CLINICAL PROCEDURE MUHC

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1 CLINICAL PROCEDURE MUHC (MÉTHODE DE SOINS CUSM) Medication included No Medication included THIS IS NOT A MEDICAL ORDER Title: Administration of a medication or vaccine via the intramuscular (IM) route to a neonatal or pediatric patient This document is attached to: MUHC Interprofessional Protocol Least Physical Restraint MUHC Collective order: Sucrose administration for minor procedures and as a pain management adjunct MUHC interprofessional protocol: Selection of an antiseptic skin solution for skin preparation for intravascular access and for site care in children MUHC policy: Hand hygiene related to general patient care MUHC policy: Patient double identification ROP Collective order for administration of topical anesthetic Preparing immediate use intravenous medications from a vial or glass ampule 1. DEFINITION AND PURPOSE The purpose of this protocol is to provide guidelines for safe and effective injection of medications via the intramuscular (IM) route for neonatal and pediatric patients. 2. CARE GOALS Administer an IM injection safely and effectively Avoid complications Minimize distress associated with IM injections 3. PROFESSIONALS INVOLVED Professionals working at the Montreal Children s Hospital who administer IM injections. Professionals are expected to review this protocol and be knowledgeable about its recommendations.. 4. PATIENT POPULATION Neonatal and pediatric patients cared for at the McGill University Health Center 5. INDICATIONS Patient requiring the administration of a medication or vaccine via the IM route Revision date: April

2 6. CONTRAINDICATIONS Patient with thrombocytopenia (low platelet count) Patient with a coagulopathy Hematology/oncology patient with platelet counts less than (30X10 9 /L) 7. PRECAUTIONS Discuss with physician before proceeding with an IM injection for patients on anticoagulant therapy 8. EQUIPMENT Appropriate size syringe Appropriate caliber and length of needle (Refer to Table 1) Table 1: Needle length, gauge and maximum volume recommendations by injection site and age Injection site Ventrogluteal Vastus lateralis Deltoid Needle Length and gauge Maximum volume Length and gauge Maximum volume Length and gauge Maximum volume Premature infant Neonate (birth to 28 days) mm (25 G 5/8 inch) mm (25 G 5/8 inch) 0.5 ml ml Infant 23 mm 25 mm 1 ml (1 to 12 months) (25 G 5/8 inch) 0.5 ml Young child 23 mm 1 ml 25 mm 1 ml 25 mm 0.5 ml (1 to 3 yrs) (25 G 5/8 inch) Child 25 mm 1.5 ml 1 ml 25 mm 0.5 ml (3 to 6 yrs) mm Older Child (6 to 14 yrs) 25 mm 2 ml 2 ml 25 mm [ 1 to 1 ¼ inches] 0.5 1mL Adolescent 25 mm 2 ml (23 G 1 inch or 2 ml 21 G 1 ½ inches ) 5mL Max for vaccines 25 mm 1 ml Disinfectant wipe according to Interprofessional Protocol: Selection of an Antiseptic Skin Solution Non sterile gauze 2x2 Filter needle if drawing a medication from a glass ampule Adhesive bandage Kidney basin Sharp box Non-sterile gloves Revision date: April

3 9. PROCEDURE General principles In the paediatric population, injections are used most often for a one time dose of medication, vaccines or iron administration. IM injections are potentially more dangerous in infants than in older children because of the infant s decreased muscle mass and variable blood flow to the muscles. IM injection is stressful for children and should be the least preferred route for medication administration. The IM route is only an alternative when: o The IV route is impossible to achieve and the medication can be given IM o The medication can only be given by IM route Care should be taken to use techniques aimed at reducing the anxiety and pain associated with the procedure. Alert The dorsogluteal muscle is not recommended as an injection site due to the proximal location of the sciatic nerve and large blood vessels. If the needle hits the sciatic nerve, the patient may suffer from partial or permanent paralysis of the leg Selection of site Injections must be administered in muscles large enough to accommodate the medication, while avoiding major nerves and blood vessels. Assess the muscle mass of the selected site prior to giving an injection. The selection of the injection site depends on the age of the child and his/her muscle mass. Refer to table 2 Consider: 1) The volume and type of the medication to be injected 2) The general condition of the muscle mass. a. The muscle should be free of pain, infection, necrosis, bruising, abrasion, and atrophy. b. Consider the location of the underlying structures: bones, nerves and blood vessels 3) The frequency or number of injections to be given during the course of treatment 4) Factors that may impede access to or cause contamination of the site 5) The child s ability to assume the required position safely Selection of needle size The needle gauge should be as small as possible to deliver the medication safely. Small diameter (25 30 gauge) needles cause the least discomfort, but larger gauges may be needed for viscous medication and prevention of accidental bending of longer needle. An obese patient may require a longer needle. Preparation Appropriately preparing the child for injections can reduce emotional and anticipatory concerns. According to the child s development level, explain the reason for the injection, any sensations the child might experience, and the length of time they are anticipated to last. Reassure the child that the injection is not a punishment but is needed to make the child better or keep the child healthy. You can practice counting, singing, deep breathing or other distraction techniques with the child in advance. Revision date: April

4 Five types of procedural preparation/discussion are suggested:. Information sharing: what will happen (where, how long it will last, what will be done) Sensory information : how it will feel (pressure, temperature, level of discomfort expected) Justifying the procedure: explaining why the procedure is necessary Teaching relaxation strategies (strategies to cope with the stressor) Role playing Z-track technique is recommended practice for all intramuscular injections The Z-track technique is a method of administering intramuscular injections in which the epidermis layer of the skin and the hypodermis layer of the subcutaneous tissue are moved 2 to 3 cm to the side or downward with the side of the non-dominant hand. This technique forces the path of entry of the needle into a zigzag shape, thus preventing the drug from coming back out of the muscle tissue. Procedure to administer an IM injection Intramuscular injection (IM) procedure Verify patient s identity using two patient identifiers; explain the procedure and what the child and family can do to help. Rationale To ensure that the correct patient receives the drug as prescribed by the physician. Ensure that the patient and family understand the procedure and consent. Select appropriate site for injection according to age, muscle size and volume that should be administered in a single site. Refer to the Table 2. The ventrogluteal site is the preferred injection site for children including infants when receiving viscous solutions and it is less painful Inspect integrity and size of muscle. Palpate muscle for tenderness and hardness. If present, select another site. Make sure to rotate injection sites. Injection sites should be free of abnormalities that interfere with drug absorption. Sites used repeatedly become hardened from lipohypertrophy Apply topical anaesthetic as per the collective order if appropriate. To minimize pain Assemble the equipment needed for the injection. Verify if the drug has specific recommendations regarding site of administration or method of administration. Prepare medication and check the 5 rights of medication administration: right patient, right medication, right route, right dose, right time (and expiry date). Change needle after preparing the medication To minimize risk of error. Select appropriate needle gauge and length To administer the IM injection, use a needle of Revision date: April

5 Intramuscular injection (IM) procedure according to Table 1. Rationale appropriate length to ensure that the medication will penetrate and be deposited into the muscle bed. Different patients need different needle sizes: never be guided by the color of needles alone as different manufacturers vary in their color-coding systems. Perform hand hygiene and don non-sterile gloves Ensure privacy and assist patient into position to facilitate the injection into the chosen site. Encourage the patient to relax the target muscle by positioning the muscle into a flexed position (see section position of child ). Obtain help to restrain the patient if needed. Refer to restraint policy Offer age appropriate distraction. Encourage breastfeeding as appropriate. Offer sucrose as per sucrose collective order. Re-assess accurately site s landmarks by palpation. Follow positioning recommendations as described in comfort zone project to reduce anxiety associated with procedure. Injection into a tense extremity causes discomfort.. These interventions reduce pain and anxiety associated with needles. Do not rely on visual identification alone to prevent injury. Cleanse the site with skin disinfectant wipe according to Interprofessional Protocol: Selection of an Antiseptic Skin Solution ( ) and allow to dry. Mechanical action of swabbing removes microorganisms. Alcohol has immediate and rapid effect. CHG takes longer than alcohol to dry. CHG binds to the skin proteins causing a prolonged antiseptic effect. Allow skin preparation to dry completely before penetrating the skin to reduce bacteria and pain. With non-dominant hand pull the overlying skin and subcutaneous tissue approximately 2.5 to 3.5 cm laterally to the side (image A). Holding the skin taut (image B) with the dominant hand, insert the needle at an angle of 90 degrees deep into the muscle using a steady and smooth motion. For neonates or emaciated patients, do not spread skin but grasp ( bunch up ) body of muscle between thumb and finger firmly before injecting Z-track technique is the recommended practice for all intramuscular injections. This technique forces the path of entry of the needle into a zigzag shape, thus minimizing local skin irritation by sealing the medication into the muscle tissue. Neonates or emaciated patients are likely to have less muscle; therefore it is helpful to grasp the muscle to isolate, stabilize it before injecting to ensure the medication reaches the muscle Revision date: April

6 Intramuscular injection (IM) procedure Z track injection technique Rationale Press down on skin Pull skin laterally Remove needle and release skin then inject After the needle pierces the skin, use the thumb and index of the non-dominant hand to hold the syringe without releasing the skin. Do not aspirate. Inject slowly the medication over 10 seconds. There is no scientific literature that supports aspiration before an IM injection. Aspiration is also thought to increase pain associated with the procedure. Recommended sites for IM injection are devoid of large blood vessels. Pressure produced by rapid administration causes pain. This slow, steady rate promotes comfort and allows time for the tissues to expand and begin absorbing the solution and helps to avoid damage to the muscle tissue. Withdraw the needle and release the skin (image C) Apply pressure to the injection site with gauze. Do not massage injection site. Apply an adhesive bandage. Discard needle in sharp box. Do not recap needle. Discard other supplies in the garbage. Massaging the site can cause tissue irritation. Observe patient s response to medication at times that correlate with the medication onset, peak and duration. When administering a vaccine, follow the recommendations in the Protocole D Immunization du Quebec (PIQ) Advise the patient or family to notify a healthcare professional, if any adverse effects such as redness, swelling, pain are observed. Document procedure and patient response. Revision date: April

7 Monitoring Observe patient s response to medication at times that correlate with the medication s onset, peak, and duration. Observe patient s response for any allergic reaction. Complications /risks Potential complications include: Contractures, muscle contraction Palsy, peripheral nerve injury, neuropathy, permanent damage to sciatic nerve resulting in paralysis Local irritation, pain, persistent nodule, fibrosis Haematomas, bleeding, arterial puncture Infection, abscess, tissue necrosis, gangrene Bone injury Revision date: April

8 Table 2 Recommended I.M. Injection Site according to age Muscle Deltoid Ventrogluteal Vastus lateralis Age & Indications 18 months and older 7 months and older Ventrogluteal muscle is an alternative to the vastus lateralis muscle for children age seven months and older Can be safely used for all ages especially infants and obese patients Muscle of choice because it is large, easily accessible and well developed at all ages Landmarks See image A See image B See image C Expose both the shoulder and the arm Locate the acromion process Give injection 2 to 3 finger widths below the acromion process in the middle of deltoid muscle Position the patient on left or right side Place heel of hand on the greater trochanter (right hand for the left hip, and left hand for the right hip). Place index finger on iliac spine Extend your middle finger back along the iliac crest to form a V Locate the greater trochanter of femur and the knee joint. Visually divide the muscle into thirds. Give injection into middle lateral third. Give injection within the V Deltoid muscle Ventrogluteal muscle Vastus lateralis Revision date: April

9 10. DOCUMENTATION IN CHART Documentation includes recording of: Medication, dose, route, site, time, and date given Patient s response to medication Any undesirable effects and adverse effect of the medication For vaccine administration, the manufacturer and lot number should be documented. 11. MAIN AUTHOR: Denise Kudirka, MSc.N. CNS Pediatric Emergency Chrisitina Rosmus, MSc.N. 12. CONSULTANTS: NPDQM committee Eren Alexander, Nursing Coordinator 13. APPROVAL PROCESS Committees Date [yyyy-mm-dd] Clinical Practice Review Committee (CPRC) (if applicable) Adult Pharmacy and Therapeutics (P&T) (if applicable) Pediatric Medication Administration Policy (PMAP) (if applicable) Pediatric Pharmacy and Therapeutics (Peds P&T) (if applicable) Multidisciplinary Council (MDC) (if applicable) NA NA NA NA 14. REVIEW DATE To be updated in maximum of 4 years or sooner if presence of new evidence or need for practice change. 15. REFERENCES Brown, J., Gillespie, M. & Chard, S. (2015). The dorso-ventro debate: in search of empirical evidence. British Journal of Nursing, 2 (22), Cocoman, A., & Barron, C. (2008). Administering subcutaneous injections to children: what does the evidence say? Journal of Children's & Young People's Nursing, 2(2), Hanson, D., Hall, W., Mills, L. L., Au, S., Bhagat, R., Hernandez, M., et al. (2010). Comparison of distress and pain in infants randomized to groups receiving standard versus multiple immunizations. Infant Behavior and Development, 33(3), Hunter, J. (2008).Intramuscular injection techniques. Nursing Standard;22:35Y40. Ogston-Tuck, S. (2014) Intramuscular injection technique : an evidence based approach. Nursing Standard, 29 (4) : Protocol d'immunisation du Québec (PIQ) (2013). Ministère de la Santé et services sociaux du Québec (6 e éd.). Revision date: April

10 Perry, A.G. & Potter, P.A. (2014). Canadian fundamentals of nursing. Canadian editors, Ross-Kerr, J. C., & Wood, M. J. et al. (5 ed.) Toronto: Elsevier. Rishovd, A. (2014) Pediatric intramuscular injections: Guidelines for best practice. MCN: The American Journal of Maternal Child Nursing. 39 (2), Wilson, D., & Hockenberry, M. J. (2012). Wong s clinical manual of pediatric nursing. St. Louis: Mosby. Version History (for Administrative use only) Version Description Author/responsable Date No 1 Development and Approval Denise Kudirka, MSc.N. CNS Pediatric Emergency No Description (Création, Adoption, Révision avec modification, Révision sans modifications, etc.) Acronyme direction, Nom fonction No Description (Création, Adoption, Révision avec modification, Révision sans modifications, etc.) Acronyme direction, Nom fonction No Description (Création, Adoption, Révision avec modification, Révision sans modifications, etc.) Acronyme direction, Nom fonction Revision date: April

11 TABLE 2 - TEACHING PROGRAM The client and family (caregivers) know : Strategies to reduce anxiety and pain associated with IM injections Signs and symptoms of a complication The client knows : The client and family or the caregiver received and understood the information : Revision date: April