Safe injection technique. Medical Embolism: Injections Can Be Dangerous Potential Complications of Intramuscular Injections

- a method of administering drugs, in which the drug enters the body by injecting an injection solution through a syringe into the subcutaneous tissue. When conducting a subcutaneous injection of the drug, it enters the bloodstream by absorption of the drug into the vessels of the subcutaneous tissue. Usually, most drugs in the form of solutions are well absorbed in the subcutaneous tissue and provide relatively rapid (within 15-20 minutes) absorption into the systemic circulation. Usually, the effect of the drug with subcutaneous administration begins more slowly than with intramuscular and intravenous administration, but faster than with oral administration. Most often, drugs are administered subcutaneously, which do not have a local irritant effect, and are well absorbed in the subcutaneous adipose tissue. Heparin and its derivatives are administered exclusively subcutaneously or intravenously (due to the formation of hematomas at the injection site). Subcutaneous injection is used when it is necessary to introduce into the muscle both an aqueous and an oily solution of drugs, or a suspension, in a volume of not more than 10 ml (preferably not more than 5 ml). Vaccinations against infectious diseases are also carried out subcutaneously by introducing a vaccine into the body.

Application

Subcutaneous injection is a fairly common type of parenteral administration of drugs due to the good vascularization of the subcutaneous tissue, which contributes to the rapid absorption of drugs; and also due to the simplicity of the administration technique, which makes it possible to apply this method of administration to persons without special medical training after mastering the relevant skills. Most often, patients self-administer at home subcutaneous insulin injections (often with a syringe pen), and subcutaneous injection of growth hormone can also be performed. Subcutaneous administration can also be used to administer oily solutions or suspensions of medicinal substances (subject to the condition that the oily solution does not enter the bloodstream). Usually, drugs are administered subcutaneously when there is no need to obtain an immediate effect from the administration of the drug (absorption of the drug during subcutaneous injection disappears within 20-30 minutes after administration), or when it is necessary to create a kind of depot of the drug in the subcutaneous tissue to maintain the concentration of the drug in the blood at constant level for a long time. Solutions of heparin and its derivatives are also injected subcutaneously due to the formation of hematomas at the injection site during intramuscular injections. Local anesthetics may also be administered subcutaneously. When administered subcutaneously, it is recommended to administer drugs in a volume of not more than 5 ml in order to avoid tissue overstretching and the formation of an infiltrate. Do not administer subcutaneously drugs that have a locally irritating effect and can cause necrosis and abscesses at the injection site. For the injection, it is necessary to have sterile medical equipment - a syringe, and a sterile form of the drug. Intramuscularly, drugs can be administered both in a medical institution (inpatient and outpatient departments) and at home by inviting a medical worker home, and when providing emergency medical care - in an ambulance.

Execution technique

Subcutaneous injection is most often given to the outer surface of the shoulder, the anterior thigh, the subscapularis, the lateral surface of the anterior abdominal wall, and the area around the navel. Before subcutaneous injection, the drug (especially in the form of an oily solution) must be warmed up to a temperature of 30-37 ° C. Before starting the injection, the health worker treats the hands with a disinfectant solution and wears rubber gloves. Before the introduction of the drug, the injection site is treated with an antiseptic solution (most often ethyl alcohol). Before the injection, the skin at the puncture site is taken into a fold, and after that the needle is set at an acute angle to the skin surface (for adults - up to 90 °, for children and people with a mild subcutaneous fat layer, injection at an angle of 45 °). After piercing the skin, the syringe needle is inserted into the subcutaneous tissue approximately 2/3 of the length (at least 1-2 cm), to prevent needle breakage, it is recommended to leave at least 0.5 cm of the needle above the skin surface. After puncturing the skin, before administering the drug, it is necessary to pull the plunger of the syringe back to check that the needle has entered the vessel. After checking the correct location of the needle, the drug is injected under the skin in full. After the end of the administration of the drug, the injection site is re-treated with an antiseptic.

Advantages and disadvantages of subcutaneous drug administration

The advantages of subcutaneous use of drugs is that the active substances, when introduced into the body, do not change at the site of contact with tissues, therefore, drugs can be used subcutaneously, which are destroyed by the action of the enzymes of the digestive system. In most cases, subcutaneous administration provides a rapid onset of drug action. If prolonged action is needed, drugs are usually administered subcutaneously in the form of oily solutions or suspensions, and should not be done with intravenous administration. Some drugs (in particular, heparin and its derivatives) cannot be administered intramuscularly, but only intravenously or subcutaneously. The rate of absorption of the drug is not affected by food intake and much less influenced by the characteristics of the biochemical reactions of the organism of a particular person, the intake of other drugs, and the state of the enzymatic activity of the body. Subcutaneous injection is relatively easy to perform, which makes it possible to carry out this manipulation if necessary, even for a non-specialist.

The disadvantages of subcutaneous administration are that often with the introduction of drugs intramuscularly, pain and the formation of infiltrates at the injection site (less often, the formation of abscesses) are observed, and with the introduction of insulin, lipodystrophy can also be observed. With poor development of blood vessels at the injection site, the absorption rate of the drug may decrease. With subcutaneous administration of drugs, as with other types of parenteral use of drugs, there is a risk of infection of the patient or health worker with blood-borne pathogens. With subcutaneous administration, the likelihood of side effects of drugs increases due to the higher rate of entry into the body and the absence of biological filters of the body along the route of the drug - the mucous membrane of the gastrointestinal tract and hepatocytes (although lower than with intravenous and intramuscular use) .. With subcutaneous application, it is not recommended to inject more than 5 ml of the solution once due to the likelihood of overstretching of muscle tissue and reducing the likelihood of infiltrate formation, as well as drugs that have a locally irritating effect and can cause necrosis and abscesses at the injection site.

Possible complications of subcutaneous injection

The most common complication of subcutaneous injection is the formation of infiltrates at the injection site. Usually, infiltrates are formed when the drug is injected into the site of induration or edema that has formed after previous subcutaneous injections. Infiltrates can also form with the introduction of oil solutions that are not heated to the optimum temperature, as well as when the maximum volume of subcutaneous injection is exceeded (no more than 5 ml at a time). When infiltrates appear, it is recommended to apply a semi-alcohol compress or heparin ointment to the site of infiltrate formation, apply an iodine mesh to the affected area, and carry out physiotherapeutic procedures.

One of the complications that arise when the technique of drug administration is violated is the formation of abscesses and phlegmon. These complications most often occur against the background of incorrectly treated post-injection infiltrates, or if the rules of asepsis and antisepsis are violated during the injection. Treatment of such abscesses or phlegmon is carried out by a surgeon. In case of violation of the rules of asepsis and antisepsis during injections of imovine, infection of patients or health workers with pathogens of infectious diseases transmitted through the blood, as well as the occurrence of a septic reaction due to bacterial infection of the blood.

When injecting with a blunt or deformed needle, the formation of subcutaneous hemorrhages is likely. If bleeding occurs during a subcutaneous injection, it is recommended to apply a cotton swab moistened with alcohol to the injection site, and later - a half-alcohol compress.

If the injection site is chosen incorrectly during subcutaneous administration of drugs, damage to the nerve trunks can be observed, which is most often observed as a result of chemical damage to the nerve trunk, when a depot of the drug is created close to the nerve. This complication can lead to the formation of paresis and paralysis. Treatment of this complication is carried out by a doctor, depending on the symptoms and severity of this lesion.

With subcutaneous administration of insulin (more often with prolonged administration of the drug in the same place), there may be a site of lipodystrophy (a site of resorption of subcutaneous fatty tissue). Prevention of this complication is the alternation of insulin injection sites and the introduction of insulin, which has room temperature, the treatment consists in administering 4-8 units of suinsulin in areas of lipodystrophy.

If a hypertonic solution (10% sodium chloride or calcium chloride solution) or other locally irritating substances are erroneously injected under the skin, tissue necrosis may occur. When this complication occurs, it is recommended to prick the affected area with a solution of adrenaline, 0.9% sodium chloride solution and novocaine solution. After chipping the injection site, a pressure dry bandage and cold are applied, and later (after 2-3 days) a heating pad is applied.

When using an injection needle with a defect, when the needle is inserted too deep into the subcutaneous tissue, as well as when the injection technique is violated, the needle may break. With this complication, it is necessary to try to independently obtain a fragment of the needle from the tissues, and if the attempt fails, the fragment is removed surgically.

A very serious complication of subcutaneous injection is drug embolism. This complication occurs rarely, and is associated with a violation of the injection technique, and occurs in cases where the health worker, when performing a subcutaneous injection of an oily solution of the drug or suspension, does not check the position of the needle and the possibility of getting this drug into the vessel. This complication can be manifested by bouts of shortness of breath, the appearance of cyanosis, and often ends in the death of patients. Treatment in such cases is symptomatic.

Article 498. Workman B (1999) Safe injection techniques. Nursing standard. 13, 39, 47-53.

In this article, Barbara Workman describes the correct technique for intradermal, subcutaneous, and intramuscular injections.

Objectives and expected learning outcomes

As knowledge of nurses' daily practice routines grows, it is prudent to review some of the routine procedures.

This publication provides an overview of the principles of intradermal, subcutaneous and intramuscular injections. It is shown how to choose the right anatomical injection site, anticipate the possibility of drug intolerance, as well as the special needs of the patient, which may affect the choice of injection site. Aspects of patient and skin preparation, as well as equipment features, and ways to reduce patient discomfort during the procedure are highlighted.

The main purpose of the article is to encourage the nurse to critically review their own injection technique, based on the principles of evidence-based medicine, and to provide the patient with effective and safe care.

After reading this article, the nurse should know and be able to:

• Determine safe anatomical areas for intradermal, subcutaneous and intramuscular injections;
• Identify muscles - anatomical landmarks for performing intramuscular injections, and explain why they are used for this;
• Explain what this or that method of processing the patient's skin is based on;
• Discuss ways to reduce patient discomfort during an injection;
• Describe the nurse's actions aimed at preventing injection complications.

Introduction

Giving injections is a routine and perhaps the most frequent job of a nurse, and good injection technique can make this manipulation relatively painless for the patient. However, technical proficiency without understanding the manipulation exposes the patient to unnecessary risk of complications. Initially, giving injections was a medical procedure, but with the invention of penicillin in the 1940s, the duties of the nurse were greatly expanded (Beyea and Nicholl 1995). Currently, most nurses perform this manipulation. automatically. Since nursing practice is now becoming evidence-based, it is logical reconsider this fundamental procedure from the standpoint of evidence-based medicine.

Drugs are administered parenterally because they are usually absorbed faster than from the gastrointestinal tract, or, like insulin, are destroyed by digestive enzymes. Some drugs, such as medoxy-progesterone acetate or fluphenazine, are released over a long period of time and require a route of administration that ensures continued absorption of the drug.

There are four main characteristics of an injection: injection site, route of administration, injection technique, and equipment.

intradermal route of administration

The intradermal route of administration is intended to provide local rather than systemic drug action, and is generally used primarily for diagnostic purposes, such as allergy and tuberculin tests, or for the administration of local anesthetics.

To perform an intradermal injection, a 25G needle with a cut up is inserted into the skin at an angle of 10-15°, exclusively under the epidermis and injected up to 0.5 ml of the solution until the so-called “lemon peel” appears on the skin surface (Fig. 1). This route of administration is used to perform allergy tests, and the injection site must be marked in order to track the allergic reaction after a certain period of time.

Intradermal injection sites are similar to those for subcutaneous injections (Figure 2), but can also be performed on the inside of the forearm and under the collarbone (Springhouse Corporation 1993).

When performing allergy testing, it is very important to ensure that an anti-shock kit is readily available if the patient has a hypersensitivity reaction or anaphylactic shock (Campbell 1995).

Rice. 1. "Lemon peel", which is formed during intradermal injection.

IMPORTANT (1):
Review the symptoms and signs of anaphylactic reactions.
What will you do in case of anaphylactic shock?
What medications are you taking that can trigger an allergic reaction?

Subcutaneous route of administration

The subcutaneous route of administration of drugs is used when slow, uniform absorption of the drug into the blood is necessary, while 1-2 ml of the drug is injected under the skin. This route of administration is ideal for drugs such as insulin, which require a slow steady release, are relatively painless, and are suitable for frequent injections (Springhouse Corporation 1993).

On Fig. 2 shows sites suitable for performing subcutaneous injections.

Traditionally, subcutaneous injections are performed by inserting a needle at a 45-degree angle into a skin fold (Thow and Home 1990). However, with the introduction of shorter insulin needles (5, 6, or 8 mm long), insulin injections are now recommended to be performed with a 90-degree needle (Burden 1994). It is imperative to take the skin in a fold in order to separate the adipose tissue from the underlying muscles, especially in thin patients (Fig. 3). Some studies using computed tomography to track the direction of the injection needle have shown that sometimes the drug is inadvertently injected into the muscle when administered subcutaneously, especially when injected into the anterior abdominal wall in lean patients (Peragallo-Dittko 1997).

Insulin administered intramuscularly is absorbed much faster and this can lead to unstable glycemia and possibly even hypoglycemia. Hypoglycemic episodes can also be observed if the anatomical injection site changes, since insulin is absorbed from different sites at different rates (Peragallo-Dittko 1997).

For this reason, a constant change of injection sites should be carried out, for example, the area of ​​\u200b\u200bthe shoulder or abdomen is used for several months, then the injection site is changed (Burden 1994). When a patient with diabetes is admitted to the hospital, one should look for signs of inflammation, swelling, redness, or lipoatrophy at the insulin injection sites, and be sure to note this in the medical record.

Aspiration of the contents of the needle during subcutaneous injection is currently recognized as inappropriate. Peragallo-Dittko (1997) reports that blood vessel puncture prior to subcutaneous injection is very rare.

Educational materials for patients with diabetes do not contain information about the need for aspiration. It has also been noted that aspiration prior to heparin administration increases the risk of hematoma formation (Springhouse Corporation 1993).

Intramuscular route of administration

When administered intramuscularly, the drug is in a well-perfused muscle, which ensures its rapid systemic effect, and the absorption of sufficiently large doses, from 1 ml from the deltoid muscle to 5 ml in other muscles in adults (for children, these values ​​\u200b\u200bshould be divided in half). The choice of injection site should be based on the general condition of the patient, his age and the volume of drug solution to be injected.

The proposed injection site should be examined for signs of inflammation, swelling and infection, and injection of the drug into areas of skin lesions should be avoided. Similarly, 2-4 hours after the manipulation, the injection site should be examined to ensure that there are no adverse events. If injections are frequently repeated, then it is necessary to mark the injection sites in order to change them.

This reduces patient discomfort and reduces the chance of developing complications such as muscle atrophy or sterile abscesses due to poor drug absorption (Springhouse Corporation 1993).

IMPORTANT (2):
When diabetic patients are hospitalized, special medical records should be maintained.
How do you mark injection rotation sites?
How do you monitor the suitability of the injection site?
Discuss this with your colleagues.

Rice. 2. Anatomical areas for intradermal and subcutaneous injections. Red dots are sites for subcutaneous and intradermal injections, black crosses are sites for performing only intradermal injections.

Rice. 3. Capturing a skin fold when performing a subcutaneous injection.

Elderly and malnourished people have less muscle mass than younger, more active people, so before performing an intramuscular injection, it is necessary to assess whether muscle mass is sufficient for this. If the patient has little muscle, the muscle can be folded before the injection (Fig. 4).

Rice. 4. How to take the muscle in the fold in malnourished or elderly patients.

There are five anatomical regions suitable for intramuscular injections.

On Fig. 5(a-d) shows in detail how to determine the anatomical landmarks of all these areas. These anatomical regions are:

• The deltoid muscle on the shoulder, this area is used mainly for the administration of vaccines, in particular the hepatitis B vaccine and the ATP toxoid.
• The gluteal region, the gluteus maximus (upper outer quadrant of the buttock), is the traditional site for intramuscular injections (Campbell 1995). Unfortunately, there are complications when using this anatomical region, damage to the sciatic nerve or superior gluteal artery is possible if the needle insertion point is incorrectly determined. Beyea and Nicholl (1995) in their publication cite data from several researchers who used computed tomography and confirmed the fact that even in patients with moderate obesity, injections into the gluteal region more often lead to the fact that the drug is in adipose tissue, and not in muscle, which certainly slows down the absorption of the drug.
• Anterior-gluteal region, gluteus medius is a safer way to perform intramuscular injections. It is recommended because there are no large nerves and vessels, and there are no reports of complications due to damage to them (Beyea and Nicholl 1995). In addition, the thickness of adipose tissue is more or less constant here, at 3.75 cm compared to 1-9 cm in the gluteus maximus, suggesting that a standard 21 G intramuscular needle (green) will end up in the gluteus medius.
• Lateral head of the quadriceps femoris. This anatomical region is most commonly used for injections in children and carries the risk of inadvertent injury to the femoral nerve with subsequent muscle atrophy (Springhouse Corporation 1993). Beyea and Nicholl (1995) suggested that this area is safe in children up to seven months of age, then the upper outer quadrant of the buttock is best used.

Rice. 5a. Determination of the position of the deltoid muscle.

The densest part of the muscle is defined as follows: a line is drawn from the acromial process to a point on the shoulder at armpit level. The needle is inserted approximately 2.5 cm below the acromion to a depth of 90º.

The radial nerve and brachial artery should be avoided (Springhouse Corporation 1993).

You can ask the patient to put the hand on the thigh (as models do during the shows), which makes it easier to find the muscle.

To identify the gluteus maximus: the patient may lie on their side with the knees slightly bent, or with the big toes pointing inward. If the legs are slightly bent, then the muscles are more relaxed and the injection is less painful (Covington and Trattler 1997).

Rice. 5b. Definition of the outer upper quadrant of the buttock.

Draw an imaginary horizontal line from the beginning of the intergluteal gap to the greater trochanter of the thigh. Then draw another imaginary line vertically in the middle of the previous one, and at the top laterally will be the upper outer quadrant of the buttock (Campbell 1995). The muscle that lies in it is the gluteus maximus muscle. If you make a mistake during the injection, you can damage the superior gluteal artery and sciatic nerve. The typical volume of fluid to be administered in this area is 2-4 ml.

Rice. 5c. Definition of the anterior-gluteal region.

Place the palm of your right hand on the greater trochanter of the patient's left thigh (and vice versa). With your index finger, feel for the superior anterior iliac crest and move your middle finger back to form a V (Beyea and Nicholl 1995). If you have small hands this may not always work, so simply move your hand towards the comb (Covington and Trattler 1997).

The needle is inserted into the gluteus medius in the middle of the V at a 90º angle. A typical volume of drug solution for administration in this area is 1-4 ml.

Rice. 5d. Definition of the lateral head of the quadriceps femoris and rectus femoris.

In adults, the lateral head of the quadriceps femoris can be located a hand below and lateral to the greater trochanter, and a hand above the knee, in the middle third of the quadriceps femoris. The rectus femoris muscle is located in the middle third of the anterior surface of the thigh. In children and the elderly, or in malnourished adults, this muscle may sometimes need to be folded in order to provide sufficient depth of injection (Springhouse Corporation 1993). The first solution of the drug is 1-5 ml, for infants - 1-3 ml.

The rectus femoris is part of the anterior quadriceps femoris and is rarely used for injections by nurses, but is often used in self-administered drugs or in infants (Springhouse Corporation 1993).

IMPORTANT (3):
Learn to identify anatomical landmarks for each of these five intramuscular injection sites.
If you are accustomed to injecting drugs only in the upper-outer quadrant of the buttocks, then learn to use new areas and regularly improve your practice.

Methodology

The pain from the injection depends on the angle of the needle insertion. The needle for intramuscular injection should be inserted at an angle of 90 ° and make sure that the needle reaches the muscle - this allows you to reduce the pain of the injection. A study by Katsma and Smith (1997) found that not all nurses insert the needle at a 90° angle, believing that this technique makes the injection more painful, as the needle quickly passes through the tissues. Stretching the skin reduces the chance of needle injury and improves the accuracy of drug administration.

To correctly insert the needle, place the non-working hand and stretch the skin over the injection site with the index and middle fingers, and place the wrist of the working hand on the thumb of the non-working hand. Hold the syringe between the pads of your thumb and forefinger, this is how you can insert the needle accurately and at the right angle (Fig. 6).

Rice. 6. Technique for performing intramuscular injection, needle insertion angle 90º, anterior-gluteal region.

There has been little research on this topic in the UK, so nurses may have very different injection skills and techniques (MacGabhann 1998). The traditional technique for performing intramuscular injections was to stretch the skin over the puncture site to desensitize the nerve endings (Stilwell 1992) and quickly prick the needle at a 90° angle to the skin.

However, a review of the literature by Beyea and Nicholls' (1995) indicated that the use of the Z-technique resulted in less discomfort and fewer complications compared to the conventional technique.

Z—method

This technique was originally proposed for the administration of drugs that color the skin or are strong irritants. It is now recommended for the intramuscular administration of any medication (Beyea and Nicholl 1995) because it is believed to reduce soreness and the likelihood of drug leakage (Keen 1986).

In this case, the skin at the injection site is pulled down or to the side (Fig. 7). This shifts the skin and subcutaneous tissue by about 1-2 cm. It is very important to remember that the direction of the needle changes and you may not get to the right place.

Therefore, after determining the injection site, you need to find out which muscle is under the surface tissues, and not what skin landmarks you see. After injecting the drug, wait 10 seconds before removing the needle so that the drug is absorbed into the muscle. After removing the needle, release the skin. The tissue over the injection site will close the deposit of the drug solution and prevent leakage. It is believed that if the limb moves after the injection, the absorption of the drug will be accelerated, since blood flow will increase at the injection site (Beyea and Nicholl 1995).

Rice. 7. Z-method.

Air bubble technique

This technique was very popular in the USA. Historically, it was developed in the days of glass syringes, which required the use of an air bubble to ensure that the dose was correct. Dead space in a syringe is no longer considered necessary because plastic syringes are more accurately calibrated than glass syringes and this technique is no longer recommended by manufacturers (Beyea and Nicholl 1995).

Recently, two studies have been carried out in the UK on dummy (slow release oil solution) (MacGabhann 1998, Quartermaine and Taylor 1995) comparing the Z-method and the air bubble technique designed to prevent leakage of the solution after injection.

Quartermaine and Taylor (1995) suggested that the air bubble technique was more effective than the Z technique in preventing leakage, but the results of MacGabhann (1998) were inconclusive.

There are questions about dosing accuracy when using this technique, since the dose of the drug in this case can be significantly increased (Chaplin et al 1985). Further research is needed on this technique as it is considered relatively new in the UK. However, if it is used, the nurse must ensure that she is administering the correct dose to the patient and that the technique is being used exactly as recommended.

Aspiration technique

Although the aspiration technique is not currently recommended for control of subcutaneous injections, it should be used for intramuscular injections. If the needle is mistakenly inserted into a blood vessel, the drug can be inadvertently injected intravenously, sometimes resulting in an embolism due to the specific chemical properties of the drugs. With intramuscular injection of the drug, aspiration of the contents of the needle should be carried out within a few seconds, especially if thin long needles are used (Torrance 1989a). If blood is seen in the syringe, then it is removed and a fresh preparation is prepared for injection in another place. If there is no blood, then the drug can be injected, at a rate of about 1 ml per 10 seconds, this seems a little slow, but allows the muscle fibers to move apart to properly distribute the solution. Before removing the syringe, you must wait another 10 seconds, and then remove the syringe and press the injection site with a napkin with alcohol.

Massaging the injection site is not necessary, as this may cause leakage of the drug from the injection site and skin irritation (Beyea and Nicholl 1995).

Leather processing

Although it is known that cleaning the skin with an alcohol wipe prior to parenteral manipulation reduces the number of bacteria, in practice there are contradictions. Rubbing the skin for subcutaneous insulin administration predisposes to skin hardening under the influence of alcohol.

Previous studies suggest that such rubbing is not necessary and that lack of skin preparation does not lead to infection (Dann 1969, Koivisto and Felig 1978).

Some experts now believe that if the patient is clean, and the nurse strictly follows all hygiene and asepsis standards during the procedure, then disinfection of the skin when performing an intramuscular injection is not necessary. If skin disinfection is practiced, the skin must be rubbed for at least 30 seconds, then allowed to dry for another 30 seconds, otherwise the whole procedure is ineffective (Simmonds 1983). In addition, injecting before the skin dries not only increases the soreness of the skin, but also allows live bacteria from the skin to enter the tissue (Springhouse Corporation 1993).

IMPORTANT (4):
What are the guidelines for pre-injection skin preparation at your facility?
Find out what recommendations are there for insulin injections.
Are these recommendations consistent with the research data in the article?
What will you do?

IMPORTANT (5):
Imagine that you are watching a student who is about to perform his first injection. What prompts or tips will you use in this case to ensure that the trainee develops proper injection skills?

Equipment

Needles for intramuscular injections should be long enough to reach the muscle, while at least a quarter of the needle should remain above the skin. The most commonly used intramuscular injections are 21G (green) or 23 (blue) gauge needles, 3 to 5 cm long. If the patient has a lot of adipose tissue, then longer needles are required for intramuscular injections to reach the muscle. Cockshott et al (1982) found that the thickness of subcutaneous fat in women in the gluteal region can be 2.5 cm more than in men, so a standard 21 G injection needle 5 cm long reaches the gluteus maximus muscle in only 5% of women and 15 % men!

If the rubber cap of the vial has already been pierced with a needle, then it becomes blunt, in which case the injection will be more painful, since the skin has to be pierced with great effort.

The size of the syringe is determined by the volume of the injected solution. For intramuscular administration of solutions in volumes less than 1 ml, only small volume syringes are used to accurately measure the desired dose of the drug (Beyea and Nicholl 1995). For administering solutions of 5 ml or more, it is best to divide the solution into 2 syringes and inject at different sites (Springhouse Corporation 1993). Pay attention to the tips of the syringes - they have different purposes.

Gloves and accessories

In some institutions, regulations require the use of gloves and aprons during injections. It should be remembered that gloves protect the nurse from patient secretions, from the development of drug allergies, but they do not provide protection from damage from needles.

Some nurses complain that it is inconvenient for them to work with gloves, especially if they initially learned to perform this or that manipulation without them. If a nurse works without gloves, then care must be taken to ensure that nothing gets into her hands - neither medicines nor patients' blood. Even clean needles must be disposed of immediately, in no case should they be re-capped, the needles are discarded only in special containers. Be aware that needles can fall from injection trays onto the patient's bed, which can cause injury to both patients and staff.

Clean disposable aprons can be used to protect workwear from splashes of blood or injection solutions, and this is also useful in cases where a special sanitary epidemiological regime is needed (to prevent the transfer of microorganisms from one patient to another). It is necessary to carefully remove the apron after the procedure so that the dirt that has fallen on it does not come into contact with the skin.

IMPORTANT (6):
Make a list of all the things that help reduce the pain of injections. Compare with Table 1.
How can you use more ways to reduce injection pain in your practice?

Table 1. Twelve steps to make injections less painful

Pain Reduction

Patients are very often afraid of performing injections because they assume that it hurts. Pain usually results from irritation of pain receptors in the skin, or pressure receptors in the muscle.

Torrance (1989b) lists factors that can cause pain:

• The chemical composition of the drug solution
• Injection technique
• The rate of administration of the drug
• The volume of the drug solution

Table 1 lists ways to reduce pain from the injection of the drug.

Patients may have a strong fear of injections and needles, fear, anxiety - all this greatly increases the pain during injections (Pollilio and Kiley 1997). Good procedure technique, adequate information to the patient and a calm, confident nurse are the best way to reduce the pain of manipulation and reduce the patient's reaction. Behavior modification techniques can also be used, especially when the patient has long courses of treatment and sometimes requires the use of needle-free systems (Pollilio and Kiley 1997).

Anesthetizing the skin with ice or cold sprays prior to injection has been suggested to reduce pain (Springhouse Corporation 1993), although there is currently no research evidence to support this technique.

Nurses should be aware that patients may even experience syncope or fainting after conventional injections, even if they are otherwise perfectly healthy. It is necessary to find out if this has happened before, and it is desirable that there is a couch nearby on which the patient can lie down - this reduces the risk of injury. Most often, such fainting occurs in adolescents and young men.

Complications

Complications that develop as a result of infection can be prevented by strict observance of asepsis measures and thorough hand washing. Sterile abscesses can result from frequent injections or poor local blood flow. If the injection site is edematous or this area of ​​the body is paralyzed, then the drug will not be absorbed well, and such sites should not be used for injection (Springhouse Corporation 1993).

Careful selection of the injection site will avoid nerve injury, accidental intravenous injection, and subsequent embolism by drug components (Beyea and Nicholl 1995). Systematic changing of the injection site prevents complications such as injection myopathy and lipohypertrophy (Burden 1994). The appropriate length of the needle and the use of the anterior gluteal region for injections allows the drug to be injected precisely into the muscle, and not into the subcutaneous fat. The use of the Z-technique reduces pain and skin discoloration associated with the use of certain drugs (Beyea and Nicholl 1995).

Professional Responsibility

If the drug is administered parenterally, then it is no longer possible to “return” it. Therefore, it is always necessary to check the dose, the correctness of the appointment, and clarify the patient's name with the patient so as not to confuse the appointment. So: the right medicine to the right patient, in the right dose, at the right time, and in the right way - this will avoid medical errors. All drugs should be prepared exclusively according to the manufacturer's instructions, all nurses should know how these drugs work, contraindications to their use and side effects. The nurse should assess whether the drug can be used at all in this patient at this time (UKCC 1992).

conclusions

Safe administration of injections is one of the primary functions of a nurse and requires knowledge of anatomy and physiology, pharmacology, psychology, communication skills, and practical experience.

There are studies that prove the effectiveness of injection techniques to prevent complications, but there are still "white spots" that need more research. This article focuses on research-proven techniques so that nurses can incorporate these procedures into their daily practice.

Bibliography

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Campbell J (1995) Injections. Professional nurse. 10, 7, 455-458.
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Cockshott WP et al (1982) Intramuscular or intralipomatous injections. New England Journal of Medicine. 307, 6, 356-358.
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BACKGROUND SUMMARY

On the topic: “Complications of injections. Measures aimed at preventing complications "

Abstract outline:

History of post-injection complications

Classification of post-injection complications

3. E tyology of post-injection inflammatory complications

Complications when performing various injections

Characteristics of post-injection complications

Prevention of the development of post-injection complications

Reference abstract

Complications of injections. Measures aimed at preventing complications.

Post-injection complications came to the attention of physicians over a hundred years ago, immediately after the invention of the syringe in 1853 and the first injections in 1855.

The current widespread introduction of disposable syringes into medical practice has greatly facilitated and simplified the injection procedure. However, the frequency of post-injection complications and their treatment still remain one of the urgent problems.

Modern medicine is unthinkable without the use of a large number of injections. Thus, according to a number of researchers, more than 1 million injections are performed daily in Russia for the purpose of treatment, immunization and diagnostic tests. In parallel with the increase in the number of injections, the number of post-injection complications also increases.

Considering the frequency of the disease, its gradual increase, the involvement of medical workers in the occurrence of post-injection complications and the poor results of the treatment of this pathology, attention should be paid to the causes of post-injection complications: where, by whom and when injections performed more often lead to complications, which drugs are more often complicated by abscesses and phlegmon ; what is the mechanism of development of the pathological process; what methods can be used to clarify the diagnosis of post-injection complications; what method of treatment will be optimal when choosing a treatment in each case.

Classification of complications.

In the etiology of post-injection inflammatory complications, two main routes of penetration of infectious agents are considered: primary(exogenous) and secondary(endogenous) infection.

Exogenous infection is associated with:

ü ingress of pathogens from the skin at the time of its puncture or along the wound microchannel;

ü the entry of microorganisms into tissues from the syringe chamber (non-sterile syringe or injectable solution);

ü using a non-sterile injection needle (used to set the drug, when touched with environmental objects, it becomes non-sterile);

ü infection with non-sterile dressing material;

ü non-sterile hands of medical staff.

In most studies, the possibility of getting a sufficient amount of pyogenic bacteria from the skin at the time of puncture or along the wound microchannel is questioned. However, this mechanism is not completely denied, especially in case of gross violations of asepsis requirements, violations associated with the fault of the nurse are distinguished:

ü the presence of long nails, manicure, rings on the hands of the staff;

ü work without gloves;

ü the place of cutting of ampoules is not disinfected;

ü processing of vials sealed for seaming is carried out with one ball;

ü use of novocaine solution or sterile water in containers larger than 50 ml;

the use of non-sterile dressings;

ü the terms of preservation of sterile injection equipment, dressings are not controlled;

ü assembly of injection instruments is carried out with hands or tweezers in violation of asepsis rules;

ü Poor preparation of the injection field.

Complications when performing various injections.

Lipodystrophy (fatty degeneration) is a pathological condition, often characterized by a general lack of volume of adipose tissue in the subcutaneous tissue.

Most often, this complication occurs with insulin injections.

Lipodystrophy - areas of atrophy or hypertrophy of the subcutaneous fat layer at the sites of insulin injections. Lipodystrophy can appear in a child from a few weeks to 8-10 years from the start of insulin therapy. Insulin lipodystrophy is observed in 10-24% of patients, mainly in women and children receiving insulin therapy, regardless of the dose and type of hormone administered, the severity of diabetes mellitus and the state of its compensation. This complication of insulin therapy manifests itself in the form of:

• atrophy (atrophic form) - partial or complete disappearance of the subcutaneous tissue, sometimes outside the injection zone (repercussion lipodystrophy), is associated with insufficient purification of insulin preparations;
• hypertrophy (hypertrophic form) - at the injection sites of insulin, seals and infiltrates of the skin and subcutaneous tissue are formed, associated with the lipogenic effect of the hormone.

Infiltrate- the most common complication after subcutaneous and intramuscular injections. Most often, infiltration occurs if: a) the injection is made with a blunt needle; b) for intramuscular injection, a short needle is used, designed for intradermal or subcutaneous injections. Inaccurate choice of injection site, frequent injections in the same place, violation of asepsis rules are also the cause of infiltrates.

Abscess- purulent inflammation of soft tissues with the formation cavity filled with pus. The reasons for the formation of abscesses are the same as infiltrates. In this case, infection of soft tissues occurs as a result of violation of the rules of asepsis.

Needle breakage during an injection is possible when using old worn out needles, as well as with a sharp contraction of the muscles of the buttocks during an intramuscular injection, if a preliminary conversation was not held with the patient before the injection or the injection was made to the patient in a standing position.

Medical embolism can occur when oil solutions are injected subcutaneously or intramuscularly (oil solutions are not administered intravenously!) and the needle enters the vessel. The oil, once in the artery, clogs it, and this will lead to malnutrition of the surrounding tissues, their necrosis. Signs of necrosis: increasing pain in the injection area, swelling, redness or red-cyanotic coloration of the skin, an increase in local and general temperature. If the oil is in a vein, then with the blood flow it will enter the pulmonary vessels. Symptoms of pulmonary embolism: a sudden attack of suffocation, coughing, blue upper torso (cyanosis), chest tightness.

Air embolism with intravenous injections, it is the same formidable complication as oil. The signs of embolism are the same, but they appear very quickly, within a minute.

Damage to the nerve trunks can occur with intramuscular and intravenous injections, either mechanically (when the injection site is not chosen correctly), or chemically, when the drug depot is near the nerve, as well as when the vessel supplying the nerve is blocked. The severity of the complication can be different - from neuritis to limb paralysis.

Thrombophlebitis- inflammation of a vein with the formation of a thrombus in it - observed with frequent venipuncture of the same vein, or when using blunt needles. Signs of thrombophlebitis are pain, hyperemia of the skin and the formation of an infiltrate along the vein. The temperature may be subfebrile.

Necrosis tissues can develop with an unsuccessful puncture of a vein and the erroneous injection of a significant amount of an irritating agent under the skin. The ingress of drugs along the course during venipuncture is possible due to: piercing the vein "through"; failure to enter the vein initially. Most often this happens with the inept intravenous administration of a 10% solution of calcium chloride. If the solution still gets under the skin, you should immediately apply a tourniquet above the injection site, then inject 0.9% sodium chloride solution into and around the injection site, only 50-80 ml (will reduce the concentration of the drug).

Hematoma it can also occur during inept venipuncture: a purple spot appears under the skin, because. the needle pierced both walls of the vein and the blood penetrated into the tissues. In this case, the puncture of the vein should be stopped and pressed for several minutes with cotton wool and alcohol. In this case, the necessary intravenous injection is made into another vein, and a local warming compress is placed on the hematoma area.

allergic reactions on the introduction of a drug by injection can occur in the form of urticaria, acute rhinitis, acute conjunctivitis, Quincke's edema, often occurring after 20-30 minutes. after drug administration. The most formidable form of an allergic reaction is anaphylactic shock.

Anaphylactic shock develops within seconds or minutes of drug administration. The faster the shock develops, the worse the prognosis. The main symptoms of anaphylactic shock: a feeling of heat in the body, a feeling of tightness in the chest, suffocation, dizziness, headache, anxiety, severe weakness, lowering blood pressure, heart rhythm disturbances. In severe cases, symptoms of collapse join these signs, and death can occur within a few minutes after the onset of the first symptoms of anaphylactic shock. Therapeutic measures for anaphylactic shock should be carried out immediately upon detection of a sensation of heat in the body.

Long-term complications that occur two to four months after the injection are viral hepatitis B, D, C, as well as HIV infection.

Viruses of parenteral hepatitis are found in significant concentrations in blood and semen; in lower concentrations are found in saliva, urine, bile and other secrets, both in patients with hepatitis and in healthy virus carriers. The method of transmission of the virus can be blood transfusions and blood substitutes, medical and diagnostic manipulations, in which there is a violation of the skin and mucous membranes.

Complications after intravenous injections can be both minor and quite serious. The consequences depend only on the qualifications of medical personnel. An experienced nurse usually does not make serious mistakes, but she is not immune from minor oversights either. So what can happen, what are the complications from intravenous injections, and how should the patient act in these situations?

Why are intravenous injections prescribed?

In medicine, the term "intravenous injection" has a synonym - "venipuncture". This is the introduction of a hollow needle through the skin into the lumen of a vein. This manipulation is assigned in the following cases:

• when it is necessary to inject drugs into a vein;
• when a patient needs a blood transfusion or blood substitutes;
• when it is necessary to draw blood for analysis or perform bloodletting.

In other cases, the patient is prescribed intramuscular injections.

If something went wrong

If an intravenous injection is unsuccessfully performed by a healthcare professional, complications may include the following:

• a bruise, or rather, a hematoma in the injection area;
• swelling at the site of venipuncture;
• thrombosis and inflammation of the venous wall (thrombophlebitis);
• oil embolism;
• air embolism.

There is another complication that does not depend on the skill of the nurse. It's about an allergic reaction.

Hematoma from an injection

A bruise at the site of a vein puncture appears quite often. This means that the intravenous injection, the complications of which are discussed here, was performed incorrectly. Most likely, the needle pierced both walls of the vein through and through. But sometimes a hematoma appears even with the correct manipulation. This happens if the patient ignored the recommendations and did not press the injection site for several minutes.

If a health worker sees that a hematoma is forming at the venipuncture site, then he usually acts as follows:

• stops the introduction of the drug into the injured vein;
• takes out the needle;
• presses the injection site with a sterile cotton ball, which is moistened with a disinfectant solution;
• applies to the site of an unsuccessful injection or heparin ointment.

Only after that, taking a new syringe, the nurse will repeat the venipuncture into another vein.

Traditional medicine in the event of a hematoma at the site of intravenous injection recommends a compress with a cabbage leaf.

Tissue swelling after injection

If an intravenous injection was not performed correctly, complications may manifest as swelling around the injection site. This means that the needle did not enter the lumen of the vein or left it. As a result of this error, the drug enters the surrounding subcutaneous tissue. In this case, the health worker does not remove the needle, but first draws out the injected liquid with a syringe. Next, the injection site should be pressed with a cotton ball, and only then remove the needle.

If calcium chloride or radiopaque agents were administered intravenously, tissue necrosis may begin at the site of swelling. In this case, the health worker should stop the administration of the drug, quickly remove the needle and prick the affected area with the drug recommended by the doctor. Usually it is a solution of adrenaline or novocaine. A pressure bandage and cold are applied over the affected area. On the third day, half-alcohol compresses can be applied.

Thrombophlebitis

As a result of improper administration of the drug during venipuncture, inflammation of the inner walls of the vessel may develop, followed by the formation of a thrombus in the lumen of the vein. This disease is called thrombophlebitis. Such a problem may arise if certain drugs are quickly introduced (calcium chloride, Doxycycline, glucose). What to do to avoid after intravenous injection and strict adherence to the procedure algorithm - this is what the medical staff should pay attention to.

In order not to provoke the appearance of thrombophlebitis, it must be remembered that intravenous injections often cannot be given in one vein. In addition, a syringe with a sharp needle should be chosen, since a blunt one injures tissues more.

Symptoms of thrombophlebitis are manifested in the form of pain at the injection site, hyperemia of the skin and accumulation of infiltrate in the area of ​​the vein. There may be a low temperature. The patient must be examined by a doctor. He may prescribe heparin ointment for compresses and most likely recommend limiting the mobility of the limb.

Oil and air embolism

There are much more difficult problems that an incorrectly performed intravenous injection can provoke. Possible complications can even threaten the life of the patient. This is an oil embolism. Just in case, let's decipher what this term means. An embolism is a blockage of blood vessels by small foreign emboli (particles) or gas bubbles. The lymph and blood carry these particles or vesicles.

Complications of intravenous injections, which are called oil embolism, can only occur when an oil preparation is mistakenly injected into a vessel, if the needle accidentally enters its lumen during intramuscular injection. Intravenous oil solutions are never prescribed! Oil emboli gradually enter the artery and clog it, disrupting tissue nutrition. As a result, necrosis develops. The skin at the same time swells, reddens or becomes red-bluish. Local and general temperatures rise. If oil particles are in a vein, they drift into the pulmonary vessels. As a result, the patient has an asthma attack, he begins to cough, the upper half of the body turns blue, and chest tightness is felt.

All methods of treatment of this complication are aimed at eliminating blockage of the vascular lumens. It is impossible to self-medicate with this problem categorically! If the oil solution is incorrectly administered at home, then the patient is urgently taken by ambulance to the hospital.

Medical personnel must understand that they have a serious responsibility when administering oily solutions. Injection complications and their prevention are reviewed and studied in all medical schools.

An air embolism can occur if the healthcare provider does not remove the air bubble from the syringe prior to venipuncture. Signs of this complication appear much faster than with oil embolism.

Intravenous injections, the complications of which are rather unpleasant and sometimes deadly, are aimed at helping the patient. They are appointed as needed, and you should not be afraid of these appointments. It is important not to trust self-taught manipulations, but to use the services of qualified nurses.

Varieties of injection complications, signs, causes, prevention, treatment.

Infiltrate.

Signs:
Seal, soreness at the injection site.
The reasons:
- Violation of injection technique,
- Introduction of unheated oil solutions,
- Multiple injections in the same places.
Prevention:
Eliminate the causes that cause complications.
Treatment:
A warming compress, a heating pad, an iodine mesh in place of the infiltrate.

Abscess

Purulent inflammation of soft tissues with the formation of a cavity filled with pus and a pyogenic membrane delimited from the surrounding tissues.
Signs:
Pain, induration, hyperemia in the area of ​​the abscess, local or general fever.
The reasons:
The causes of infiltration include infection of soft tissues as a result of a violation
asepsis rules.
Prevention:
Eliminate the causes causing infiltrates and abscesses.
Treatment:
Surgical.

Needle breakage.

Signs: no.
The reasons:
- Insertion of the needle up to the cannula,
- Use of old, worn out needles,
- Sharp muscle contraction.
Prevention:
- Insert the needle 2/3 of its length,
- Do not use old needles
- Give injections with the patient lying down.
Treatment:
Remove the broken needle with tweezers or surgically.

oil embolism.

Signs:
The oil that is in the vein - the embolus, with the blood flow enters the pulmonary vessels. There is an attack of suffocation, cyanosis. This complication often ends in the death of the patient.
The reasons:
- Accidental entry of the end of the needle into the lumen of the vessel during subcutaneous or intramuscular injections,
- Erroneous administration of oily solutions intravenously.
Prevention:
Introduce oil solutions in a two-stage manner.
Treatment:
By doctor's prescription.

Air embolism.

Signs:
See "oil embolism", but in time it manifests itself very quickly.
The reasons:
The entry of air into the syringe and its introduction through the needle during injection into the vessel.
Prevention:
Carefully expel the air from the syringe before injection.
Treatment:
By doctor's prescription.

Incorrect drug administration.

Signs:
They can be different: from pain reaction to anaphylactic shock.
The reasons: -
Prevention:
Before injection, carefully read the edition of the drug, dosage, expiration date.
Treatment:
- Inject 0.9% sodium chloride solution into the injection site,
- Put an ice pack on the injection site,
- If the injection is made on the limbs - apply a tourniquet above,
- Further treatment as prescribed by the doctor.

Damage to the nerve trunks.

Signs:
They can be different: from neuritis to paralysis.
The reasons:
- Mechanical damage to the needle with the wrong choice of injection site,
- Chemical damage when a drug depot is created close to the nerve.
Prevention:
Choose the right injection site.
Treatment:
By doctor's prescription.

Thrombophlebitis (inflammation of a vein with the formation of a blood clot in it).

Signs:
Pain, hyperemia, infiltrate along the vein, fever.
The reasons:
- Frequent venipuncture of the same vein,
- Use of blunt needles.
Prevention:
- Alternate veins when performing injections,
- Use sharp needles.
Treatment:
by doctor's prescription.

Necrosis (tissue death).

Signs:
Increasing pain in the injection area, swelling, hyperemia with cyanosis, the appearance of blisters, ulcers and tissue necrosis.
The reasons:
Erroneous injection of an irritating substance under the skin (for example, 10% calcium chloride solution).
Prevention:
Follow the injection technique.
Treatment:
- Stop injecting the solution,
- Suck the injected medicine as much as possible with a syringe,
- Prick the injection site with 0.5% novocaine solution,
- Place an ice pack on the injection site.

Hematoma (bleeding under the skin).

Signs:
The appearance of a bruise under the skin in the form of a purple spot.
The reasons:
- Inaccurate intravenous injection (puncture of the vessel wall),
- Use of blunt needles.
Prevention:
- Compliance with the technique of intravenous injections;
- Use of sharp needles.
Treatment:
- Stop the injection;
- Apply cotton wool with alcohol to the vein;
- Apply a half-alcohol compress to the hematoma area.

Lipodystrophy.

Signs:
Under the skin, pits form at the injection sites of insulin due to the resorption of adipose tissue.
The reasons:
Regular injection of insulin in the same place.
Prevention:
Alternating the site of insulin injection.
Treatment: -

Sepsis, AIDS, viral hepatitis.

Signs:
Long-term complications manifest as a general disease of the body.
The reasons:
Gross violation of the rules of asepsis, pre-sterilization cleaning and sterilization of instruments.
Prevention:
Exclusion of the cause of these complications.
Treatment: -

Allergic reactions.

Signs:
Itching, rash, acute runny nose, etc. Anaphylactic shock.
The reasons:
Individual intolerance to the drug.
Prevention:
- Before the first injection, the patient should be asked about the tolerance of this drug;
-On the title page of the history there may be data on intolerance to any medicinal substances,
- Before the first injection of antibiotics, test for sensitivity to this drug.
Treatment:
- Stop administering the drug,
- Suck the injected substance as much as possible with a syringe,
- Prick the injection site with 0.5% novocaine solution,
- Put an ice pack on.