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

Ayvah, RN · Aug 20, 2013

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

The referenced presentation is not from the CDC (if that's what you were thinking since you quoted my CDC portion?) but it does quote their guideline that immunizations specifically don't need aspiration.

Lets highlight portions of the presentation which were found at the end of the presentation:

Review limitations – relatively narrow focus of administered medications, mainly vaccines, immunizations, insulin and penicillin

Recommendations for Consideration
Aspiration is not indicated for SC injections of vaccines, immunizations and insulin (2,8)
Aspiration is not indicated for IM injections of vaccines and immunizations (2,5)
Aspiration may be indicated for IM injections of large molecule medications, such as penicillin (4,10,13)

Until a standard can be determined, injection techniques must be individualized to the patient, the equipment, and the medication being administered in order to decrease the risk of incorrect needle placement (3,11,13,14,15)

As quoted above, their review focuses on immunizations/vaccines/insulin/penicillin, and the recommendations regarding immunizations/vaccines and insulin I've already agreed with and have shown evidence that agrees with this such as Lippincott and CDC evidence. Their penicillin recommendation was that it could still be done with aspiration. Overall they state more research is needed before recommendations could be made regarding other types of medication, which I'm guessing is likely to be the final consensus of this thread.

Your first post on this thread made statements (which seemed to be saying that no injection needs aspiration, and you also said it was anatomically impossible to inject into a blood vessel) which directly contradicts the evidence I had posted earlier, and I'm asking about what you base that on/to provide evidence/medical consensus which supports that. I'm not trying to rail against you specifically, I'd really like to have an evidence based discussion on this, since I think there is a ton of confusion regarding this issue out there.

Ayvah, RN · Aug 20, 2013

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?

Yes, in this thread BrandonLPN and I have aspirated blood ourselves and Classicdame has had a coworker this happened to. Your instructor may have been referring to specifically vaccines, which is OK not to aspirate per the CDC.

nurseprnRN, BSN, RN · Aug 20, 2013

Your first post on this thread made statements (which seemed to be saying that no injection needs aspiration, and you also said it was anatomically impossible to inject into a blood vessel) which directly contradicts the evidence I had posted earlier, and I'm asking about what you base that on/to provide evidence/medical consensus which supports that. I'm not trying to rail against you specifically, I'd really like to have an evidence based discussion on this, since I think there is a ton of confusion regarding this issue out there.

Several of the refs in the posted PowerPoint presentation address that directly.

Ayvah, RN · Aug 20, 2013

Several of the refs in the posted PowerPoint presentation address that directly.

Can you be more specific? Again, I'm asking for evidence about non immunizations/insulin (as I've given evidence from the start agreeing that those don't need aspiration based on CDC/medical consensus), and I've quoted the presentation where it says that it is focused on immunizations/insulin/penicillin (and it says that penicillin may need aspiration).

The presentation is a little confusing because at the beginning it seems to be discussing all IM/SC but as I quoted, at the end it says that their research and their recommendations are specific to immunizations/insulin/pcn. They do not give recommendations for all injections nor do they give recommendations to cease all aspiration.

CodeteamB · Aug 20, 2013

The studies that have been done do focus mostly on the named medications. In the summary they do state that aspiration has not been proven reliable for determining whether you are in a vessel, that recommended sites (other than the dorsal gluteal) do not contain major vessels, and that in order to be effective practice aspiration should be done over 5-10 seconds!

I was certainly not taught that I should be aspirating over five seconds and have never in my life seen a nurse pull back longer than 1 second, so every nurse I have ever worked with, myself included could be injecting willy-nilly into vessels with not a clue.

Truth is, I aspirate by habit (incorrectly, apparently). After working years of flu clinic, and being educated as I was it is a difficult habit to break, but I do believe that best practice is leaning towards the abolishment of this procedure, already there for vaccines!

nurseprnRN, BSN, RN · Aug 21, 2013

Can you be more specific? Again, I'm asking for evidence about non immunizations/insulin (as I've given evidence from the start agreeing that those don't need aspiration based on CDC/medical consensus), and I've quoted the presentation where it says that it is focused on immunizations/insulin/penicillin (and it says that penicillin may need aspiration).
The presentation is a little confusing because at the beginning it seems to be discussing all IM/SC but as I quoted, at the end it says that their research and their recommendations are specific to immunizations/insulin/pcn. They do not give recommendations for all injections nor do they give recommendations to cease all aspiration.

Let's see here. There are approximately eleventy-seven bazillion injectable medications. Do you want them all studied, or is there a particular reason that the data on an essentially mechanical procedure done with common ones ("penicillin" and immunizations given IM) aren't enough for you? There's something inherently different between these IM substances and others in terms of delivery? And the CDC and all the other orgs cited aren't good enough? Is ritualistic practice so ... so ... sacred that we have some sort of justification for "that's the way I was taught" in perpetuity?

I have not gone back to review the presentation to answer your question, but if you have, you will see that one slide in particular makes reference to anatomical reasons why it's unlikely that a properly-sited IM is unlikely in the extreme to result in placement into a vessel analogous to placing an intravenous catheter. For some reason the "3" reference sticks in my mind, but there were several.

Moving back a bit, we have two people here --two-- who state that they once got great gobs of blood back in their aspirants. Considering the numbers of IMs that must have been given by the numbers of RNs and LPNs reading this thread, I find that telling. Where are the studies or even anecdotal case reports (bearing the lowest form of validity in EVP) about the horrible consequences of not aspirating?

BrandonLPN, LPN · Aug 21, 2013

My question is: in the rare instances where nurses have aspirated a significant amount of blood, what does that signify? That they were in a vein? In a particularly blood rich capillary-filled part of the muscle? What?

Is the assertion that, in that one instance I aspirated blood, it would have been fine for me to give the injection anyway?

Or is the assertion that nurses who say they've aspirated blood are either a) lying, or b) don't know how to give a IM?

nurseprnRN, BSN, RN · Aug 21, 2013

My question is: in the rare instances where nurses have aspirated a significant amount of blood, what does that signify? That they were in a vein? In a particularly blood rich capillary-filled part of the muscle? What?
Is the assertion that, in that one instance I aspirated blood, it would have been fine for me to give the injection anyway?
Or is the assertion that nurses who say they've aspirated blood are either a) lying, or b) don't know how to give a IM?

False dichotomy, but I'll bite.

1) Who knows? That's why the experience is anomalous. By definition, presence of anomalies cannot mean that everything has to be treated as one, particularly if so rare. (see: House of God, zebras*)

2) Who knows? That's why there's no answer.

3) Who knows? I've never seen it, the people who did extensive research on it didn't see it, there's no big body of evidence that supports it.

*As described in this classic book: When a BMS (Best Medical School, largely accepted to be HMS, Harvard Med School) student hears hoofbeats outside the building on Avenue Louis Pasteur (in Boston, where HMS is), he will deduce the presence of a zebra, when it is far more likely to have been a horse. Implications for further intervention should be clear.

s0ad · Aug 22, 2013

I had a small debate once with the older nurses on the floor. I was newly out of school and taught that many IM injections don't, in fact, need to be aspirated. They looked up the policy in the nursing guide we use, and low and behold, it did not say that you have to for all. I mostly give IM injections for vaccines, so I'm not sure about ALL medications. A quick google search revealed this:

"

The results were not surprising; there was no research evidence to support the use of aspiration in giving I.M. or subcutaneous injections. The researchers recommended the following for consideration:

Aspiration is not indicated for subcutaneous injections of immunizations, heparin, and insulin
Aspiration is not indicated for I.M. injections of vaccines and immunizations
Aspiration may be indicated for I.M. injections of medications such as penicillin
Until a standard can be established, injection techniques must be individualized to the patient to prevent incorrect needle placement (Crawford & Johnson, 2012). "

(Source)

Ayvah, RN · Aug 22, 2013

Let's see here. There are approximately eleventy-seven bazillion injectable medications. Do you want them all studied

Yes, I do, and that's what the patients deserve. When administering a medication the nurse should study/be familiar with manufacturer's guidelines/medical consensus and follow them. For example, lovenox should be administered into the abdomen specifically per manufacturer's instructions, even though there are multiple sub-q sites. You mentioned that some injections should be given Z-track which is awesome to point out too. Some manufacturer's guidelines say to administer into a large muscle only. So when manufacturer's guidelines specifically state to aspirate, it should reinforce the need to aspirate(I already posted proof of several examples). The study you reference states there are differences in medications and it should be individualized to the situation, and states that penicillin may need aspiration, so, again, this study is not saying to stop aspirating everything. If you are going to make a blanket statement that no injection needs aspiration, you need to back that up with strong evidence of medical consensus, especially when it directly contradicts manufacturer's instructions which were posted earlier. I posted an excerpt from Lippincott, which state routine aspirations should be done (except for the listed exceptions) too. Like you said there are tons of injections out there. When the CDC's recommendation is regarding for just a few specific injections, I don't see it wise to extrapolate to all the other injections out there. They were specific for a reason. Not all injection meds are alike.

, or is there a particular reason that the data on an essentially mechanical procedure done with common ones ("penicillin" and immunizations given IM) aren't enough for you? There's something inherently different between these IM substances and others in terms of delivery?

And the CDC and all the other orgs cited aren't good enough?

see above. Have you not seen that I've repeatedly throughout this thread advocated following the CDC's specific guidelines of not needing to aspirate vaccines? This is a little frustrating. Regarding random other studies, they are a great point to start discussing! You mentioned evidence based practice in your post which is why I asked you to present some, as I was excited by the possibility of a real discussion about this issue, and maybe we all could further our knowledge, myself included, which I think is one of the main points of this board.

Is ritualistic practice so ... so ... sacred that we have some sort of justification for "that's the way I was taught" in perpetuity?

Were I to fall into this category I'd have been advocate aspirating vaccines even though the CDC says no (and again, I've advocated to follow the CDC this entire time), but I'm really trying to follow evidence here, and I'm asking for strong evidence that trumps things like manufacturer's guidelines and Lippincott (or, at least a starting point for discussion about non-vaccines, since I think vaccines are already case-closed since the CDC has made its stance). No prudent nurse should stop following manufacturer's guidelines without solid medical consensus to back that up.

I have not gone back to review the presentation to answer your question, but if you have, you will see that one slide in particular makes reference to anatomical reasons why it's unlikely that a properly-sited IM is unlikely in the extreme to result in placement into a vessel analogous to placing an intravenous catheter. For some reason the "3" reference sticks in my mind, but there were several.

Unlikely does not mean impossible, and I'm wondering if the possibility of hitting a vein with such a benign injection like the flu shot helped push that over the edge of being considered safe? I'm not sure of the rationale on that. And its ok to say you're not sure of something! I was hoping that by a discussion we could share information and learn from each other, and that maybe someone would have the answer to that question for me? But it is also important to note that the CDC states "There are only two routinely recommended IM sites for administration of vaccines, the vastus lateralis muscle (anterolateral thigh) and the deltoid muscle (upper arm). Injection at these sites reduces the chance of involving neural or vascular structures. Because there are no large blood vessels in the recommended sites, aspiration before injection of vaccines (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary.". Seeing as how there are additional IM sites besides these, making a general blanket statement that no injections should be aspirated due to the CDC is incorrect as they do not list all sites nor all medications, unless I'm missing additional information which is what I'm asking for?

Moving back a bit, we have two people here --two-- who state that they once got great gobs of blood back in their aspirants. Considering the numbers of IMs that must have been given by the numbers of RNs and LPNs reading this thread, I find that telling.

Where are the studies or even anecdotal case reports (bearing the lowest form of validity in EVP) about the horrible consequences of not aspirating?

I agree it is an extremely rare circumstance and it shocked me when it happened to me. But being prudent with spending a few extra seconds with a patient to ensure a rare circumstance doesn't happen is worth it to me for my patients. I aspirated blood during an allergy injection which really shook me. The implication of that even partially going IV is enough for me to continue to advocate for patients getting the benefit of aspiration when medical consensus/manufacturer guidelines instruct it. But perhaps there was another explanation such as a random bleeding issue which I wasn't aware of? Who knows. And perhaps with more study the consensus will move away from aspiration, and if it does, well, that is the point of research and discussion, and at that time more of these answers will have been discovered. :) But at this time, medical consensus does not recommend ceasing all aspiration.

Guest219794 · Aug 22, 2013

While I can't fault anybody for following facility or policy, or manufacturer recommendations, I take issue with some of the arguments here.

While it seems there is a reasonable case for either approach- Asprate vs don't, some of the rationales given by people are just not logical. Or rational.

1- "I have aspirated blood before. Therefore aspiration is the correct technique".

That is a bit of a leap in a couple regards. Given the fact that virtually nobody uses correct aspiration technique anyway, one would assume there would be some adverse consequences from inadvertent venous/arterial delivery. But that is not what is being reported here. What is being reported is getting some blood back into a syringe. It is a bit of a stretch to say A: This is likely from a vein or artery, B: If used it would result in venous/arterial administration, C: There would be an adverse effect from an incorrect route, and D: this risk is significant.

For the sake of argument, lets assume there were some adverse consequences to not aspirating. That alone is still not sufficient rationale for aspirating. Virtually everything we do has a risk/benefit ratio. Take for example choice of diluents for IM administration of Rocephin. While it can be mixed with NS or D5, most use Lidocaine. Obviously there is a risk of an allergic reaction to Lidocaine, but current practice standards indicate decrease in discomfort to outweigh the risk.

2- "I know that nursing schools now teach not to aspirate, but when I went to nursing school I was taught to aspirate, and I will continue to do so."

This is truly a poor rationale. Imagine if your surgeon told you that his technique was outdated, but since it was how he was taught, he would continue to use it. If you want to be considered a professional, you have an obligation to continue your learning.

3- "By aspirating and getting no blood back, I am confirming that I am not in a blood vessel". This is flat out wrong. I have, on a number of occasions, used IV's from which I could not aspirate blood. Even if there was a blood vessel large enough for iv administration in the ventrogluteal or deltoid (there isn't), lack of blood aspiration would not confirm that you were not in the vessel. (Which doesn't exist anyway.)

I am not criticizing anybody for choosing to aspirate. But, I do believe nursing practice should be based on sound rationale.

lily136 · Feb 21, 2014

I recently came across a situation where I was giving an IM injection of phenergan in the glut and aspirated and drew back blood, a lot. I know a lot of nurses that don't aspirate and I always made sure I did just in case this happened because I was taught this in school, which was only a couple of years ago. I aactually had a discussion with another nurse not long ago about aspirating and the odds of hitting a vein are so rare. Glad I did it though, because phenergan is hard on the veins. Doesn't take but a second and can save the patient from further issues.

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

Do you aspirate while injecting IM?