575074 research-article2015

CNRXXX10.1177/1054773815575074Clinical Nursing ResearchThomas et al.

Article

Blood Aspiration During IM Injection

Clinical Nursing Research 1­–11 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773815575074 cnr.sagepub.com

Christine M. Thomas, PhD, RN1, Megan Mraz, PhD, RN1, and Lois Rajcan, MSN, RN2

Abstract The World Health Organization and Centers for Disease Control and Prevention no longer recommend aspiration during intramuscular (IM) injections. The purpose of this study was to investigate the technique registered nurses (RNs) use during IM injections and incidence of blood aspiration. This descriptive study surveyed 164 RNs. Results noted that 74% of the sample continue to aspirate at least 90% of the time. Of the participants who continue to aspirate, only 3% aspirate for the recommended 5 to 10 s. Forty percent reported having aspirated blood at least once, whereas 6 RNs (4%) noted blood aspiration ≥13 times. Blood aspiration occurred most frequently in the dorsal gluteal (15%) and deltoid (12%). Based on the findings, it is recommended that RNs use a decisionmaking process to select the safest technique for IM injections. If a parental medication has different administration rates, dose, viscosity, or other concerns when given IM versus intravenously (IV), aspiration during IM administration should be implemented. Keywords IM injection, aspiration, blood aspiration

1West 2The

Chester University, PA, USA Chester County Hospital, West Chester, PA, USA

Corresponding Author: Christine M. Thomas, West Chester University, West Chester, PA 19383, USA. Email: [email protected]

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Introduction The World Health Organization’s (WHO; 2004) and Centers for Disease Control and Prevention’s (CDC; 2011) recent recommendation to eliminate the practice of aspiration during all intramuscular (IM) injections may be premature. The recommendation was based on the assertions that aspiration is not a reliable indicator of correct needle placement; there is a lack of evidence that blood aspiration occurs; adverse reactions of non-aspiration center mostly on the molecular makeup of the medication and not necessarily on the technique; and most nurses do not follow slow aspiration procedures, thereby, rendering the technique of aspiration unnecessary. The recent WHO and CDC recommendations were based on studies conducted with children and infants investigating pain levels during injection (Ipp, Taddio, Sam, Goldbach, & Parkin, 2007; Taddio et al., 2010). The studies noted that the technique of aspiration and the time it took to implement the procedure were related to higher pain levels in children and infants. Taddio et al. (2010) also identified no adverse reactions occurred during IM immunization of children when non-aspiration injection technique was used. Although immunizations recommended to be given in muscles do not pose a danger if given intravenously (IV), there should be considerations for other medications that can pose a danger if given inadvertently in another route (Gammel, 1927; Gorski et al., 2011; Li, Lockey, Bernstein, Portnoy, & Nicklas, 2003; Ozel, Yavuz, & Erkul, 1995).

Background Nursing textbooks continued to list aspiration as a necessary component of IM injection technique until about 2011 (Lynn, 2011). The rationale for aspiration was to prevent a serious reaction if a drug intended for IM injection was injected into a vein or artery (DeLaune & Ladner, 2002; Lynn, 2008). Different medications are tolerated better by certain routes. For example, some medications have a high pH and are better tolerated IV, as the higher pH is neutralized faster as the medication mixes into the general circulation. Different routes also require changes in dose for safe use. The onset and peak of medications are much faster in IV administration (immediately, 3-5 min) compared with IM (15 min, 30-60 min). Therefore, if a higher narcotic medication dose is mistakenly given IV, the patient could have a much more serious adverse reaction to the medication. Although these problems are not issues for common immunizations, these are real issues for medication routinely given the IM route in acute care settings in the United States (Morphine, Dilaudid [hydromorphone], Ativan [lorazepam], Haldol [haloperidol], and Penicillin G).

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A few adverse events such as paralysis, necrosis, and parathesia related to IM injection have been documented in the past (Gammel, 1927; Ozel et al., 1995). The WHO (2004) and CDC (2011) note that no published evidence indicates that blood aspiration actually occurs when the technique is used. However, many nurses anecdotally note blood aspiration during IM injection does occur in practice. Although there is no recent documented research evidence regarding the incidence of blood aspiration, how does the lack of evidence become evidence? Further research is needed to identify the safe practice for IM injection technique. It is speculated that IM injections for therapeutic use became a standard practice in the late 1880s by physicians (Hanson, 1963; Howard-Jones, 1971; Nicoll & Hesby, 2002). By 1960, IM injection by nurses was a routine procedure. IM technique and equipment have steadily changed over the last century. A review by Rodger and King (2000) noted that the literature is “consistent in recommending aspiration for blood . . . following insertion of the needle” (p. 580). Mallet and Bailey (1996) advocated that the plunger of the syringe should be drawn back for 5 to 10 s, thereby creating a negative pressure in the tissue below it. If the needle is in a low flow blood vessel, a 5- to 10-s period of negative pressure was needed for blood to appear in the syringe (Keen, 1990; Nicoll & Hesby, 2002). If a blood vessel is compromised, blood will appear in the syringe, and the needle should be withdrawn. At this point, the whole medication and site-preparation procedure should be repeated (Workman, 1999). Most of the recommended procedures for IM injection techniques are theory based to help diminish the incidence of injury reported by documented injury cases (Lachman, 1963; Ozel et al., 1995; Talbert, Haslam, & Haller, 1967). However, a study by Beecroft and Redick (1989) reported that incidence of blood aspiration was the second most common complication during IM injection and occurred about 28% of the time for a sample of 596 pediatric nurses. Beecroft and Redick identified that the frequency of blood aspiration although low, does occur. Historically, the aspiration technique was taught as a precaution against accidental intravenous or intraarterial administration of medications that can potentially lead to systemic dose reactions, allergic reactions, chemical phlebitis of the vascular system, or arterial embolism (Gammel, 1927; Gorski et al., 2011; Li et al., 2003). Within the last 20 years, the technique of IM injection has evolved. The difference between slow versus fast aspiration was recommended in the mid 1990s and began to show up in nursing education textbooks in the 2000s (Kozier, Erb, Berman, & Burke, 2003; Lynn, 2008). Slow aspiration over 5 to 10 s was recommended because it takes time for the blood to appear if the needle is in a small blood vessel. Whether the use of

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slow aspiration increased or decreased the incidence of blood aspiration during IM injection in practice has not been investigated. Based on the conflicting evidence, recent recommended changes in IM technique, and anecdotal experience of many nurses, further research and its dissemination are needed to provide evidence for practice standards of IM injection technique. The purpose of this study was to investigate the technique registered nurses (RNs) use during IM injections and incidence of blood aspiration.

Design/Method The study used a descriptive design to survey RNs on their IM injection technique, incidence of blood aspiration, and injury that had occurred during their nursing career. Research questions for the study included the following: Research Question 1: How often is aspiration used during IM injection by RNs? Research Question 2: What amount of time do nurses spend in aspiration during IM injection? Research Question 3: What is the incidence of RN blood aspiration while performing IM injections? Research Question 4: What is the incidence of injury that occurs from IM injection by the RN? A pilot study (N = 12) was conducted with nursing faculty in a state university. Based on feedback from the pilot study, three questions were changed on the survey regarding ability to aspirate due to equipment/syringe and demographic information. Because the survey was changed, pilot data were not folded into the main study and faculty were again recruited to participate in the main study. The finalized survey included demographic questions and eight questions of varying response types (select best option, Likert-type scale, and fill in the blank), which included calendar year participants learned to administer IM injections; whether participants currently use aspiration when administering IM injections; frequency in which they used aspiration technique (7-point Likert-type scale from never to every time); if they aspirate, what amount of time is spent when aspirating prior to injection (in seconds), and, if not, rationale for not aspirating. The survey asked for incident of blood aspiration during their career as a nurse, muscles in which blood aspiration occurred, and type of injury that may have occurred as a result of IM injection.

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To control for Type I and II errors, a moderate effect size, an alpha of .05, and a power of 0.80 were used to calculate the study sample size. Based on this, approximately 122 participants were needed. The main study recruited 165 participants in one community hospital and one state university over a 1-month period. Of the 165 surveys collected, 164 were complete and used for data analysis. For inclusion, participants had to be a practicing RN. Institutional review board approval for both the pilot and main study was obtained. Participant verbal consent to participate and completion of the questionnaire served as consent. Researchers recruited participants during regularly scheduled committee meetings in the hospital and university. Paper surveys were distributed to participants with a return envelope. Participants were instructed to return surveys in the envelope to protect those who did not wish to participate and/or withdraw from the study during data collection. The researcher and study letter of explanation explained that results would remain confidential, only group aggregate data would be reported, participation or non-participation would not affect employment, and no compensation would be given for participation in the study. Institutions were not notified of participant inclusion or exclusion in the study.

Results See Table 1 for sample demographics. The majority of participants (63%) learned their IM injection technique before 2000, when slow aspiration was recommended. Three percent of the sample learned IM injection technique in 2011 and later, when no aspiration began to be recommended. When asked how often they aspirated during IM injection, the most frequent response was every time (48%) followed by about 90% of the time (26%), with 15% of the sample listing between 30% and 70% of the time, and 10% listed rarely or never (see Table 2 for frequency of performing aspiration). As to reasons why they did not aspirate during IM injection (n = 45), 22% selected “I see no purpose/benefit in aspirating,” 16% selected “I was taught not to aspirate,” and 9% selected “The equipment/syringe provided did not allow aspiration.” Other reasons listed by participants included that the injection was needed in an emergency situation (29%), a change in practice has been recommended (13%), it takes too long to aspirate (9%), and one participant listed forgetting to aspirate (2%). Of those participants who reported aspirating during IM injections, the amount of time they spent aspirating was low. Most aspirated 2 s or less (67%), 26% reported aspirating 3 to 4 s, and only 3% reported aspirating 5 s. No participant reported aspirating more than 5 s. Whereas 60% of the sample reported never having aspirated blood during IM injections, 40% noted aspirating blood at least once, and 6 RNs (4%)

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Table 1.  Sample Demographics. Variable Age (years) Years of RN practice RN specialty   Adult acute, Medical/Surgical, ICU, ER   Maternal child  Other   Pediatric acute  Psychiatric Highest level of education  Diploma  Associate  Bachelor  Masters  Doctoral  Other

M (SD)

n (%)

44.5 (11.5) 17.7 (12.1)

    85 (52%) 15 (9%) 52 (32%) 7 (4%) 2 (1%) 28 (17%) 25 (15%) 76 (46%) 24 (15%) 8 (5%) 2 (1.2%)

Note. RN = registered nurse; ICU = intensive care unit; ER = emergency room.

noted blood aspiration 13 times or more (see Table 2 for blood aspiration incidence). Of the RNs who aspirated blood during injection (n = 65), 31% reported not remembering which muscle it occurred in. However, the dorsal gluteal was the most frequently reported muscle (15%), followed by deltoid (12%), ventral gluteal (6%), vastus lateralis (4%), and rectus femoris (1%). Only 4% of the participants identified that an injury may have occurred related to IM injection. The types of injuries identified included abscess, nerve injury, tissue necrosis, and infection.

Discussion The CDC and WHO state that it is not necessary to aspirate prior to IM injection, and they no longer recommend the technique as part of health care practice. This is based on recent studies of pediatric vaccinations (Ipp et al., 2007; Taddio et al., 2010). While lower levels of pain were identified and no injuries were noted in previous studies when aspiration was eliminated from IM injection technique during pediatric immunization, the present researchers question as to whether this is safe practice in all settings and/or when administering all medications IM. This study supports findings of Beecroft and Redick (1989) and found that blood aspiration does occur in the acute care

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Thomas et al. Table 2.  Frequency of Performing Aspiration and Blood Aspiration Incidence. Variable

n (%)

Frequency of performing aspiration during IM injection (n = 156)  Never  Rarely   Occasionally—about 30%   Sometimes—about 50%   Frequently—about 70%   Usually—about 90%   Every time Incidence of blood aspiration  0  1  2  3  4  5  >13

  3 (2%) 13 (8%) 8 (5%) 10 (6%) 5 (3%) 42 (27%) 75 (48%) 99 (60%) 32 (20%) 11 (7%) 7 (4%) 4 (3%) 3 (2%) 6 (4%)

Note. IM = intramuscular injections.

setting and other patient populations. Of the RNs surveyed, 40% noted having aspirated blood at least once during IM injections, and 4% reported a high incidence of 13 or more times. This evidence identifies that aspiration of blood does occur. The recommendation of complete elimination of aspiration during IM injection for all IM injections may not be safe practice. Instead, nurses should identify whether a medication, dose, or administration rate would be harmful if given IV. When these instances occur and could pose a threat to patient safety if accidently given IV versus IM, then the practice of aspiration during the IM injection procedure should be implemented. However, judgment should be used as to whether the patient condition or emergent situation permits the safe implementation of aspiration during IM injection. This descriptive study had limitations. The sample was limited to nurses in one small community hospital and one state university. The study did not survey all the nurses in these settings. As a result, the sample may not represent the population of nurses practicing and cannot be generalized. The study noted that the majority of the sample do not aspirate for the recommended amount of time (5-10 s); therefore, location of the needle into a small blood

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vessel may occur more frequently without evidence of blood appearing in the syringe. The survey indirectly measured the frequency of aspiration of blood based on the memory of the nurses sampled. Some participants may have forgotten or estimated the frequency in which they experienced aspiration of blood during IM injections.

Clinical Application As identified by this study and noted by Beecroft and Redick (1989), when aspiration is used during IM injections, aspiration of blood can occur. This contradicts the information that was used for the recent recommendations from the CDC and WHO for changes in IM injection technique. Therefore, implementing aspiration during certain IM injections could assist in decreasing the incidence of injury due to inadvertent venous/arterial administration during IM injections. Instead of a blanket policy of no aspiration or aspiration for all IM injections, nurses should use a decision-making model for IM injection technique. The decision-making process should include the following: 1. Aspiration should not be used if the length of time used for effective aspiration would pose a danger to patient or nurse and when the medications would not pose a patient safety concern if mistakenly given venous/arterial. Study results noted participant examples of this such as “emergency situation, combative patient” and “patient safety, that is, unable to stabilize limb, etc., with patient actively withdrawing.” Previous research notes significant increases in pediatric pain levels during immunizations when aspiration is used and no significant side effects when aspiration was not used (Ipp et al., 2007; Taddio et al., 2010). Because the immunization medication dose or components if inadvertently given in IV or arterially do not pose a significant risk, no aspiration is needed for this type of medication. 2. Aspiration should be used if the medication would be a safety concern if mistakenly given venous or arterial. The nurse should evaluate whether the medication being administered would be harmful if injected into the vasculature based on rate of administration, dose, viscosity, or other reasons. Prior to IM administration, the nurse should identify whether the medication if inadvertently given into the vascular system poses a danger to the patient. Examples of medications that should include the procedure of aspiration include high doses of narcotics, as IM and IV narcotic rate of administration and doses are different. Viscous medications such as Ativan (lorazepam) require a 1:1 dilution if administered IV versus IM.

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The data noted that most nurses do not aspirate for the recommended time of 5 to 10 s, which may have lowered the 40% blood aspiration incidence noted in the study. Practice theory notes that aspiration for less time than recommended could render aspiration ineffective (Keen, 1990; Nicoll & Hesby, 2002). If all conditions warrant the nurse to move forward with aspiration, it is essential to the process that the nurse aspirates for 5 to 10 s. More research is needed regarding blood vessel size in muscles used, needle penetration, and how medications are disbursed when a blood vessel is nicked versus cannulated during IM injections.

Conclusion Research has noted that aspiration of blood during IM injection does occur. A decision-making process is needed for all nursing care, including IM injection technique. If a parental medication has different administration rates, dose, viscosity, or other concerns when given IM versus IV, aspiration during IM administration should be implemented. However, further research is needed. Currently, no precise incidence or ratio of blood aspiration occurrence during IM injection is known. It has been theorized that if during IM injection technique aspiration of blood occurs and the medication is administered, the medication will directly enter the venous or arterial system versus the muscle. Research investigating where the medication is disbursed in this case and to what degree is needed. This would provide more information for decision making regarding when the practice of aspiration should or should not be implemented during IM injections to protect patient safety. This study identifies the need for further evidence to inform the practice of IM injection technique that blends practice, theory, and research. The researchers recommend a systematic decision-making process that includes patient condition, medication properties, and the situation at hand be used by nurses during IM injections to decide whether aspiration is warranted. Acknowledgments The authors would like to thank Angela Coladonato, MSN, RN, Nurse Executive Advanced-Board Certified(NEA-BC), and West Chester University Department of Nursing for their support in this study.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References Beecroft, P. C., & Redick, S. A. (1989). Possible complication of intramuscular injections on a pediatric unit. Pediatric Nursing, 15, 333-336. Centers for Disease Control and Prevention. (2011). General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practice (ACIP). Morbidity and Mortality Weekly Report, 60(2), 1-60. DeLaune, S. C., & Ladner, P. K. (2002). Fundamentals of nursing: Standards and practice (2nd ed.). New York, NY: Delmar. Gammel, J. A. (1927). Arterial embolism: An unusual complication following the intramuscular administration of bismuth. The Journal of the American Medical Association, 88(13), 998-1000. Gorski, L. A., Eddins, J., Hadaway, L., Hagle, M. E., Orr, M., Richardson, D., & Williams, P. A. (2011). Infusion nursing standards of practice, Standard 47: Phlebitis. Journal of Infusion Nursing, 34(Suppl. 1), S65-S66. Hanson, D. J. (1963). Intramuscular injection injuries and complications. General Practitioner, 27, 109-115. Howard-Jones, N. (1971). The origins of hypodermic medication. Scientific American, 224, 96-102. Ipp, M., Taddio, A., Sam, J., Goldbach, M., & Parkin, P. C. (2007). Vaccine-related pain: Randomized controlled trial of two injection techniques. Archives of Disease in Childhood, 92, 1105-1108. Keen, M. (1990). Get on the right track with Z-track injections. Nursing, 20(8), Article 59. Kozier, B., Erb, G., Berman, A. J., & Burke, K. (2003). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Prentice Hall. Lachman, E. (1963). Applied anatomy of intragluteal injections. The American Surgeon, 29, 236-241. Li, T., Lockey, R. F., Bernstein, I., Portnoy, J. M., & Nicklas, R. A. (2003). Allergen immunotherapy: A practice parameter. Annals of Allergy, Asthma & Immunology, 90(1), 1-39. Lynn, P. (2008). Lippincott’s photo atlas of medication administration (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Lynn, P. (2011). Lippincott’s photo atlas of medication administration (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Mallet, J., & Bailey, C. (1996). The Royal Marsden NHS trust manual of clinical nursing procedures (4th ed.). London, England: Blackwell Science. Nicoll, L. H., & Hesby, A. (2002). Intramuscular injection: An integrative research review and guidelines for evidence-based practice. Applied Nursing Research, 16, 149-162.

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Ozel, A., Yavuz, H., & Erkul, I. (1995). Gangrene after penicillin injection: A case report. Turkish Journal of Pediatrics, 37(1), 67-71. Rodger, M. A., & King, L. (2000). Drawing up and administering intramuscular injections: A review of the literature. Journal of Advanced Nursing, 31, 574-582. Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., . . . Shah, V. (2010). Reducing the pain of childhood vaccination: An evidence-based clinical practice guideline. Canadian Medical Association Journal, 182(18), E843-E855. Talbert, J. L., Haslam, R. H., & Haller, J. A. (1967). Gangrene of the foot following intramuscular injection in the lateral thigh. Journal of Pediatrics, 70, 110-114. Workman, B. (1999). Safe injection techniques. Nursing Standard, 13(39), 47-53. World Health Organization. (2004). Immunization in Practice, Module 6: Holding an immunization session. In Immunization in practice: A practical resource guide for health workers—2004 update (pp. 1-29). Retrieved from http://whqlibdoc. who.int/publications/2004/9241546514_(Module6).pdf

Author Biographies Christine M. Thomas, PhD, RN, is an associate professor at West Chester University. Megan Mraz, PhD, RN, is an associate professor at West Chester University. Lois Rajcan, MSN, RN, CRNI (Certified Registered Nurse Intravenous), is IV/PICC (Intravenous/Peripherally Inserted Central Catheter) team leader at Chester County Hospital.

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Blood Aspiration During IM Injection.

The World Health Organization and Centers for Disease Control and Prevention no longer recommend aspiration during intramuscular (IM) injections. The ...
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