Injectable immunobiologics should be administered where local, neural, vascular, or tissue injury is unlikely. INJECTION ROUTES, MAXIMUM NEEDLE SIZES, AND VOLUMES Because the majority of vaccines have a similar appearance after being drawn into a syringe, prefilling might result in administration errors. Evidence indicates that this cream does not interfere with the immune response to MMR (43). Persons administering vaccinations should follow appropriate precautions to minimize risk for disease exposure and spread. For inactivated vaccines manufacturers, typically recommend use within the same day that a vaccine is withdrawn or reconstituted. Best practice guidance for route, site, and dosage of immunobiologics is derived from data from clinical trials, practical experience, normal intervals of health care visits, and theoretical considerations. Comfort measures, such as distraction (e.g., playing music or pretending to blow away the pain), cooling of the injection site(s), topical analgesia, ingestion of sweet liquids, breastfeeding, swaddling, and slow, lateral swaying can help infants or children cope with the discomfort associated with vaccination (38-40). AAP Immunization Training Guide​​​ 2. Needle length is also a common way in which intramuscular injection needles can be different. USA.gov. Jet injectors are needle-free devices that pressurize liquid medication, forcing it through a nozzle orifice into a narrow stream capable of penetrating skin to deliver a drug or vaccine into intradermal, subcutaneous, or intramuscular tissues (30-31). Saving Lives, Protecting People, Vaccine Recommendations and Guidelines of the ACIP, Adapted from Immunization Action Coalition, https://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6510a2.pdf, List of safety-engineered sharp devices and other products designed to prevent occupational exposures to bloodborne pathogens, National Center for Immunization and Respiratory Diseases, Comprehensive Recommendations and Guidelines, Preventing and Managing Adverse Reactions, Vaccine Recommendations for Emergency Situations, CDC's International Travelers Yellow Book, Clinical Travel Notices, Updates, and Vaccine Shortages, U.S. Department of Health & Human Services. Intramuscular injection may be preferred because muscles have larger and more numerous blood vessels than subcutaneous tissue, leading to faster absorption than subcutaneous or intradermal injections. Quickly insert the needle all the way into the pinched skin at a 90-degree angle (45-degree angle if there is not much fatty tissue). iii. If multiple vaccines are administered at a single visit, administer each preparation at a different anatomic site (26). In this medical video shot at The Adelaide and Meath Hospital in Dublin, we explore the effectiveness of needle length for hypodermic needle injections. For adults a measurement of body mass/weight is allowable prior to vaccination, understanding that resources to measure body mass/weight are not available in all clinical settings. if the subcutane-ous tissue is not bunched and the injection is made at a 90° angle; a 1" needle is sufficient in adults weighing 130–152 lbs (60–70 kg); a 1–1½" needle is recommended in women weighing 153–200 lbs Engineering controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazardexternal icon from the workplace). A decision on needle length and site of injection must be made for each person on the basis of the size of the muscle, the thickness of adipose tissue at the injection site, the volume of the material to be administered, injection technique, and the depth below the muscle surface into which the material is to be injected (Figure 1). Source: Adapted from the Minnesota Department of Health. The deltoid muscle is preferred for children aged 3-10 years (21); the needle length for deltoid site injections can range from ⅝ to 1 inch on the basis of technique. Since the 40 mg potency provides a high concentration in a small volume, particular care should be observed to administer the full dose. 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. Occupational Safety and Health Administration (OSHA) regulations do not require gloves to be worn when administering vaccinations, unless persons administering vaccinations have open lesions on their hands or are likely to come into contact with a patient’s body fluids (2). If the subcutaneous and muscle tissue are bunched to minimize the chance of striking bone (17), a 1-inch needle or larger is required to ensure intramuscular administration. For administration of routinely recommended vaccines, there is no evidence of risk of exposure of vaccine components to the health care provider, so conditions in the provider labeled as contraindications and precautions to a vaccine components are not a reason to withdraw from this function of administering the vaccine to someone else. Band-aid. Other persons at increased risk for influenza complications can administer LAIV. 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). National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Clean the injection site with alcohol. The tip should be inserted slightly into the naris before administration. The anterolateral thigh also can be used. The deltoid muscle is preferred for adolescents 11-18 years of age. Needle length is usually 1"–1½", 22–25 gauge, but a longer or shorter needle may be needed depending on the patient's weight. Pretreatment (30-60 minutes before injection) with a 5% topical lidocaine-prilocaine emulsion might decrease the pain of vaccination by causing superficial anesthesia (41-42). Source: Adapted from Minnesota Department of Health. (b) Note that prefilled syringes of High-Dose Fluzone have a volume of 0.7 cc and the recommended volume of administration is 0.7 ccs. Additional information about implementation and enforcement of these regulations is available from OSHA. 3. However, local reactions or injuries (e.g., skin laceration, transient neuropathy, hematoma) are sometimes more frequent on delivery of vaccine by jet injectors compared with needle injection, depending on the inherent irritability of the vaccine and operator technique (31). bIf the skin is stretched tightly and subcutaneous tissues are not bunched. 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). The vial must be accessed in the immediate patient area to reduce environmental contamination by vaccine virus. This should be 1 to 2 inches (2.5 to 5 centimeters) below that bone. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP), Printer friendly version pdf icon[27 pages]. Vaccine Administration Resources 1. Select the correct needle size for IM based on patient age and/or weight, site, and recommended injection technique. Use of longer needles has been associated with less redness or swelling than occurs with shorter needles because of injection into deeper muscle mass (14). It is useful for allowing access to different regions of the body. The principal sites of injection are the gluteal (buttocks), deltoid (upper arm), and vastus lateralis (thigh) muscles. Equipment: required for IM injection includes: IM medication ampoule; large-bore needle for withdrawing medication from ampoule; 1 mL or 2 mL syringe; 23 gauge 25 mm needle or 25 gauge 16 mm needle for preterm babies two months or younger (see table below) antiseptic swab if used must be allowed to dry before injection given; cotton wool swab Intramuscular shots are given at 90 degree angle. It is also important that health care settings have evidence-based policies in place and the necessary resources provided to ensure safe and correct administration of medication. The barrel holds the medicine and has markings on it like a ruler. 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 (49).  |  (23-25 Gauge Needle. One needle is larger and used to draw the medication into the syringe. 4 Min Read. 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). Release the skin and pull out the needle. For women who weigh >200 lbs (>90 kg) or men who weigh >260 lbs (>118 kg), a 1.5-inch needle is recommended (table 6-2) (18). 10. In this case the needle length should be 1 inch to 1.25 inches. With the exceptions of bacille Calmette-Guérin (BCG) vaccine and smallpox vaccine (administered intraepidermally), injectable vaccines are administered by the intramuscular or subcutaneous route. Step 1: Setting Up for the Injection. See “Needle Gauge/Length and Injection SiteGuidance” below . cSome experts recommend a ⅝-inch needle for men and women who weigh less than 60 kg. ≥1 inch] if possible) so that any local reactions can be differentiated (11,27). To decrease risk of local adverse events, inactivated vaccines containing an adjuvant should be injected into a muscle. Variation from the recommended route and site can result in inadequate protection. Severely immunosuppressed persons (i.e., those who require care in a protected environment, e.g., bone marrow transplant recipients, individuals with severe combined immunodeficiency diseases) should not administer LAIV. Needle sizes were not determined based on body mass index, and the possibility of true intramuscular penetration was minimal. Intramuscular (IM) injections are made into the striated muscle fibers that are under the subcutaneous layer of the skin. Understanding Terms in Continuing Nursing Education and Professional Development. Nisbet recommends that intramuscular gluteal injections should be avoided for most drugs or longer needles should be used. Calves have thinner skin, and a smaller-diameter needle (18-gauge) can be used. 1. Muscle fibrosis; 6. NIH Clipboard, Search History, and several other advanced features are temporarily unavailable. The needle length and gauge are the same as when the deltoid muscle is … Complications of poorly performed IM injection include: 1. 8. HHS 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 (20). AAP Red Book: General Instructions for Vaccine Administration(Login required) 3. Maintain aseptic technique throughout, including cleaning the rubber … If a vaccine and an immune globulin preparation are administered simultaneously (e.g., Td/Tdap and tetanus immune globulin [TIG], hepatitis B and hepatitis B immunoglobulin [HBIG]), separate limbs should be used for each injection (27-28). These include the age and size of the person receiving the medication, and the volume and type of medication. muscle only if the skin is stretched flat between the thumb and forefinger and the needle is inserted at a 90º angle to the skin; a 1" needle is sufficient in patients weighing 130–152 lbs (60–70 kg); a 1–1½" For the majority of infants, the anterolateral aspect of the thigh is the recommended site for injection because it provides comparatively larger muscle mass than the deltoid (Figure 2) (21). 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). Needles and syringes used for vaccine injections must be sterile and disposable. Last Date Updated: September 3, 2020. A larger-diameter needle (no smaller than 16-gauge) is preferred for mature cattle with thick hides, because you’re less apt to bend or break the needle. two. Alcohol swab or Alcohol and Cotton Balls. Choose appropriate needle size and length for the product given, taking the injection site into consideration. Intradermal injection produced antibody responses similar to intramuscular injection in vaccinees aged 18-60 years (55). Needle size for vaccination procedures in children and adolescents. It would be uncommon for persons with these conditions to be in a role administering vaccines. The revised standards became effective in 2001 (2). BMI of 30 in women and 35 in men seem to be upper limits for successful ventral gluteal IM injections with 3.75-cm (1.5-inch) hypodermic needle. Wynaden D, Tohotoa J, Al Omari O, Happell B, Heslop K, Barr L, Sourinathan V. Nurse Educ Today. For women who weigh 152-200 lbs (70-90 kg) and men who weigh 152-260 lbs (70-118 kg), a 1- to 1.5-inch needle is recommended. Once the needle is all the way in, slowly press down on the plunger or injection button to inject all the medicine. (a) For the majority of infants, a 1-inch needle is sufficient to penetrate the thigh muscle. There are 3 parts to a syringe: the needle, the barrel, and the plunger. The needle gauge for intramuscular injection is 22-25 gauge. RESULTS: In most instances, intramuscular medication was inappropriately administered. Certain medicines need to be given into the muscle for them to work correctly. Vaccinators should be familiar with the anatomy of the area into which they are injecting vaccine. What should I know about the syringe? PPSV23and IPV are recommended by the manufacturer to be administered by the subcutaneous or intramuscular route. 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 36°F to 46°F (2°C to 8°C) and should be discarded within 8 hours if not used. The administration device is a nasal sprayer with a dose-divider clip that allows introduction of one 0.1-mL spray into each naris. These include persons with underlying medical conditions placing them at higher risk or who are likely to be at risk, including pregnant women, persons with asthma, and persons aged ≥50 years (2). 2015 Apr;35(4):620-4. doi: 10.1016/j.nedt.2014.12.008. Injection drug users have high rates of unsafe needle use including sharing needles between people. Drugs administered by the intramuscular (IM) route are deposited into vascular muscle tissue, which allows for rapid absorption into the circulation (Dougherty and Lister, 2015; Ogston-Tuck, 2014). 2006 Sep;15(3):195-200. doi: 10.1111/j.1447-0349.2006.00423.x. Abscess formation; 4. This should be 1 to 2 inches (2.5 to 5 centimeters) below that bone. However, because of a theoretical risk for infection, vaccination with ACAM2000 can be offered to health care personnel administering this vaccine, provided individual persons have no specified contraindications to vaccination (8). For live vaccines that require reconstitution, manufacturers typically recommend the vaccine be used as soon as possible after reconstitution and be discarded if not used within 30 minutes after reconstitution. Administering intramuscular injections: how does research translate into practice over time in the mental health setting? Intramuscular Administration. Rotavirus vaccines are licensed for infants. A decision on needle Beirne PV, Hennessy S, Cadogan SL, Shiely F, Fitzgerald T, MacLeod F. Cochrane Database Syst Rev.