Question about IM vs IV injection, when to aspirate, what to look for

[jeshicuhx3]

Hello everyone!

I am in nursing school right now, and my father has diabetes.

We recently went over our prescription drug coverage for the year,

so his doctor decided to have him do weekly IM injections at the top of his glutes.

Since he can't do it himself, obviously, they showed me the procedure for doing it.

However, I have a couple of questions (that I forgot to ask at the time).

I've done some research, and some sites say that you don't have to aspirate before doing an IM injection, and some sites say that you have to aspirate, and when you do, if you draw back blood that means you hit a vein/artery. So my first question is thus: do I aspirate or not? And if so, I make sure that no blood draws back, right?

When they showed me how to do it, I don't recall her aspirating, she just quickly "jabbed" the needle in (that's the best way I could describe it, it kinda shocked me since I'm not that far into my training lol).

My third question is this: for IV injections, if you draw back blood, that always means you are in a vein, correct? And there is no chance that you hit a muscle, right?

All responses are greatly appreciated!! I'm about to apply to TWU in February, and I'm so excited! I have a 3.9 GPA (just .1 more point would be so great! lol), and I have 3 more years until I have my BSN!!! :] Science is my life, and I can NOT wait until I can become a neonatal nurse and take care of newborns :] I'm also excited that I have the chance to practice certain things like injecting medication for my parents (my mother has MS and I sometimes help her injecting her daily meds). I also have a 3 year old, so cleaning boo-boos and taking care of her (giving her medicines when she is sick) is something I love. I don't necessarily enjoy her being sick, but it makes me feel good to have the knowledge of how to take care of her when she is sick or hurt.

Sorry to ramble, but I just wanted to give a little background information so people aren't like, "how do you not know this if you're in nursing school?" I haven't quite gotten to the point of doing clinicals yet, or anything like that. However, I am a fast learner, and it's always better to ask questions if you don't know something.

Anyways, if someone could clear up this confusion for me, that would be great!

I put the 3 questions I had in bold, so that it is easier for everyone to see them in my long, rambling thread, lol.

Thanks again everyone for the help!

Jess

[KelRN215, BSN, RN]

I have always aspirated when I administer an IM. When I worked in the hospital, we taught family members to administer IM injections frequently and our Clinical Nurse Specialist always said that we were not to teach family members to aspirate because the odds of hitting a vein were so small. I've never drawn blood when giving an IM.

As far as IV injections go... very rarely would you be injecting medication via a needle directly into a vein. IV drugs are usually administered through an existing catheter.

[BloomNurseRN, ASN, BSN, RN]

My nursing school taught us that aspiration was done previously but that it is no longer recommended. When doing them during clinical it was not expected and we did not aspirate. I just graduated in May.

It sounds like you're getting a great start on helping your family (and on your nursing school!). Good luck!

[akulahawkRN, ADN, RN, EMT-P]

Years ago, when I was originally taught IM injections, I was taught to aspirate every time. It was because some drugs just aren't to be given intravenously. Yes, it's rare that you actually hit a blood vessel big enough to aspirate visible blood. That's all fine, well, and good if the drug is OK to give (inadvertently) IV. If not, then there might be a problem. So, I would think it would not be a bad idea to look up the IM drug and see if there's an IV notation. If so, then no need to aspirate. If there isn't, aspirate.

That's just my take on it, and although I'm a student... I think this approach makes sense even though the current thinking says you don't need to aspirate.

[Ayvah, RN]

Anyone who is claiming that aspiration across the board is not indicated needs to supply hard evidence/medical consensus that backs those claims.

Assume all IM (and YES including sub-Q) injections require aspiration unless you find otherwise. There are some exceptions of a few specific medications such as insulin and heparin and the flu shot which don't require aspiration. If you do enter a blood vessel (I have before on both an IM and a sub-q injection), blood will GUSH into the syringe. Capillary blood will be only a small drop/tinge in the syringe which does not gush in with sustained aspiration. Here is my proof regarding aspiration.

Rocephin prescribing information states you need to aspirate: http://www.gene.com/download/pdf/rocephin_prescribing.pdf

As with all intramuscular preparations, Rocephin should be injected well within the body of a relatively large muscle; aspiration helps to avoid unintentional injection into a blood vessel.

Cimzia (Sub-Q injection) manufacturer instructions states you need to aspirate: Instructions on Using the Prefilled Syringe | CIMZIA® (certolizumab pegol)

Step 10

Release the skin pinch, keeping the syringe in position. Pull back slowly on the plunger. If blood enters the syringe, this means you have entered a blood vessel. Do not inject CIMZIA. Pull the needle out and throw away the prefilled syringe and needle in a puncture-proof container. Repeat the steps to prepare for an injection using a new prefilled syringe. Do not use the same prefilled syringe.

CDC says you don't need to aspirate vaccines given in the vastus lateralus/deltoid http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/d/vacc_admin.pdf

Because there are no large blood vessels in the recommended sites, aspiration before injection of vaccines (i.e., pulling back on th e syringe plunger after needle insertion but before injection) is not necessary.

Lippincott says sub Q injections DO NEED aspiration except for insulin/heparin Lippincott's Nursing Procedures - Google Books (bullet 4-5, won't let me copy/paste)

Also, even if a drug is also indicated for IV, you need to be aware that there is a big difference between IV (drip) and IVP (IV-push).

[Asystole RN]

I aspirate all injections all the time simply because of muscle memory and professional diligence and prudence. Its like hand washing, get into the habit of doing it every time and you will do it all the time. It costs nothing to aspirate and only takes a single oops to harm your patient.

[nurseprnRN, BSN, RN]

OK, I got curious and bored.

Here's the results of one study I found online:

Although the authors were most interested in aspiration’s effects on

injection-related pain, other injection technique evidence-based

information was also gathered. Literature review conclusions were:

• A rapid IM injection technique without aspiration results in less

pain.

• Aspiration does not confirm correct needle placement.

• As a result, aspiration is not a recommended procedure for IM

injections in any age group.

The bit about aspiration not confirming correct needle placement puzzled me. If one aspirates blood, I was taught that means the needle hit a vein.

As to the aspiration thing per se, I can't think of how many bazillions of IMs I gave before I realized there was NEVER any blood return.

You might have "hit" one but chances are vanishingly slim that you are in one. Look at the anatomy of where you give IMs. There are no big veins that would accept a beveled needle put in at that angle and make it possible to give your whole dose intravenously. It's just not anatomically possible. When you aspirated, did you get that nice free blood flow associated with a successful IV start? No, of course not. Maybe a leetle drop or two? That's what we call "incidental."

And what's this about "contaminated"? With what? A drop of the patient's own blood or body fluid? Come on. Nonsense. It's dangerous to give him a drop of his own blood? Come ON.

Listen to the CDC. What they mean by "Aspiration does not confirm correct needle placement" means "Think of all the other wrong places you could be putting that needle besides a blood vessel. Some fools will do that, so just cuz they got no blood aspiration doesn't mean they're automatically in a good place."

This is why they call it "evidence-based practice."

One more thing occurs to me: The OP doesn't say what's being injected. Some things should be given with Z-track technique to prevent skin staining when an injectate flows back along the needle track.

To give an injection by Z-track, you pull the tissue laterally where the needle will pass, so the layers slide over each other. Think of, oh, poking a chopstick into a three-layer cake with frosting in between the layers to make a hole all the way to the plate. If you stick it straight in, the hole goes from the plate to the top. If, however, you push the layers sideways so they make sort of a stepwise look, push the chopstick straight down in, remove it, and replace the layers they way they came, there is no hole from the plate to the top, because the layers closed it off when they slid back into place. That's Z-track.

OP, be sure that's not what they meant to teach you.

[Ayvah, RN]

As to the aspiration thing per se, I can't think of how many bazillions of IMs I gave before I realized there was NEVER any blood return.

Just because you haven't had it happen doesn't mean others haven't. Examples of this happening have been discussed in this thread, where blood continuously gushes into the syringe, not just a tiny drop for a second. I have had this happen before myself, as I mentioned a few posts up, thanks to a job where I gave injections all day. It was quite shocking, but I am sure glad I aspirated.

There are no big veins that would accept a beveled needle put in at that angle and make it possible to give your whole dose intravenously. It's just not anatomically possible.

Please provide evidence. In my post I quoted 2 manufacturers which state it is possible to enter a blood vessel and that injections should not be given if so (and Lippincott which states to aspirate even sub-Q). Also you must keep in mind that not everyone has the same textbook anatomy. Liklihood does not equal certainty.

Listen to the CDC.

Please note that the CDC information I found which stated aspiration is not needed was in reference to vaccines only. Please provide evidence for other types of injection where the CDC states no aspiration is necessary (besides insulin/heparin)

This is why they call it "evidence-based practice."

Yes! Please provide evidence!

[CodeteamB]

A fantastic little summary here...

http://www.stti.iupui.edu/pp07/vancouver09/41810.Crawford,%20Cecelia%20L.-F%2010.pdf

I especially love the part where we are all doing it wrong

I know the new grads coming out of school in my area are no longer taught aspiration.

[BrandonLPN, LPN]

Yes, I've given many IM injections myself. My facility doesn't "do" IVs and we rely heavily on IM antibiotics.

I aspirated blood only once, but it was more than a few drops. It was a "gush" of blood that filled the syringe. My site and technique were correct.

I guess it could have been a fluke?

If the rationale is "You don't have to aspirate, beacause nobody ever aspirates blood anyway" then I don't buy it. It's rare, but it happens.

If the rationale is that evidence shows it doesn't matter if one were to aspirate blood or not, well, then okay. But implying it's an outmoded practice because "no one ever gets blood back anyway" is untrue.

[Nurse SMS, MSN, RN]

I was taught NOT to aspirate. Graduated 12/2011.

[apoppyfield, BSN, RN]

Has anyone ever gotten blood return while giving an IM injection? One of my clinical instructors said it's EBP that it is no longer done. Then I worked at a hospital that required it according to policy. I wonder what the chances are of turning an IM into an IV?

[nurseprnRN, BSN, RN]

Please note that the CDC information I found which stated aspiration is not needed was in reference to vaccines only. Please provide evidence for other types of injection where the CDC states no aspiration is necessary (besides insulin/heparin) Yes! Please provide evidence!

CodeteamB has nicely done so before could, and a much nicer presentation with plenty of references. I hope that is helpful.