Digital Edition: SKILLS - INTRAMUSCULAR INJECTIONS 01 July, 2003 An intramuscular (IM) injection is the administration of medication through the cutaneous and subcutaneous layers, into the muscle. Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. For an infant who is unable to breastfeed or for an infant who does not breastfeed, consider nonnutritive sucking, sucrose, and warmth. The maximum amount of medication for a single injection is 3 ml. Don appropriate PPE based on the patients need for isolation precautions or the risk of exposure to bodily fluids. The patient can be positioned lying on their stomach or standing up. When choosing a needle size, factors to be considered include the weight of the patient, age, amount of adipose tissue, medication viscosity, and injection site (Hunter, 2008; Perry et al., 2018; Workman, 1999). Anderson, C.E., Herring, R.A. (2022). Pediatrics (1982) 70 (6): 944-948. Chapter 20: Pediatric nursing interventions and skills. The needle gauge for intramuscular injection is 22-25 gauge. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Rarely, nerves or blood vessels around the injection site can be damaged, resulting in severe pain or paralysis. 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. Intramuscular (IM injection is one of many routes for administering medications, including antibiotics, vaccines, hormonal therapies, and corticosteroids. The deltoid muscle is the preferred injection site in children aged 3-18 years when muscle mass is more developed. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. Choosing a muscle is dependent on the medication volume and the age or size of the patient. 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. Technically Speaking columns cover practical topics in immunization delivery such as vaccine . Additional information about implementation and enforcement of these regulations is available from OSHA. Use of longer needle (1inch) significantly reduces the local reaction instead of short needle except in neonate, when 16mm needle is suitable. 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 (33). 3 mL in an adolescent Maximum volumes to be injected subcutaneously: Recommended maximum volumes to be injected subcutaneously may range from 0.5 mL to 2 mL depending on your patient. 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. Apply a gauze with light pressure for several seconds over the site; do not massage. Stated, estimated, or historical weight should not be used. Which site should be used to administer an intramuscular injection for a 6-month-old patient? You also have the option to opt-out of these cookies. These federal regulations require the use of engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens. Local anesthesia or tactile stimulation should be considered to decrease pain at the injection site. What is the fastest way to get rid of a tight foreskin? 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 . 1 What is the maximum volume that can be injected intramuscularly? 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. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. How many mL can be given IM to an infant's? AGE INJECTION SITE* NEEDLE LENGTH & GAUGE (G) MAXIMUM VOLUME 5 years and under ventrogluteal 5 . Some experts allow intramuscular injection with a -inch needle but ONLY if the skin is stretched flat (21). The site of injection is usually rotated when injections are frequently given. Assess the family for ways they can assist in the procedure. We also use third-party cookies that help us analyze and understand how you use this website. To decrease risk of local adverse events, non-live vaccines containing an adjuvant should be injected into a muscle. Syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) but unused should be discarded at the end of the clinic day. Place the middle finger toward the iliac crest creating a 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. Avoid moving the syringe. Guidelines for subcutaneous and intramuscular injection Click here to proceed to intramuscular injection information . Source: Adapted from Minnesota Department of Health and Immunize.org. & Greenberg, C. S. (2003). Insert the needle at a 90-degree angle (straight up and down) into the injection site. The act directed OSHA to strengthen its existing bloodborne pathogen standards. They will have . The administration device is a nasal sprayer with a dose-divider clip that allows introduction of one 0.1-mL spray into each naris. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". Rotavirus, adenovirus, cholera vaccine, and oral typhoid vaccines are the only vaccines administered orally in the United States. Source: Adapted from California Immunization Branch. 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. 37415 . The cookie is used to store the user consent for the cookies in the category "Performance". What is the maximum volume for subcutaneous injection? Learn more about Clinical Skills today! Instruct the family regarding the potential adverse effects of the medication. Hydralazine hydrochloride injection, USP is an antihypertensive available in a 1 mL vial for intravenous and intramuscular administration. 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). Needle size Gauge 25 (1 inch, in length, 0.6 mm) is the most appropriate size for intramuscular injection to minimize local irritation and pain in children. Gather supplies: alcohol pads . Assess the patients and familys understanding of the reasons for and the risks and benefits of the procedure. PPSV23and IPV are recommended by the manufacturer to be administered by the subcutaneous or intramuscular route. Explain to the patient and family the step-by-step procedure for IM medication administration. In general, for an adult male weighing 60 kg to 118 kg (130 to 260 lbs), a 1-inch (25 mm) needle is sufficient. To prevent contamination of the vial, make sure the patient area is clean and free of potentially contaminated equipment. Breastfeeding or giving supplemental breast milk during the injection can reduce pain in infants. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Appropriate needle length depends on age and body mass. What happens if you inject into muscle? *The ventrogluteal site may be used for children greater than 7 months when large volumes or viscous solutions must be . Verify the patients daily weight in kilograms. Routes of administration are recommended by the manufacturer for each immunobiologic (Table 6-1). The injection should be given 3-5cms below the acromion, in the middle of the triangle. If injecting into the vastus lateralis , ventrogluteal, gluteus medius, or dorsogluteal muscles of an adult, the volume should not exceed 3 mL. is it okay to take melatonin after covid vaccine. When in doubt about the appropriate handling of a vaccine, vaccination providers should contact that vaccines manufacturer. 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. 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 orremove the bloodborne pathogens hazard from the workplace). Vaccinators should be familiar with the anatomy of the area into which they are injecting vaccine. Attach an appropriate-size needle to the syringe (. Muscle contracture occurs most commonly after injections in the anterior and lateral thigh, and sciatic nerve injury is the most frequently reported serious complication of the gluteal area. But opting out of some of these cookies may affect your browsing experience. The deltoid muscle is preferred for children aged 3-10 years (23); the needle length for deltoid site injections can range from to 1 inch on the basis of technique. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Intramuscular (IM) injections deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route (Malkin, 2008; Ogston-Tuck, 2014a; Perry et al., 2014). The maximum amount of medication that can be subcutaneously injected is about 2 ml. Analytical cookies are used to understand how visitors interact with the website. Steps on How to Give an IM Injection. Health-care practices should consider using a vaccination site map so that all persons administering vaccines routinely use a particular anatomic site for each particular vaccine. Medication administered per the six rights of medication safety, Patient and family able to state the purpose and side effects of the medication, Medication not administered per the six rights of medication safety, No sign of intended response to medication, Patient or family cannot state the purpose and side effects of the medication, Name of the medication, dose, volume, injection site, time of administration, and name of person administering it, Patients response to the medication, including adverse reactions, Pain assessment and interventions provided, Unexpected outcomes and related interventions. 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. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. The site of injection is usually rotated when injections are frequently given. 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 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. A 1 inch long, 25 to 27 gauge needle is used in a child. 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 . The FDA does not license administration syringes for vaccine storage. Obtain the medication, check the practitioners order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity. 4 mL 100mg/mL . Infants and children weighing up to 20 kg (44 pounds)Dose is based on body weight and must be determined by your doctor. (4, 10) Using reduced doses administered at multiple vaccination visits that equal a full dose or using smaller divided doses is not recommended (4). It was estimated that needles 38 mm (1.5 inches) or more would be needed for . Tetanus and pertussis. Immune responses generated by jet injectors against both attenuated and non-live viral and bacterial antigens are usually equivalent to, and occasionally greater than, immune responses induced by needle injection. Use a filter needle if drawing the medication from a glass ampule. A volume of 1 ml to be injected at one site was exceeded 10 (47%) times. The purpose of IM injections is to administer medication safely into the muscle below the subcutaneous layer. Rodgers, D. Wilson (Eds. The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. For women under 60 kg (130 lbs), a -inch (16 mm) needle is sufficient, while for women between 60 kg and 90 kg (130 to 200 lbs) a 1-inch (25 mm) needle is required. MeSH terms Ambulatory Care What are some examples of how providers can receive incentives? P.S. For doses higher than 1gram, the dose must be split between 2 sites. Inactivated influenza vaccine is immunogenic when administered in a lower-than-standard dose by the intradermal route to healthy adult volunteers. Needle-shielding or needle-free devices that might satisfy the occupational safety regulations for administering injectable vaccines are available in the United States (12-13). However, the immunogenicity for persons aged 65 years is inadequate, and varying the recommended route and dose either with the intradermal product licensed through 64 years of age or with other influenza vaccines is not recommended (24). What is the maximum injectable amount for an ID injection? Source: Adapted from Minnesota Department of Health. If injecting medication into the deltoid muscle of an adult, the volume of solution should not exceed 1 mL. This cookie is set by GDPR Cookie Consent plugin. Tell them when and how to notify the practitioner about a problem. After the needle pierces the skin, use the thumb and forefinger of the nondominant hand to hold the syringe barrel while still pulling on the skin. <2 months), (38mm length preferred in larger, overweight or obese patients). Choosing a muscle is dependent on the medication volume and the age or size of the patient. Up to 1ml can be injected into this site in neonates, up to 3mls in children and up to5mls in adults. Begin by having the patient relax the arm. It would be uncommon for persons with these conditions to be in a role administering vaccines. what med did you give? (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). Pneumococcal conjugate. I give 3 mL doses ALL THE TIME in DG (and VL on patients that I can talk into it). Oral typhoid capsules should be administered as directed by the manufacturer. at the Children's Hospital of Philadelphia. In this case the needle length should be 1 inch to 1.25 inches. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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. Administering volumes smaller than recommended (e.g., inappropriately divided doses) might result in inadequate protection. A higher gauge needle refers to a smaller outside diameter of the needle tubing. The deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. The most common serious complications of intramuscular injections in children are muscle contractures and nerve injury. Currently the most commonly used sites for the rapid delivery of rescue medications are the IV, IM, and subcutaneous sites. IM injection included poor injection-site selection and not advancing the needle to full length. 2 How many milliliters can be injected intramuscularly? Multiple use jet injectors using the same nozzle for consecutive injections without intervening sterilization were used in mass vaccination campaigns from the 1950s through the 1990s (33); however, these were found to be unsafe because of the possibility of bloodborne pathogen transmission (34-37) and should not be used. Necessary cookies are absolutely essential for the website to function properly. (2022). 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). Children (3-11 years) Deltoid Anterolateral thigh 5/8" - 1" needle for deltoid 1" - 1" needle for thigh 23-25 gauge needle . 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. Verify the correct patient using two identifiers. 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. (c) Do not withdraw more than 0.5 mL from the reconstituted product, even if some product is left in the vial. The choice of a site depends on the volume to be injected. Visualizaes: 46. Using the vastus lateralis muscle avoids the risk of sciatic nerve damage from gluteal injection. For more than 150 additional . Evidence indicates that this cream does not interfere with the immune response to MMR (45). Hepatitis A. An IM site is chosen based on the age and condition of the patient, and the volume and type of medication injected. A child life specialist should be enlisted to support the patient, if available. Which site is most desirable for a 3 ml intramuscular injection? Which is the best muscle for IM injections? In certain circumstances (e.g., physical obstruction to other sites and no reasonable indication to defer doses), the gluteal muscle can be used. For pediatric patients, 2 mL is the max in the VL. Perform hand hygiene. 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. The Australian Immunisation Handbook. If administering an IM injection into a child under age 2, the maximum amount that should be administered is 1 mL. Doctors frequently use intramuscular injections to administer vaccines and certain other drugs. What is the maximum volume that can be injected intramuscularly? If the subcutaneous and muscle tissue are bunched to minimize the chance of striking bone (19), a 1-inch needle or larger is required to ensure intramuscular administration. Subcutaneous injection: injection of a biological product into the layer of fatty tissue between the skin and muscle. Divide the muscle into thirds and administer the injection into the middle third of the muscle, in the outer anterolateral AGE NEEDLE LENGTH INJECTION SITE Infants (1-12 mos) " Fatty tissue over antero-lateral thigh muscle Children 12 mos or older, adolescents, and adults " Fatty tissue over . If blood appears in the syringe, remove the needle, discard the medication, obtain a new syringe, and try again. The injection site is about two inches below that spot (or roughly two or three finger widths). Do not touch this area until you give the injection. Adrenaline injection is administered to you by your doctor, nurse or paramedic. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 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. How many mL can you inject into the deltoid muscle? Assess for the intended response to medication. What is the largest amount of medication that can be injected into the deltoid muscle? 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. Adults and children 12 years of age and older1 milligram (mg) or 0.2 milliliter (mL) injected under your skin. For immunizations, a smaller 22 to 25 gauge needle should be used. Palpate the muscle below the greater trochanter and above the lateral femoral condyle (knee joint). Pediatric Intramuscular Injections Guidelines for Best Practice Author Information . Determine the patients desire for the family to be present during the procedure. 5 For smaller adults or those with less muscle mass, the volume injected may need to be adjusted. Children 1 month: 50mg/kg (to a maximum of 500mg) as a IM single dose. Intradermal injection: injection of a minimal quantity (0.01 mL to 0.1 mL) of a biological product just under the dermis. If over age 2, then 2 mL in DG is ok, even though I never do it because I HATE giving DG injections. General Best Practice Guidelines for Immunization. a For nonaqueous injectates, consideration must be given to the time of absorption before redosing. If landmarked correctly however, it is safe to use. Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. reduced attenuation of smallpox vaccine virus (9)]. CDC twenty four seven. Children above 5 kg: 10 micrograms/kg (0.1 ml/kg of Adrenaline 1:10,000 solution) is given into a vein or into a bone every 3-5 minutes every 3-5 minutes until the heart starts to work. 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. Anterolateral: Anterior and lateral position situated in the front and to the side. (a) For the majority of infants, a 1-inch needle is sufficient to penetrate the thigh muscle. 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). The ventrogluteal site, rectus femoris and vastus lateralis location are the preferred location for large volume deep muscle IM injections. The anterolateral thigh also can be used. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. 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. The maximum amount of fluid an adult can safely be given intramuscularly is 3 mL; for a child, the maximum is 1 mL. 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). Children's Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in . Follow the organizations practice for emergency response. (slow injection) Mouse: 10 (50) . The anterolateral thigh can also be used (25). static compliance and maximum expiratory flow at 50% of awake total lung capacity (V max) increase. How should I prepare my child? Children 2 to 11 years of age and weighing 45 kg or more1 mg or 0.2 mL injected under . A medication administered into a muscle is known as an intramuscular (IM) injection. 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. Checklist 56 outlines the steps to administer an intradermal injection. 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. ? The cookies is used to store the user consent for the cookies in the category "Necessary". iliac spine and the greater trochanter of the femur. The maximum volume should not exceed 1 mL. Because unused prefilled syringes also typically must be discarded if not used within the same day that they are filled, vaccine wastage might occur. Such practices increase the risk for infectious complications and neurovascular and muscle injuries. Persons administering vaccinations should follow appropriate precautions to minimize risk for disease exposure and spread. The development of this nursing guideline was coordinated by Mica Schneider, RN Specialist Clinics, and approved by the Nursing Clinical Effectiveness Committee. For adults, the deltoid muscle is recommended for routine intramuscular vaccinations (23) (Figure 3). Whats the maximum volume of an IM injection? 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. However, these tools . Haemophilus influenzae type b. The injection site affects how much fluid can be given and how quickly the medication will be absorbed. Dorsogluteal site: 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. The deltoid in infants is not sufficiently bulky to absorb IM medications adequately. Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state. Studies of children with previous febrile seizures have not demonstrated antipyretics to be effective in the prevention of febrile seizures (48). 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). 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) (23).
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