I'm a new nurse and I know I'm supposed to know how to do it already, but... I think I aspirate a bit too violently when checking for blood return (intramuscular injection). My preceptor says aspiration is a must for IM injections, and I'm quite scared at the thought of accidentally injecting medication into a blood vessel, so I always aspirate, even in delts.
Whenever I give IM injections, I aspirate 2-3 times, just to make sure. We were taught to aspirate for about 5-10 seconds. Curiously, blood enters the syringe only the second or third time I draw up the plunger... If I was to hit a vein, I'd be in the danger of giving the injection on the wrong route if I aspirated only once. Is this normal? Isn't blood supposed to enter the syringe from the first aspiration? I aspirate quite violently, so can this be the issue? I mean, perhaps my violent aspiration is causing damage to the muscle tissue.
Also, sometimes I've noticed some kind of "particles" entering the syringe. My preceptor says it's coagulated blood. Does it mean I've hit a blood vessel as well? Can I inject the medication anyway as long as it's not "regular" blood (bright red and liquid, so to speak)?
Sorry for the many questions, but I'd like to hear multiple opinions.
Specializes in Psych, Addictions, SOL (Student of Life).
Thanks everyone for sharing your opinions/experiences.
By the way, what are the risks of injecting in the same spot? For example, if a patient needs regular IM injections in the delts, and the medication is oily, it will dissipate very slowly. So the next time I inject him/her in the delt, the medication I've injected the previous day may still be there if the new spot is very close to the old one. Is this correct? So if I aspirate, the old med might enter the syringe if it hasn't completely absorbed. It's quite confusing for me. My nurse says I should always alternate the delts to avoid this, but I was just curious.
Not sure because nursing school was a long time ago - but I remember being taught that thick oily or viscous solutions need to be injected in to a large muscle - so that pretty much rules out the delt unles this is a body builder . My favorite muscle for these types of injections is the Ventral Gluteal since it is a very large muscle and no major blood vessels run through it. That beig said if the patient will be getting several injections over the course of several days it is always wise to rotate injection sites. Even insulin in the abdomen should be give in different sites. I really want to know what Violent Aspiration looks like - could you post a video you tube using an orange.
Think about IM injections, the force that is required, and if you are going to aspirate, even though it is not required, 0.1 ml is adequate enough pullback to determine if you are in the vein.
You need to fear less of hitting a vein and select areas with less potential for hitting a vein and be confident in you selection to not suck capillary particles and tissues while trying to deliver medication during an overall uncomfortable experience.
As far as I'm aware, aspiration is no longer required/recommended due to an increase in pain and potential for tissue damage (AEB your patients), except in the case of specific medications (penicillin being one of them).
So really, unless you're giving tons of IM PCN, the issue is that you're aspirating at all.
Injection technique
Aspiration prior to injection and slowly injecting medication are practices that have not been evaluated scientifically. Aspiration was originally recommended for safety reasons and injecting medication slowly was thought to decrease pain from sudden distension of muscle tissue. Although aspiration is advocated by some experts, and most nurses are taught to aspirate before injection, there is no evidence that this procedure is necessary. The ACIP's General Recommendations on Immunization document states that aspiration is not required before administering a vaccine. There are no reports of any person being injured because of failure to aspirate. In addition, the veins and arteries within reach of a needle in the anatomic areas recommended for vaccination are too small to allow an intravenous push of vaccine without blowing out the vessel. A 2007 study from Canada compared infants' pain response using slow injection, aspiration, and slow withdrawal with another group using rapid injection, no aspiration, and rapid withdrawal. Based on behavioral and visual pain scales, the group that received the vaccine rapidly without aspiration experienced less pain. No adverse events were reported with either injection technique.
Not sure because nursing school was a long time ago - but I remember being taught that thick oily or viscous solutions need to be injected in to a large muscle - so that pretty much rules out the delt unles this is a body builder . My favorite muscle for these types of injections is the Ventral Gluteal since it is a very large muscle and no major blood vessels run through it. That beig said if the patient will be getting several injections over the course of several days it is always wise to rotate injection sites. Even insulin in the abdomen should be give in different sites. I really want to know what Violent Aspiration looks like - could you post a video you tube using an orange.
Hppy
I haven't dealt with any oily meds thus far, but I've heard they're quite hard to inject because they're denser. Anyway, my favorite site for IM injections is the deltoid muscle, but I usually select the ventrogluteal site if I need to inject more than 2ml of solution or if the solution needs to be absorbed over the course of several hours or even days (meds get absorbed faster in the deltoids). I find the delts easier to work with because the chances of hitting a blood vessel are smaller, and it's a lot more comfortable for me. I never inject in the same spot twice -- I rotate injection sites to avoid soreness and tissue damage. If I were to inject, say, 4 or 5ml of solution at a time, I'd split it into two injections and I'd probably choose either the delts or the glute (one injection/muscle).
About the video -- I'd rather not. :))
Short answer-yes.
Think about IM injections, the force that is required, and if you are going to aspirate, even though it is not required, 0.1 ml is adequate enough pullback to determine if you are in the vein.
You need to fear less of hitting a vein and select areas with less potential for hitting a vein and be confident in you selection to not suck capillary particles and tissues while trying to deliver medication during an overall uncomfortable experience.
That's pretty much what older nurses have told me, but I wasn't sure so I wanted to ask for someone else's opinion first. So those were capillary particles? This means I can't inject the med if those enter the syringe, is that right?
I think all your violent aspiration may be busting capillaries and thats what you are seeing. I would suggest that you spend a little time researching journals and studies that have been done so that you know what the most up to date practice is based on scientific evidence, and then follow that. It sounds like a lot of people both here and that you know in person have told you that you dont need to aspirate so violently (or not at all), but you seem to need more convincing. It may be time to do some of your own searching so that your concerns will be answered to your satisfaction.
I think all your violent aspiration may be busting capillaries and thats what you are seeing. I would suggest that you spend a little time researching journals and studies that have been done so that you know what the most up to date practice is based on scientific evidence, and then follow that. It sounds like a lot of people both here and that you know in person have told you that you dont need to aspirate so violently (or not at all), but you seem to need more convincing. It may be time to do some of your own searching so that your concerns will be answered to your satisfaction.
I will spend some time doing research, but from now on I guess I'll probably aspirate for just 1-2 seconds or so, if at all. I guess that as long as blood doesn't enter the syringe from the very first moment, I shouldn't worry about having hit a blood vessel, so I can confidently inject medication.
Btw, what's the recommended distance between two injection spots of the same muscle? I remember it's about 1 inch or so for the glute, but can't recall anything about the delts or vastus lateralis. The deltoids are small so you can't really have spots distanced at 1 inch from each other, unless we're talking about a muscular person, but what about the vastus lateralis?
Can't help you there. When we do immunizations on babies, the spots end up close together by default.
Just as I thought. Plus, some patients will naturally be skinnier or more muscular than others, so the proximity of injection spots will be different as well.
Thank you all for sharing your opinions! I'm still learning so it's helpful to get input from more experienced nurses.
My first answer is that you should review your policy and/or procedures on this administration technique. *Best practices* may no longer indicate aspiration for IM administration of many medications, however, you will be judged by your policy should something (anything) go wrong. If there's nothing in the policy to contraindicate, I would favor the evidence based practice (despite the fact that as recently as when I graduated nursing school, we were taught to aspirate for IMs).
I rarely give anything IM as an OR nurse (I honestly can't remember the last time I did so). We give subcutaneous heparin from time to time but not frequently (generally given pre-op or on the floor if inpatient). I would probably be looking at the policy before every IM I need to give because we don't do it that often. In reality - almost always our patients have adequate IV access and utilize other routes for medication administration. *Obviously* my situation is different than that of floor, ED, clinic nurses, etc.
Thank you all for sharing your opinions! I'm still learning so it's helpful to get input from more experienced nurses.
Yes, I'm sorry I doubted you earlier, there was previously a new member who was pretending to be a nurse but just injecting someone with steroids who sounded very similar- I answered them in good faith and felt a bit conned. Glad you got your answers, I'll dial my scepticism back down again!
Back when it was still considered good practice to aspirate, that was the amount of time you were supposed to aspirate for (5 seconds).
I had to dig to find it again, but during a previous conversation about this I saw this article, which found that among a small group of RNs (164) 74% aspirated when giving IM injections, but only 3% actually did it correctly. So, even when they thought they were doing the right thing, they were doing it wrong.
. My favorite muscle for these types of injections is the Ventral Gluteal since it is a very large muscle and no major blood vessels run through it. That beig said if the patient will be getting several injections over the course of several days it is always wise to rotate injection sites. Even insulin in the abdomen should be give in different sites. I really want to know what Violent Aspiration looks like - could you post a video you tube using an orange. 
hppygr8ful, ASN, RN, EMT-I
4 Articles; 5,212 Posts
Not sure because nursing school was a long time ago - but I remember being taught that thick oily or viscous solutions need to be injected in to a large muscle - so that pretty much rules out the delt unles this is a body builder
. My favorite muscle for these types of injections is the Ventral Gluteal since it is a very large muscle and no major blood vessels run through it. That beig said if the patient will be getting several injections over the course of several days it is always wise to rotate injection sites. Even insulin in the abdomen should be give in different sites. I really want to know what Violent Aspiration looks like - could you post a video you tube using an orange.
Hppy