In this type of injection, a short needle is used to inject a drug into the tissue layer . Intramuscular (IM injection is one of many routes for administering medications, including antibiotics, vaccines, hormonal therapies, and corticosteroids. An IM injection should be given only when less painful options are not feasible. Preferred site: Deltoid muscle in the upper arm Use anatomical landmarks to determine the injection site. MeSH terms Ambulatory Care Because the recommended sites for pediatric IM injections for vaccines have no large blood vessels, the practice of aspiration for immunization or toxoids is unnecessary.2 However, aspiration is routinely used and is recommended when medications other than vaccines or toxoids are administered. The IM route allows for rapid absorption of specific medications. Position the patient and initiate developmentally appropriate distraction measures. The cookies is used to store the user consent for the cookies in the category "Necessary". However, you may visit "Cookie Settings" to provide a controlled consent. Begin by having the patient relax the arm. (about 80 times the maximum recommended human dose). Analytical cookies are used to understand how visitors interact with the website. https://www.clinicalkey.com/nursing/#!/content/drug_monograph/6-s2.0-5295, https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html, https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf, https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html. Retrieved May 23, 2022, from. Don appropriate personal protective equipment (PPE) based on the patients need for isolation precautions or the risk of exposure to bodily fluids. Use of longer needle (1inch) significantly reduces the local reaction instead of short needle except in neonate, when 16mm needle is suitable. To locate the muscle, place the palm of a hand over the greater trochanter of the femur, facing the index finger and thumb towards the umbilicus, along the anterior iliac spine. In certain circumstances (e.g., physical obstruction to other sites and no reasonable indication to defer doses), the gluteal muscle can be used. Let the area dry. Instruct the family regarding the potential adverse effects of the medication. In M.J. Hockenberry, C.C. Monitor the patient for adverse and allergic reactions to the medication. The anterolateral aspect of the thigh, or vastus lateralis muscle, is the preferred IM site for neonates and infants. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. Centers for Disease Control and Prevention. Subcutaneous injection: injection of a biological product into the layer of fatty tissue between the skin and muscle. 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. . It does not store any personal data. For this reason, laboratory devices and in-process measurement injection molding tools have been developed to measure demolding forces. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. What is the maximum volume to inject on a horse if you are giving an intramuscular injection? For serious infections, AAP recommends a dose of 100 mg/kg/day IV or IM divided every 12 to 24 hours (Max: 4 g/day). The smallpox/monkeypox vaccine (Jynneos) is primarily administered by the subcutaneous route but in some circumstances is administered by the intradermal route. The location of all injection sites with the corresponding vaccine injected should be documented in each patients medical record. Label all medications, medication containers, and other solutions. angle. ACIP discourages the routine practice of providers prefilling syringes for several reasons. Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. 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). aspect, lateral to the midpoint of the thigh. Intramuscular (IM) administration is by injection into the striated muscle ( Hopkins and Arias, 2013 ). The FDA-approved labeling recommends 50 to 75 mg/kg/day IV or IM divided every 12 hours (Max: 2 g/day) for serious infections. With a new, sterile dose chamber and nozzle for each patient and correct use, these devices do not have the same safety concerns as multiple-use nozzle jet injectors. ), Institute for Safe Medication Practices (ISMP). The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Erythema or swelling at the injection site. Do you need underlay for laminate flooring on concrete? 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 (15,19-22). Maximum volume is 3 mL in adults, 2mL for ages between 6-13 years, 1.5 mL for between 3-6 years, and 1 mL for ages between 1 - 3 years. Other persons at increased risk for influenza complications can administer LAIV. This cookie is set by GDPR Cookie Consent plugin. Source: Adapted from Minnesota Department of Health. These side effects are generally mild and last no more than a few days at most. . Choosing a muscle is dependent on the medication volume and the age or size of the patient. For deep IM injections, the recommended volume ranges from 2 to 5 ml. 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. We also use third-party cookies that help us analyze and understand how you use this website. The cookie is used to store the user consent for the cookies in the category "Performance". The most appropriate sites for IM injections are the vastus lateralis (anterolateral thigh) for infants and toddlers and the deltoid muscle for pediatric patients 3 years and older.6 Selection of the injection site is based on the patients age, muscle mass, medication volume, and medication viscosity. The apparent volume of distribution at steady state (Vss) of ertapenem in adults is approximately 0.12 liter/kg, approximately 0.2 liter/kg in pediatric patients 3 months to 12 years of age and . For older children and adults, the deltoid muscle can be used for more than one intramuscular injection. For more than 150 additional . What characteristics allow plants to survive in the desert? What is the maximum volume for intramuscular injection in pediatrics? 4 What is the largest amount of medication that can be injected into the deltoid muscle? Injections (intramuscular) Your child needs to take a medicine by intramuscular (into the muscle) injection. Because the majority of vaccines have a similar appearance after being drawn into a syringe, prefilling might result in administration errors. 1,2 Even when alternate routes of administration are available, IM injections may be preferred when a patient cannot tolerate oral, 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 iNTRAMUsCUlAR iNJECTiONs Once administered exclusively by physicians, IM injections became a primary-nurse responsibility during the 1960s.1. However, if 2 half-volume formulations of vaccine have already been administered on the same clinic day to a patient recommended for the full volume formulation, these 2 doses can count as one full dose. read the disclaimer. Attach an appropriate-size needle to the syringe (. The doses should be administered as soon as possible after filling, by the same person who filled the syringes. The maximum amount of medication for a single injection is generally 1 ml. Oral typhoid capsules should be administered as directed by the manufacturer. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Volumes of up to 4 ml can be administered to this site if the patient's available muscle tissue is limited and dorsogluteal muscle is required. Smoothly, quickly, and steadily withdraw the needle and release the skin. Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. The recommended volume ranges from 2 to 5 ml for "deep" IM injections. In general, for an adult male weighing 60 kg to 118 kg (130 to 260 lbs), a 1-inch (25 mm) needle is sufficient. What is causing the plague in Thebes and how can it be fixed? The needle gauge for intramuscular injection is 22-25 gauge. 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). ), Centers for Disease Control and Prevention (CDC). Intramuscularly (IM): An intramuscular injection is one that is given in the muscle. For deep IM injections, the recommended volume ranges from 2 to 5 ml. Hepatitis B. Many medications must be injected intramuscularly because of chemical properties, pharmacokinetics, desired onset, intensity and duration of the effect, and certain patient characteristics related to treatment compliance. The tip should be inserted slightly into the naris before administration. The purpose of IM injections is to administer medication safely into the muscle below the subcutaneous layer. CDC twenty four seven. static compliance and maximum expiratory flow at 50% of awake total lung capacity (V max) increase. The cookie is used to store the user consent for the cookies in the category "Other. This cookie is set by GDPR Cookie Consent plugin. Unused syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) should be discarded at the end of the clinic day. Your deltoid muscle is the large muscle in your upper arm, just below your shoulder. These cookies track visitors across websites and collect information to provide customized ads. If worn, gloves should be changed between patients. (4, 10) Review medication information pertinent to the medications action, purpose, onset of action and peak action, normal dose, and common side effects and implications. Assess the patients and familys experiences with IM medication administration. 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. - 5-mL syringe; 2-inch (5-cm), 20-gauge needle - 1 mL syringe; -inch (1.25-cm), 26-gauge needle -insulin syringe; 1-inch (2.5-cm), 16-gauge needle - 1 mL syringe; -inch (1.25-cm), 26-gauge needle A nurse is using the Z-track technique to administer an injection to a client. IM injection included poor injection-site selection and not advancing the needle to full length. iliac spine and the greater trochanter of the femur. The anterolateral thigh can also be used (25). ACIP discourages variations from the recommended route, site, volume, or number of doses of any vaccine. Document the procedure in the patients record. Guidelines for subcutaneous and intramuscular injection Click here to proceed to intramuscular injection information . Children receive numerous vaccines, and pediatric nurses administer the majority of these vaccines via the intramuscular route, and thus must be knowledgeable about safe and evidence-based immunization 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. They will have . -Rapid injection is preferred. Generally only limited injection volumes can be given by intramuscular injection: 2 ml in the deltoid and thigh muscles, and up to 5 ml in the gluteus maximus. What happens if you inject into muscle? Position the ulnar side of the nondominant hand just below the site and pull the skin laterally. 2 ml in a school-age child. The injection site affects how much fluid can be given and how quickly the medication will be absorbed. It is suitable for small volume injections. 1 mL in an older infant >1month. The most common serious complications of intramuscular injections in children are muscle contractures and nerve injury. Jet injectors prevent needlestick injuries to health-care providers (2) and can overcome improper, unsterile reuse and other drawbacks of needles and syringes in developing countries (9, 38-39). Learn more about Clinical Skills today! Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. For injection into the anterolateral thigh muscle, a 1.5-inch needle should be used, although a 1-inch needle may be used if the skin is stretched tightly and subcutaneous tissues are not bunched. The combination of oral sucrose and radiant warmth is effective analgesia for healthy neonates and young infants receiving IM vaccination.3 Diversional activities and education may comfort a patient receiving an IM injection. If giving a larger shot, give 15 mls, pull the needle out until you are almost out if the skin, push it back in at a much different angle, check for blood, then complete the injection. 7. 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). Maximum volumes to be injected intramuscularly: 0.5 mL in a small infant <1month. Administering a vaccine containing an adjuvant either subcutaneously or intradermally can cause local irritation, induration, skin discoloration, inflammation, and granuloma formation. 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 (40-42). The cookie is used to store the user consent for the cookies in the category "Performance". An additional dose of 1 mg or 0.2 mL may be repeated if there has been no response after 15 minutes while waiting for emergency assistance. (b) If skin is stretched tightly and subcutaneous tissues are not bunched. Small muscles absorb small volumes. Haemophilus influenzae type b. Perform hand hygiene. Follow the organizations practice for emergency response. A higher gauge needle refers to a smaller outside diameter of the needle tubing. Vaccine recommendations and guidelines of the ACIP: Vaccine administration. March/April 2014 - Volume 39 - Issue 2 Previous Abstract; Next Abstract CE Connection. Learn how Elsevier can support you in providing care to patients. But opting out of some of these cookies may affect your browsing experience. Whats the maximum volume of an IM injection? 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. *The anterolateral thigh may be used. Share. The ventrogluteal muscle can accommodate up to 2.5 ml, with a maximum volume of 3 ml. Apply a gauze with light pressure for several seconds over the site; do not massage. Rodgers, D. Wilson (Eds. 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. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 7. If over age 2, then 2 mL in DG is ok, even though I never do it because I HATE giving DG injections. Needles are generally 3/8 to 1 inch in length and 24 to 27 gauge. 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. 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) (20). 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. In general, for an adult male weighing 60 kg to 118 kg (130 to 260 lbs), a 1-inch (25 mm) needle is sufficient. d. The anterolateral thigh can also be used. It does not store any personal data. These cookies will be stored in your browser only with your consent. Apply a topical anesthetic as ordered. Smoothly, quickly, and steadily withdraw the needle. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. Hepatitis A. If injecting into the vastus lateralis , ventrogluteal, gluteus medius, or dorsogluteal muscles of an adult, the volume should not exceed 3 mL. Using reduced doses administered at multiple vaccination visits that equal a full dose or using smaller divided doses is not recommended (4). The method of administration of injectable vaccines is determined, in part, by the inclusion of adjuvants in some vaccines. These cookies track visitors across websites and collect information to provide customized ads. 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). Repeating doses of vaccine administered by the intramuscular route when recommended to be by the subcutaneous route is not necessary (10). Similarly, doses of rabies vaccine administered in the gluteal site should not be counted as valid doses and should be repeated (54). Place the middle finger toward the iliac crest creating a NOTE: Values are in ml/kg unless otherwise specified. Infants and children weighing up to 20 kg (44 pounds)Dose is based on body weight and must be determined by your doctor. up to a maximum dose of 1 g/day . Necessary cookies are absolutely essential for the website to function properly. Follow the manufacturers instructions for application and time to peak effect. 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). V shape. Bloodborne diseases (e.g., hepatitis B, hepatitis C, human immunodeficiency virus [HIV]) are occupational hazards for clinicians and other health-care providers. What are some examples of how providers can receive incentives? Do not touch this area until you give the injection. Open the alcohol wipe: Wipe the area where you plan to give the injection. Figure 4.1 Preferred site for intramuscular and deep subcutaneous injections in older children and adults Figure 4.3 Preferred site for BCG injections in babies and adults Figure 4.2 Preferred site for intramuscular and deep subcutaneous injections in infants under one year of age IM or deep SC injection site Immunisation procedures June 2012 This is the preferred site for anaphylaxis What is maximum safe volume that a neonate can receive in an intramuscular injection? Many medications must be injected intramuscularly because of chemical properties, pharmacokinetics, desired onset, intensity and duration of the effect, and certain patient characteristics related to treatment compliance. A child life specialist should be enlisted to support the patient, if available. Be truthful about discomfort but be positive about the benefits of the medicine. The maximum amount of medication that can be subcutaneously injected is about 2 ml. Clinical judgement is required when selecting an injection site and needle length. Which site is most desirable for a 3 ml intramuscular injection? Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. Up to 4mls can be injected into this site. Verify the patients daily weight in kilograms. If administering an IM injection into a child under age 2, the maximum amount that should be administered is 1 mL. A -inch, 23- to 25-gauge needle should be inserted into the subcutaneous tissue (Figures 4and 5) (4). Greater (2022). Once the ID injection is completed, a bleb (small blister) should appear under the skin. May be the safest and least painful IM injection site. What can go wrong with an intramuscular injection? Hepatitis A vaccine and meningococcal conjugate vaccine do not need to be repeated if administered by the subcutaneous route (55-56). 1 What is the maximum volume that can be injected intramuscularly? The sites most commonly used for IM injection are the deltoid, dorsogluteal, rectus femoris, vastus lateralis, and ventrogluteal muscles. The site of injection is usually rotated when injections are frequently given. Explain how the patient can assist by holding still. Please remember to 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. To find the injection site, feel for the bone at the top of your arm where your arm meets your shoulder. Rodgers, D. Wilson (Eds. If the skin is stretched flat, a 1/2 inch needle is sufficient. The regulations also require maintenance of records documenting injuries caused by needles and other medical sharp objects and that nonmanagerial employees be involved in the evaluation and selection of safety-engineered devices before they are procured. 2. The maximum volume should not exceed 1 mL. shoulder. Dorsogluteal site: Evidence indicates that this cream does not interfere with the immune response to MMR (45). Assess for the intended response to medication. Use of longer needles has been associated with less redness or swelling than occurs with shorter needles because of injection into deeper muscle mass (16). (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). Consider consulting a child life specialist if available. The vial must be accessed in the immediate patient area to reduce environmental contamination by vaccine virus. With the exceptions of bacille Calmette-Gurin (BCG) vaccine and smallpox vaccine [ACAM2000] (both administered by the percutaneous route), injectable vaccines are administered by the intramuscular or subcutaneous route. Hold the syringe between the thumb and forefinger of the dominant hand as if holding a dart, palm down. Pediatric Nursing Procedures (pp. Select an appropriate injection site based on the patients age and muscle mass, the medication volume, and the viscosity of the medication (. Variation from the recommended route and site can result in inadequate protection. With a maximum volume of 3 ml, the ventrogluteal muscle can hold up to 2.5 ml. Explain that the patient may feel pain and anxiety during the procedure. Intramuscular injection: injection of a biological product into muscular tissue. With the exception of new born babies or premature neonates, evidenced-based practice demonstrates that a needle size of 25 Gauge (1 inch) 0.6mm by 25mm length, is the most appropriate size to . Verify the correct patient using two identifiers. Use a bar code system or compare the MAR to the patients identification band. Pediatric Intramuscular Injections Guidelines for Best Practice Author Information . These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Overall, 5 mL has been cited for adults as the maximum volume for a single IM. Guidelines for Intramuscular and Subcutaneous In Intramuscular In 'ections .ection Administration SITE Vastus lateralis Ventrogluteal Deltoid Dorsogluteal Infant Needle length: 5/8 inch Volume: 0.5 ml, * *recommended for infants < 7 . For a well-developed adult, no more than 5 ml of medication should be administered in a single IM injection because the muscle tissue does not absorb it well.
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