to aspirate or not while giving insulin and flu vaccines

lannisz · Oct 29, 2006

Here are some sources:
http://www.immunize.org/catg.d/p2021f.htm
"ACIP does not recommend aspiration when administering vaccines because no data exist to justify the need for this practice. Intramuscular injections are not given in areas where large vessels are present. Given the size of the needle and the angle at which you inject the vaccine, it is difficult to cannulate a vessel without rupturing it and even more difficult to actually deliver the vaccine intravenously. We are aware of no reports of a vaccine being administered intravenously and causing harm in the absence of aspiration. (10/05)"
From the CDC:
http://www.cdc.gov/mmwr/PDF/rr/rr5102.pdf (page 12)
"Although certain vaccination specialists advocate aspiration
(i.e., the syringe plunger pulled back before injection),
no data exist to document the necessity for this procedur[/quot
I do not aspirate when administering vaccines as per CDC recc., or SQ insulin.

miko014 · Oct 30, 2006

That's interesting...I hit a vessel the other night with a SQ heparin shot in a belly. I pulled back and that sucker FILLED with blood - I got a nicer backflow that I usually get with an IV start, lol. I think I'm going to be aspirating my insulin injections despite the recommendation...I work with a nurse who got a backflow on an insulin shot in an arm about a year ago. Granted, the risk is small, and I doubt 2 units would be awful, but what about my out of control people who get 20? Or 30 of lantus? I don't think I'd want to give that IV. I think I'll have to check my policy...I've always aspirated. Hmmmmmm...

WindyhillBSN · Oct 30, 2006

Interesting, they taught us to aspirate all except for heparin. :confused:

dream'n, BSN, RN · Oct 30, 2006

At my job all of us have heard and discussed the new CDC guidelines about not aspirating. All of the nurses so far have refused to stop aspirating. I have personally gotten blood back during aspiration (granted very rarely, but I was an injection nurse and did upwards of 50 to 100 injections a day at the time.) Not aspirating just doesn't feel like safe practice, no matter what the CDC is saying. By the way, please don't flame me, but at a conference I recently went to the CDC presenter stated that the new guidelines were released because of the worry that more and more MAs were giving injections and that the CDC is concerned about tissue damage from 'too forceful aspiration,' although I have never heard of or seen that before. He said that the risk of injection into a vessel was lower than the risk of tissue damage from aspiration. Now that is not my opinion, I work with MAs that could dance all over some nurses when giving injections. Just food for thought...they also said no more gluteal injections either, everything that went dorso-gluteal is now to go in the hip, ventral-gluteal.

StNeotser, ASN, RN · Oct 30, 2006

I feel it's wrong not to aspirate. I wonder sometimes about B12 as it's red coloured anyway. Subq I have never aspirated for because this is how I was taught.

Justhere, BSN, RN · Oct 30, 2006

Interesting, they taught us to aspirate all except for heparin.

We were taught the same way. One of the nurses the other day in the nursery got a blood return giving vit. K. And I have heard some of the other nurses talking about getting blood return. I always aspirate. Would hate to give something IVP that wasn't meant to be no matter how small the risk.

TazziRN, RN · Oct 30, 2006

So the CDC recommends not aspirating when giving vaccines? That means we're now supposed to stop and think, "Oh, I'm giving a vax so I'm not going to aspirate?" I don't think so! I agree fully with the poster who said that if aspirating is not recommended just because it may be unneccesary, then we might as well do it anyway to be safe. I would hate to forget just once what I'm giving and not aspirate because we are now being told not to with vax, only to find out I should have aspirated and I hit a vessel and caused a problem. Methinks that saying "I thought I was giving a vaccine" is not going to wash when I'm standing in front of the BON after being turned in for harming a pt.

rn/writer, RN · Oct 30, 2006

I cannot address the aspiration of flu vaccines, but I do know a bit about heparin and insuling injections.

Aspirating heparin or lovenox is unnecessary as long as you stay two inches away from the umbilicus. You are injecting with a short needle at a 90 degree angle into an area that doesn't contain major vessels. The fact that they are anticoagulants can, all by itself, produce a blood return. It is a waste of expensive medication and a valuable injection site to make another attempt bacause you are not familiar with the principles at work and the guidelines sent with the medications. The manufacturers specifically say NOT to aspirate.

Aspirating insulin is also unnecessary. Again, the short needle and the angle of injection make injecting into a major vessel nigh unto impossible.

I've been injecting Lantus into either thigh on a nightly basis for a long time. (I save abdominal sites for Humalog.) On very rare occasions, I will see blood. What research and experience have taught me is that you can hit a small vessel (all that is reachable sub-q) and still not be in any danger of giving that insulin IVP. Even with the high doses I use. The worst thing that happens is a small bruise. I have never noticed any kind of difference in blood sugars or symptomatology following a stick that bleeds.

The literature that is available does recognize that a small vessel might be breached, but nothing equates that sort of through-and-through puncture with the kind of access available through an IV cannula. One of the reasons that we quickly pull a blown IV is that any medication going in through that line is escaping with the fluids into the surrounding tissues. The same principle is in operation with the puncture of a small vessel. Hemodynamic pressure will push blood OUT rather than allow the medication in. That would be true even if the needle ended IN the blood vessel. What is far more likely is that the needle will end up in good ol' sub-q tissue. Either way, the patient is not in danger.

People who need ongoing multiple injections become protective of their available sites. Please do not aspirate out of habit when it is not recommended.

loriannlpn · Oct 31, 2006

We were taught not to aspirate SC at any tiime. IM, always aspirate.

The rationale taught to us in school for not aspirating a SC, by injecting into adipose tissue, the vascular supply is less then in the muscle.

loriannlpn · Oct 31, 2006

Are MA's not held at the same standards as Nurses? That is bizzar. Is there not a scope of practice for them? Anyone know the answers?

Cosper123 · Oct 31, 2006

I would rather someone aspirates when giving me an IM injection. This new changing data kinda scares me.

May help to consider the intent behind aspiration...in that you don't want to enter directly into the bloodstream something intended for a slower absorption...

With a flu shot however, it's not like you're going to OD or anything.

So that's probably why they don't aspirate. What I don't understand about the theory of all the vaccine not being administered, is why they don't just add a air bubble to it. Anyone more experienced have any idea on this? I know some subQ shots come with air bubbles, is it feasible for an IM?

SharonH, RN · Oct 31, 2006

I cannot address the aspiration of flu vaccines, but I do know a bit about heparin and insuling injections.
Aspirating heparin or lovenox is unnecessary as long as you stay two inches away from the umbilicus. You are injecting with a short needle at a 90 degree angle into an area that doesn't contain major vessels. The fact that they are anticoagulants can, all by itself, produce a blood return. It is a waste of expensive medication and a valuable injection site to make another attempt bacause you are not familiar with the principles at work and the guidelines sent with the medications. The manufacturers specifically say NOT to aspirate.
Aspirating insulin is also unnecessary. Again, the short needle and the angle of injection make injecting into a major vessel nigh unto impossible.
I've been injecting Lantus into either thigh on a nightly basis for a long time. (I save abdominal sites for Humalog.) On very rare occasions, I will see blood. What research and experience have taught me is that you can hit a small vessel (all that is reachable sub-q) and still not be in any danger of giving that insulin IVP. Even with the high doses I use. The worst thing that happens is a small bruise. I have never noticed any kind of difference in blood sugars or symptomatology following a stick that bleeds.
The literature that is available does recognize that a small vessel might be breached, but nothing equates that sort of through-and-through puncture with the kind of access available through an IV cannula. One of the reasons that we quickly pull a blown IV is that any medication going in through that line is escaping with the fluids into the surrounding tissues. The same principle is in operation with the puncture of a small vessel. Hemodynamic pressure will push blood OUT rather than allow the medication in. That would be true even if the needle ended IN the blood vessel. What is far more likely is that the needle will end up in good ol' sub-q tissue. Either way, the patient is not in danger.
People who need ongoing multiple injections become protective of their available sites. Please do not aspirate out of habit when it is not recommended.

That's very persuasive Miranda. I have not read the research on this subject but you make excellent points.