(b) If skin is stretched tightly and subcutaneous tissues are not bunched. The maximum amount of medication for a single injection is generally 1 ml. Choosing a muscle is dependent on the medication volume and the age or size of the patient. The IM route allows for rapid absorption of specific medications. Other persons at increased risk for influenza complications can administer LAIV. The cookies is used to store the user consent for the cookies in the category "Necessary". Oral typhoid capsules should be administered as directed by the manufacturer. Pediatrics (1982) 70 (6): 944-948. What is the intramuscular injection angle? Needles and syringes used for vaccine injections must be sterile and disposable. Single-dose vials and manufacturer-filled syringes are designed for single-dose administration and should be discarded if vaccine has been withdrawn or reconstituted and subsequently not used within the time frame specified by the manufacturer. (e) Some experts recommend a 1-inch needle if the skin is stretched tightly and subcutaneous tissues are not bunched. 9 mss atrs. Don appropriate PPE based on the patients need for isolation precautions or the risk of exposure to bodily fluids. You can review and change the way we collect information below. A volume of 1 ml to be injected at one site was exceeded 10 (47%) times. Maximum volumes to be injected intramuscularly: 0.5 mL in a small infant <1month. For pediatric patients, 2 mL is the max in the VL. IM injection: Maximum recommended single IM dose is 2grams. Tetanus and pertussis. 0.5 mL IM MMRV (ProQuad) 0.5 mL Subcut HepA-HepB (Twinrix) 1.0 mL IM Injection Site and Needle Size Subcutaneous (Subcut) injection the person's age and body mass. Explain which strategies (e.g., breastfeeding, local anesthetic use, distraction), may be used to minimize the patients pain and anxiety during the procedure. 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). NWCommons: Institutional Repository of Northwestern College Have the family of an infant begin breastfeeding or feeding breast milk. 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). 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). Intradermal injection produced antibody responses similar to intramuscular injection in vaccinees aged 18-60 years (57). Which site should be used to administer an intramuscular injection for a 6-month-old patient? 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). The vastus lateralis is the site of . 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 (10). To decrease risk of local adverse events, non-live vaccines containing an adjuvant should be injected into a muscle. If blood appears in the syringe, remove the needle, discard the medication, obtain a new syringe, and try again. 50 Flemington Road Parkville Victoria 3052 Australia, Site Map | Copyright | Terms and Conditions, A great children's hospital, leading the way, Kids Health Info: Allergic and anaphylactic reactions, How to don and remove Personal Protective Equipment (PPE), The evidence table for this guideline can be accessed here, Preferred site in neonates and children under walking age but can be used in any age group (up to 5mls can be given in adults), Clinical judgement is used based on the size of the child and their development (see considerations above and below), Can be given in children >12 months if muscle mass is developed, Only recommended at The Royal Children's Hospital (RCH) if appropriately trained, Appropriate size needle for administration, Drawing up needle and syringe (if medication not pre-filled), Alcohol impregnated swab (if area visibly soiled), Personal Protective Equipment (PPE) for hazardous medications or infectious patients, Complete the six rights of medication administration, Don PPE if required (particularly for hazardous medications), Position patient in a safe and comfortable position, Consider the use of comfort techniques such as distraction, buzzy bee, ice or a countdown, Clean site with an alcohol swab (if required), Stretch the skin flat (Z-tracking if applicable), Inject the needle to the hub at a 90-degree angle, Do not aspirate or drawback as this can increase pain and discomfort in children, Inject the medication at a slow and steady pace, Remove the needle and apply a cotton ball, Monitor for immediate adverse reactions, e.g., fever, rash, vomiting, shortness of breath. Contraindications Relative Known bleeding disorder or thrombocytopenia. The purpose of IM injections is to administer medication safely into the muscle below the subcutaneous layer. Doctors frequently use intramuscular injections to administer vaccines and certain other drugs. Multi-dose vials to be used for more than one patient should not be kept or accessed in the immediate patient treatment area. Discard supplies, remove PPE, and perform hand hygiene. To prevent contamination of the vial, make sure the patient area is clean and free of potentially contaminated equipment. 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. Vaccinators should be familiar with the anatomy of the area into which they are injecting vaccine. (a) For the majority of infants, a 1-inch needle is sufficient to penetrate the thigh muscle. 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. For immunizations, a smaller 22 to 25 gauge needle should be used. Document the procedure in the patients record. Be truthful about discomfort but be positive about the benefits of the medicine. Bloodborne diseases (e.g., hepatitis B, hepatitis C, human immunodeficiency virus [HIV]) are occupational hazards for clinicians and other health-care providers. Cookies used to make website functionality more relevant to you. The revised standards became effective in 2001 (2). The doses should be administered as soon as possible after filling, by the same person who filled the syringes. informed practice: Trauma-informed care is a way of approaching interactions with children and families in which providers remain cognizant of the impacts of trauma while also taking actions to prevent potentially traumatic experiences (Boles, 2017). Similarly, doses of rabies vaccine administered in the gluteal site should not be counted as valid doses and should be repeated (54). ). Using the vastus lateralis muscle avoids the risk of sciatic nerve damage from gluteal injection. Drug administration route. These federal regulations require the use of engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens. (0.5-1 ml maximum), are . a For nonaqueous injectates, consideration must be given to the time of absorption before redosing. 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. Explain that the patient may feel pain and anxiety during the procedure. Needles are generally 3/8 to 1 inch in length and 24 to 27 gauge. Using larger-than-recommended dosages can be hazardous because of excessive local or systemic concentrations of antigens or other vaccine constituents. MeSH terms Ambulatory Care Haemophilus influenzae type b. Palpate the muscle below the greater trochanter and above the lateral femoral condyle (knee joint). For men and women who weigh 130-152 lbs (60-70 kg), a 1-inch needle is sufficient. Assess the patients and familys understanding of the reasons for and the risks and benefits of the procedure. Displace the skin and subcutaneous tissue by pulling the skin laterally or downward from the injection site. 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). management in all ages. 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). What can go wrong with an intramuscular injection? A medication administered into a muscle is known as an intramuscular (IM) injection. It would be uncommon for persons with these conditions to be in a role administering vaccines. 4 mL 100mg/mL . The cookie is used to store the user consent for the cookies in the category "Other. The cookie is used to store the user consent for the cookies in the category "Analytics". Position the patient and initiate developmentally appropriate distraction measures. Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state. The vaccine adheres to the sides of the bifurcated needle, and is administered via skin puncture. The smallpox/monkeypox vaccine (Jynneos) is primarily administered by the subcutaneous route but in some circumstances is administered by the intradermal route. Providers are sometimes concerned when they have the same contraindications or precautions as their patients from whom they withhold or defer vaccine. Subcutaneous means under the skin. ACIP discourages variations from the recommended route, site, volume, or number of doses of any vaccine. The anterolateral thigh also can be used. The ventrogluteal muscle can accommodate up to 2.5 ml, with a maximum volume of 3 ml. Analytical cookies are used to understand how visitors interact with the website. The point of injection should be as far as possible from major nerves and blood vessels to avoid neural damage and accidental intravenous administration. Please remember to Pediatric Intramuscular Injections Guidelines for Best Practice Author Information . 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. 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. 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 . 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). 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. 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. A separate needle and syringe should be used for each injection. Assess the patients muscle mass and skin condition. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". When all the medicine has been given, remove the needle from the skin at the same angle it went in. Position the ulnar side of the nondominant hand just below the site and pull the skin laterally. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. 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). Who wrote the music and lyrics for Kinky Boots? Chapter 5: Pain assessment and management in children. Let the area dry. Infants and children weighing up to 20 kg (44 pounds)Dose is based on body weight and must be determined by your doctor. . Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. What is the maximum volume that can be injected intramuscularly? To avoid these complications, guidelines for pediatric intramuscular injections are presented. If multiple vaccines are administered at a single visit, administer each preparation at a different anatomic site (28). 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. Mix and draw up the exact volume of medication. Checklist 56 outlines the steps to administer an intradermal injection. Monitor the patients tolerance of the procedure. Chapter 6: Vaccine administration. The maximum volume generally accepted for an SC injection is around 1.5 ml , although higher volumes (of up to 4 ml) can be administered if necessary . If injecting medication into the deltoid muscle of an adult, the volume of solution should not exceed 1 mL. If injecting into the vastus lateralis , ventrogluteal, gluteus medius, or dorsogluteal muscles of an adult, the volume should not exceed 3 mL. Dorsogluteal site: Activate the needle safety device per the manufacturers instructions. The deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. If 2 vaccines are to be administered in a single limb, they should be spaced an inch apart (4, 24). The site of injection is usually rotated when injections are frequently given. 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. 3,13,14 . This is often called an "IM" injection. These cookies ensure basic functionalities and security features of the website, anonymously. The deltoid muscle can be used if the muscle mass is adequate. 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. up to a maximum dose of 1 g/day . b. Using reduced doses administered at multiple vaccination visits that equal a full dose or using smaller divided doses is not recommended (4). Pedi- Technically Speaking columns cover practical topics in immunization delivery such as vaccine . Children 2 to 11 years of age and weighing 45 kg or more1 mg or 0.2 mL injected under . In a 2-year carcinogenicity study of rats given hydralazine by gavage at dose levels of 15, 30, and 60 mg/kg/day (approximately 5 to 20 times the . Attach an appropriate-size needle to the syringe (. Any vaccination using less than the standard dose should not be counted, and the person should be revaccinated according to age unless serologic testing indicates that an adequate response has developed.