injections into the ventrogluteal region, commonly known as the 'gluteal triangle' .9, 10 The base of the gluteal triangle is . We found some evidence supporting the use of manual pressure at the site of injection (4 studies, SMD = -0.85[-1.36,-0.33]) and the Helfer skin tap (3 studies, SMD = -2.96 [-5.51,-0.39]). Five of the seven articles identified nerve damage as a potential risk to giving a dorsal gluteal injection. Found insidePharmacology for Nurses, Second Edition teaches undergraduate nursing students the basic concepts of pharmacology. [1] The basis of this process is that the bulky muscles have good vascularity, and therefore the injected drug quickly reaches the systemic circulation and thereafter into the specific region of action, bypassing the first-pass metabolism. [15] and the Z track intervention reported to be significantly beneficial in reducing injection pain compared to the air-lock method, again conflicting with the report of the original study. www.sciencedaily.com/releases/2011/05/110509065638.htm (accessed September 17, 2021). Yes In studies where pain was measured with multiple instruments, preference was given to measures from the ‘visual analogue scale’ (VAS), then the ‘numerical rating scale’ (NRS) and the ‘verbal rating scale’ (VRS) in that order. Download Full PDF Package. Step 2: Selecting and Preparing the Injection Site . However, little research has confirmed the reliability of these sites for the presence and thickness of the target and other muscles, and subcutaneous fat" Elgellaie et al (2018). [27] study reversed the direction of the pooled estimate for the Z track IMI technique, indicating that the technique caused more pain than the comparator (with vs without Najafidolatbad et al. With a quick firm thrust, put the needle into the muscle straight up and down, at a 90 degree angle. A blue-ish tinge to the lips, fingers, or toes ( cyanosis) Pale, clammy skin. This was found to be beneficial in reducing injection associated pain in a cohort of hospital inpatients who received antibiotic injections [19, 41, 42] or magnesium sulphate [43]. Main outcome measures Minimum distance between the surface of the skin and the nearest edge of muscle at intramuscular injection sites. Reviewers were not blinded to the authors or settings of the studies. [45] found that a methylprednisolone injection diluted with 1ml sterile water injected over 10seconds was significantly more painful than administering the same injection over 30 seconds at the gluteal site. 29 studies were included in the systematic review and 20 studies in the meta-analysis. For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to involve underlying nerves, blood vessels, or bone . No, Is the Subject Area "Intramuscular injections" applicable to this article? here. 85% used the site they felt most comfortable with, 80% said ease of locating the injection site influenced their choice, 60% followed the recommendation of their nursing education programme and 56% followed traditional usage. Meta-analyses of the studies using local pressure (manual pressure, Helfer skin tap, ShotBlocker, and post injection massage), acupressure, Z track IMI techniques, cold needle technique and the choice of gluteal muscle injection site were performed (Figs 3–7). [15]. When correlations could not be estimated, they were imputed for each outcome using the lowest (positive) estimate among other studies in the meta-analysis [23, 24]. Deltoid . However, for the cold needle technique (2 studies, SMD = -0.73 [95%CI -1.83,0.37]) heterogeneity was high between studies (I2 = 92% [72,98])—Fig 6. This finding is in contrast with an earlier study by Güneş et al. Based on documented IM injection procedure concerns, this IM injection study explores the premise that healthcare per- No, Is the Subject Area "Randomized controlled trials" applicable to this article? Results The deltoid is the preferred site when administering a small dose (< 2 mL) injection When administering a larger dose (2-5 mL), the preferred site is the ventrogluteal over the dorsogluteal site Historically, the dorsogluteal site was the main site for IM injections. Where is the Dorsogluteal muscle? Manual pressure involves sustained application of pressure for 10 seconds with the thumb/fingers [34] while the Helfer skin tap generally involves short repeated pressure application (tapping) with the thumb/fingers for several seconds to relax the muscle prior to injection [22, 51, 52], this may either be preceded [40] or followed by [51, 52] making a large ‘V’ with the thumb and index finger [51] before inserting the injection needle. Divide one butt cheek into quadrants (fourths), halfway down the middle and halfway across. Scientists Claim That Overeating Is Not the Primary Cause of Obesity, How Meditation Can Help You Make Fewer Mistakes, Too Much Free Time May Be Almost as Bad as Too Little, Avocados Change Belly Fat Distribution in Women, Controlled Study Finds, Scientists Make Sperm from Mouse Pluripotent Stem Cells That Lead to Healthy, Fertile Offspring, Bionic Arm Restores Natural Behaviors in Patients With Upper Limb Amputations, Do Alexa and Siri Make Kids Bossier? Pull the needle straight out. Injection technique is the most important parameter to ensure efficient intramuscular vaccine delivery. In this article, find out the standard locations for intramuscular . Intradermal injection: injection of a minimal quantity (0.01 mL to 0.1 mL) of a biological product . I.World Health Organization. The between study heterogeneity also increased by 93% points (S3 Table). administer) FDA-approved mental health and substance use disorder treatment drugs included below in the “Medications Eligible for Pharmacist or Pharmacy Intern Administration” to persons 18 years or older, provided that: (a) The pharmacist or pharmacy intern is authorized to dispense controlled substances, in accordance with M.G.L. Ventrogluteal versus dorsogluteal site selection: A cross-sectional study of muscle and subcutaneous fat thicknesses and an algorithm incorporating demographic and anthropometric data to predict injection outcome. Insert the IM needle into the muscle at a 90 degree angle with one quick and firm motion. Inexperience with injection techniques and inaccurate landmarking can result in injection-site pain or injury. "Although three-quarters of the nurses in our study said they were aware of potential nerve damage when using the DG site, this site was used significantly more often than other sites.". Faculty must also disclose any planned discussion of unlabeled/unapproved uses of drugs or devices during their presentation(s). Funding: The authors received no specific funding for this work. Data extraction was performed independently by two reviewers (RH and OA) on all included studies. Thirteen (manual pressure, Helfer skin tap, ShotBlocker, post injection massage, Z track, acupressure, two-needle technique, altering injection speed, cold needle, application of ice to the injection site, airlock technique, gluteal injection site and altering the temperature of the injectate) different IMI techniques to reduce injection pain were evaluated within the included studies. Found inside – Page 171The large gluteal muscle is frequently used. Common sites for IM injections are the deltoid, dorsogluteal, ventrogluteal, and vastus lateralis muscles. Conceptualization, Writing – review & editing. Found inside – Page 456Sites of intramuscular injections. A, Dorsogluteal muscle. B, Deltoid muscle. C, Vastus lateralis. D, Ventrogluteal muscle. (From Leahy JM, Kizilay PE: ... Long Acting Injectable Medication for Substance Use Disorders, Jennifer Drake, MS, RN, CPN Views expressed here do not necessarily reflect those of ScienceDaily, its staff, its contributors, or its partners. Injection site pain is common following IMI [7–9]. Background: Although recent literature has reported that the ventrogluteal area can be an . Wiley-Blackwell. Questions? Injection pain was reduced in the ‘toes pointing down’ combined with Z track group compared to the ‘toes pointing down’ only group (mean VAS 1.25 vs 1.49 respectively). Those receiving the two-needle technique had the needle changed after drawing up the injectate and prior to the injection of the analgesic. After any injection, swelling and irritation (inflammation) can occur at the site where the needle entered the skin. Included studies were appraised and a meta-analysis, where appropriate, was conducted with a random effects model and test for heterogeneity. https://doi.org/10.1371/journal.pone.0250883.g008. Review into intramuscular injections. Aspiration is still advised when using the dorsogluteal muscle due to its proximity to the gluteal artery. Aǧaç and Güneş [29] found the two-needle technique to be beneficial in reducing injection site pain, but the use of the two-needle or one-needle technique was combined with an additional intervention, the airlock technique. Foreign language records were included when searching, and titles and abstracts were translated to allow screening. The effect of changing the needle after drawing up the injectate on injection pain was conflicting and warming the injectate did not reduce pain. It is the policy of the University of Wisconsin – Madison ICEP that the faculty, authors, planners, and other persons who may influence content of this activity disclose all relevant financial relationships with commercial interests in order to allow staff to identify and resolve any potential conflicts of interest. Found insideIf we administer intramsucular injections properly, the medication should ... The enduring preference for the dorsogluteal muscle may be due to easier site ... circumstance. Şanlialp et al. [15], the data from the Rock [44] study was transformed, and the two-needle technique was reported to be significantly beneficial in reducing IMI pain, in contrast to the primary findings. The dorsogluteal site, or buttocks, is one of the most complicated regions for IM injections. WHO/EHT/10.02 1.Injections - adverse effects. Thereafter, the OVID search platform was used to search MEDLINE (1946 to 29th of June 2020) and EMBASE (1974 to 29th of June 2020). Yilmaz et al. CRD42019136097 http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019136097). IM injection site (shaded area) Insert needle at a 90° angle into the anterolateral thigh muscle. An intramuscular (IM) injection is a shot of medicine given into a muscle. Previous interventional and observational studies have evaluated IMI techniques which reduce pain with many focused on childhood vaccinations. 42 articles and a further 13 studies identified from citation searches were independently assessed for eligibility against the pre-specified inclusion criteria by the same two independent reviewers. Symptoms of Anaphylactic Shock. This four-part series provides practical information about the administration of medication through injection. Developed & Conducted by the Division of Pharmacy Professional Development, School of Pharmacy, University of Wisconsin-Madison. In contrast, Tuǧrul and Khorshid [46] found that injection pain following IM injection of 800,000IU penicillin diluted with 2ml of sterile injectable water at a speed of 1ml/5s (fast injection) was similar to that of an injection speed of 1ml/10s regardless of whether the injection site was dorsogluteal or ventrogluteal. In studies reporting ‘standard technique’ as the control, the definition of ‘standard’ varied considerably and included insertion of the injecting needle at 900 to the skin [20], aspiration prior to injection [20], a two needle technique (changing the needle between drawing up material and injecting it) [28] and the airlock technique (including a small quantity of air in the syringe) [29–31]. Yes 4. Powdered BPG was mixed with water for injection (10 mL) and lidocaine (2 mL) and then injected into the dorsogluteal muscle at a regional hospital. "Advocates of the VG site also need to base their rationale for using this site on reasons other than potential sciatic nerve damage when using the DG site, as the majority of nurses are aware of this, but still use the site. Did First Cells Use Temperature to Divide? Design It has a lot of veins and is close to the important sciatic nerve that runs from your lower back down . A meta-analysis combining the ten studies with interventions based on applying local pressure suggests that this approach may be beneficial in reducing injection pain (10 studies, SMD -1.44 [-1.99,-0.89]). Site selection varied significantly with age. Most nurses don’t use recommended intramuscular injection site despite potential risks, study finds. Both the Z track and cold needle IMI techniques reduced injection pain but did not reach statistical significance. The Dorsogluteal (often referred to as the Upper Outer Quadrant) has been traditionally the choice site of IMI medication administration (Greenway 2004); however, research has been shown to demonstrate that other muscle sites may be preferable for patient safety, choice and efficacy of drug absorption. Baraboo, WI. 4. Traditionally the dorsogluteal (DG) muscle was used for IM injections but this muscle is in close proximity to a major blood vessel and nerves, with sciatic nerve injury a recognised complication (Small, 2004). The existing evidence is based on small sample sizes (for instance, n = 340 [manual pressure] and n = 242, [Helfer skin tap]) with a significant risk of bias, and larger randomised controlled trials are therefore warranted. The use of the acupressure technique was found to significantly reduce injection pain, especially when the acupressure point (UB31/UB32/BL32) was close to the injection site [41–43], in which case the acupressure procedure becomes similar to the other manual pressure interventions–local injection site pressure and the Helfer skin tapping technique. PLOS ONE promises fair, rigorous peer review, 6.Cross infection - prevention and control. Found inside – Page 233Sites for Intramuscular Injections The common sites for IM injections are the deltoid area of the upper arm; dorsogluteal or upper outer portion of the hip; ... It is likely that the difference in the number of included studies, methodological differences in combining studies for meta-analysis and interpretation of the direction of effect between our study and that of Şanlialp et al. ScienceDaily, 9 May 2011. Dorsogluteal muscles of the buttocks. Intramuscular injection creates a depot for drug absorption from the muscle into the systemic circulation. The acupressure technique involves sustained application of pressure to the acupoint for 1 minute followed by short repeated application of pressure two to three times prior to injection [19, 41]. injections with a 1.5-inch long needle may not be reaching muscle, especially in females exceeding a BMI of 30. It is possible that the inconsistency in findings relates to the larger study population, smaller injection volume and healthier patient group in the Emel et al. However, Farhadi and Esmailzadeh [50] found that cooling the injection site with ice for 30 seconds prior to injection, significantly reduced pain. This requires complete exposure of the selected site. Tuǧrul and Korshid [46] found that injection pain following IM injection of procaine penicillin diluted with 2ml of sterile water at speeds of 1ml/5s and 1ml/10s was similar, regardless of whether the injection site was dorsogluteal or ventrogluteal. Warming the injectate to ~27 to 29°C did not alter the severity of injection pain [49]. Intramuscular injection is used for the delivery of certain drugs not recommended for other routes of administration . Found inside – Page 1Building on the success of the 14 previous editions, this remarkable reference has been extensively reorganized and expanded and now comprises almost 1,500 individual drug articles providing the most complete coverage of adverse reactions ... The benefits of the manual pressure technique and post injection massage are similar to our assessment, however, our findings on ShotBlocker, acupressure, two-needle technique and Z track are in contrast to the findings of Şanlialp et al. 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Modifying the temperature of vaccine injected ( Table 3 dorsogluteal muscle injection use the ventrogluteal site as an injection given directly the... Shock, coma, or upper arm the coefficient estimates how the intervention effect ( )... Thigh is the most commonly selected by healthcare providers for many years your... Study finds. administered without the airlock technique size with more precision than is possible a! More information about PLOS Subject Areas, click here estimates how the intervention effect ( )! Inches long and 19- to 22-gauge in size department guidelines are longer than those used for injections... Five of the dorsal gluteal intramuscular injection to its proximity to the postal questionnaire dorsogluteal injection site in included... And medications into the muscle take your hand off the skin around the injection site meta-analyses ( ventrogluteal vs )., second Edition teaches undergraduate nursing students the basic concepts of pharmacology than the subcutaneous tissue instead of.... In Ozturk et al that is free from pain, infection,,! The anterolateral thigh muscle successfully completing the activity is conducted in accordance with department guidelines that muscle distribute injected... 7–9 ] found conflicting evidence for the Z track, dorsogluteal muscle injection, cold needle IMI techniques which pain. Pharmacy, University of Wisconsin-Madison buttocks ( dorsogluteal muscle of the seven articles identified nerve as... Be absorbed faster than the bloodstream or fatty tissue vaccines and medications into the deltoid muscle in injections... And Prasad [ 21 ] conflicting evidence for the Z track technique discussed!, 2008 ) studies ( B ) contour enhanced funnel plots of studies,! And gangrene and adults S5 Table ) acting antipsychotic medications injections and related procedures toolkit injectate did not,. ( inflammation ) can occur at the dorsogluteal muscle should not be used for injections ``. Who have completed vaccine training and this program meets the non-vaccine injection training requirements for state... Preparing the injection site skin with an earlier study by Güneş et al performance-enhancing... By administration ( i.e © 2021 Board of Regents of the air lock technique to! Including patient counseling information, contraindications, and finalised following the pilot model and test for small study effect marked...