IM injections

Anna Flaxis, BSN, RN · Oct 8, 2015

You can use NS or 1% lidocaine to reconstitute Rocephin for IM administration. However, I would follow your facility's protocol. Your pharmacy would be the best resource for this. Next time you need to give Rocephin, give the pharmacy a call and ask.

Bicillin is so viscous that it must be administered through a large needle, and it must be administered at a slow steady rate so the needle doesn't occlude. It's a painful injection regardless of whether you are an adult or a child. I would make sure to explain this to the parent prior to administration so that they are prepared to see their child experiencing a lot of discomfort. You should also be prepared for the potential for the child to attempt to get away from the source of pain, as this is a natural reaction. Depending on the age and size of the child, you may need to have someone help hold them.

I'm not saying this to make you feel badly, but from your description, this sounds like a horrible experience for the child and parent, and I don't blame the parent for being upset. In fact, if the attitude in this post is what you projected during your interactions with this parent, I would have been fuming, and I would be filing a complaint were I that parent. I suggest you take this as a learning experience and an opportunity to improve your practice in the future.

Knowing how awful Bicillin can be, I wonder if there is a reason the prescriber wrote for Bicillin as opposed to something oral? Did you ask?

As far as injection sites and volumes, I recommend you carry a clinical resource with you so you can look things up when you need to know them, if your facility does not provide these resources.

klone, MSN, RN · Oct 8, 2015

I was wondering about the Bicillin as well. The only time we give it is for treating syphilis. I assume the little girl did not have syphilis.

I always reconstitute Rocephin in 1% lidocaine.

As far as max dosages per site, this article is a good resource (look on the chart on page 2). Typically, I don't give more than 1 ml in the deltoid, and will give up to 3 ml in the ventrogluteal (adult patients).

Large-volume IM injections: Ã¢Â€Â¨A review of best practices - ONA

Anna Flaxis, BSN, RN · Oct 8, 2015

^ Sometimes a provider will order Bicillin if the patient is unlikely to cooperate with oral antibiotics, for whatever reason- ie "compliance", N/V, etc. But it's not really one of our "go-to" meds, so when a provider orders it, I like to know why. If I'm going to poke a child with a huge needle and give them a really painful injection, I want to know it's really the best option- and I will be certain to explain that to the parent.

iwantsome · Oct 8, 2015

You can use NS or 1% lidocaine to reconstitute Rocephin for IM administration. However, I would follow your facility's protocol. Your pharmacy would be the best resource for this. Next time you need to give Rocephin, give the pharmacy a call and ask.
Bicillin is so viscous that it must be administered through a large needle, and it must be administered at a slow steady rate so the needle doesn't occlude. It's a painful injection regardless of whether you are an adult or a child. I would make sure to explain this to the parent prior to administration so that they are prepared to see their child experiencing a lot of discomfort. You should also be prepared for the potential for the child to attempt to get away from the source of pain, as this is a natural reaction. Depending on the age and size of the child, you may need to have someone help hold them.
I'm not saying this to make you feel badly, but from your description, this sounds like a horrible experience for the child and parent, and I don't blame the parent for being upset. In fact, if the attitude in this post is what you projected during your interactions with this parent, I would have been fuming, and I would be filing a complaint were I that parent. I suggest you take this as a learning experience and an opportunity to improve your practice in the future.
Knowing how awful Bicillin can be, I wonder if there is a reason the prescriber wrote for Bicillin as opposed to something oral? Did you ask?
As far as injection sites and volumes, I recommend you carry a clinical resource with you so you can look things up when you need to know them, if your facility does not provide these resources.

Using NS for an injection will increase the pain. Rocephin is already a painful shot that is why it is usually mixed with lidocaine.

Anna Flaxis, BSN, RN · Oct 8, 2015

Using NS for an injection will increase the pain. Rocephin is already a painful shot that is why it is usually mixed with lidocaine.

I'm aware of the rationale, thank you. Still, different facilities have different policies, and one should follow their facility's P&P. If the P&P needs to be updated, that's a different topic.

Tenebrae, BSN, RN · Oct 8, 2015

The only time I would give an IM antibiotic shot is for a child who is on prophylaxis antibiotics for rheumatic fever.

But generally 1-2cc into the deltoid

Anything larger into the ventrogluteal

klone, MSN, RN · Oct 8, 2015

I'm aware of the rationale, thank you. Still, different facilities have different policies, and one should follow their facility's P&P. If the P&P needs to be updated, that's a different topic.

Our facility states that it should be reconstituted per the instructions on the vial. The vial states sterile water or lidocaine.

Anna Flaxis, BSN, RN · Oct 8, 2015

You can use any compatible solution, but again, your facility may have a policy that specifies a solution. At my facility, it is 1% lidocaine (which we need an order for, since lidocaine is a medication that is kept in the Omnicell). The OP's workplace may not have a specific policy, in which case, NS is a compatible solution- so the RN who said to use NS isn't wrong. You CAN use NS. It is a compatible solution. It's not very nice if lidocaine is an option, but it's not WRONG.

Guest838984 · Oct 9, 2015

Thank you all for your responses and @Annaflaxis (love the name) we just opened up a new hospital so we don't exactly have set p&ps in place yet or they haven't been clearly explained that there is a preference for either solution. And I did have a good hold down on the kid but she was just very strong. She was little so I thought I could've handled it on my own and I did explain to mother that it would be a painful shot but yea I just don't like anyone being upset with me as no one would but working in the ER that's likely to happen here and there atleast

Hoosier_RN, MSN · Oct 9, 2015

we just opened up a new hospital so we don't exactly have set p&ps in place yet or they haven't been clearly explained

I know you can't possibly mean this. A facility, no matter its age, should have p&ps in place for all common and most anticipated circumstances. To not would mean an opening for many legal issues. Ask your charge nurse or dept head where the p&p manual is located and save yourself some headaches in the future

Guest838984 · Oct 10, 2015

I mean there's p&ps for things like phenegran admin which is IM only at my facility. They never explained the specifics for medication reconstitution for certain medications. If I ask I'm sure they would then let me know. But it's just here were a small ER so we don't have an on call cath lab so we don't have a stemi protocol, we don't have a stroke protocol we don't have a set heparin drip protocol/insulin drip protocol in place we've just been using what other nurses would use from other facilities it gives me an uneasy feeling but that's just how it is