When performing an IM injection Why is ventrogluteal considered best practice?

Intramuscular injection (IM) is installing medications into the depth of specifically selected muscles. The bulky muscles have good vascularity, and therefore the injected drug quickly reaches the systemic circulation and thereafter into the specific region of action, bypassing the first-pass metabolism. It is one of the most common medical procedures to be performed annually. This activity outlines and highlights the role of the interprofessional team in improving care for patients who undergo an intramuscular injection. This activity also summarizes the anatomic landmarks, safety precautionary checklists, the recommended procedural steps, and the complications to be aware of following the procedure.

Objectives:

• Identify the safe anatomical landmarks for intramuscular injection.

• Describe the technique of intramuscular injections.

• Summarize the potential complications of intramuscular injection.

• Review interprofessional team strategies for improving care coordination and communication to advance intramuscular injection and improve outcomes.

Introduction

Intramuscular injection (IM) is installing medications into the depth of specifically selected muscles.[1] The bulky muscles have good vascularity, and therefore the injected drug quickly reaches the systemic circulation and thereafter into the specific region of action, bypassing the first-pass metabolism.[2] It is one of the most common medical procedures to be performed annually.[3] However, there is still a lack of adherence to recommended guidelines and an algorithm for giving IM among health professionals worldwide.[2] 

Drugs may be given intramuscularly both for prophylactic (around 5% for immunization) as well as curative purposes (accounting for more than 95% of IM injections).[2]

The most common medications given by IM route include:

• Antibiotics- penicillin G benzathine penicillin, streptomycin

• Biologicals- immunoglobins, vaccines, and toxoids

• Hormonal agents- testosterone, medroxyprogesterone[2]

Any nonirritant and soluble drugs may be given IM during an emergency scenario.

Anatomy and Physiology

Anatomical Landmarks

There are specific landmarks to be considered while giving IM injections to avoid any neurovascular complications. The specific landmarks for the most commonly used sites are discussed below.

Dorsogluteal Region

• 5 to 7.5 cm below the iliac crest

• Upper outer quadrant within the buttocks[4]

Ventrogluteal Region

• The heel of the opposing hand is placed in the greater trochanter, the index finger in the anterior superior iliac spine, and the middle finger below the iliac crest - the drug is injected into the triangle formed by the index, middle finger, and the iliac crest[4]

Deltoid

• 2.5 to 5 cm below the acromion process[1]

Vastus Lateralis

• The middle third of the line joining the greater trochanter of the femur and the lateral femoral condyle of the knee[5]

Indications

IM for therapeutic purposes is indicated for the following patients:

• Unable to receive drugs through other common routes

• Do not tolerate oral medications[2]

Contraindications

• Active infection, cellulitis, or dermatitis at the site of administration.

• Known allergy or hypersensitivity to the drug.

• Acute myocardial infarction- the release of muscle enzymes complicate the management strategy.

• Hypovolemic shock - the drug's absorption may be hampered due to compromised vascularity of the muscle.

• Associated muscular atrophy - leads to delayed drug absorption and increases the risk of neurovascular complications.

Equipment

1. An appropriately sized syringe with a correct needle length;

   • For infants, vastus lateralis, 22 and 25 mm during ‘bunching,’ 16-mm needle while stretching the skin

   • For toddlers and older children, deltoid, or VL, is preferred, 25mm to 38.[6][7][8]

2. Alcohol-based antiseptic solution

3. The correct drug in an appropriate dose

4. The safe needle and waste disposal unit

Personnel

• A trained nurse, pharmacist, or a paramedic

Preparation

Evaluate the Need for IM Injection [2]

Out of 12 billion injections administered on the global front annually, 50% of them have been found to be administered by an inadequately trained staff. Furthermore,75% of them are being injected unnecessarily.[9]

Review and Confirmation from the “Medication Administration Record” [2]

Comply with the “Rights of Medication Administration”

Counseling the Patient

Consent

Choose an Appropriate Site for Injection

• Children-vastus lateralis and deltoid 

• Adults-ventrogluteal and deltoid[2]

Technique

Sequential Method of IM Injection

• Thoroughly clean the hands and wear gloves.

• 70% isopropyl swab for 30 seconds and allow the skin to dry.[10]

• Use of filter needle and change the needle prior to injection under aseptic precautions.

• To prevent bent or dulling of the needle due to coring by the rubber, insert the needle in the bevel up fashion.

• When withdrawing the injectate, the container should be held down and avoid withdrawing the last drops.

• If medication drips on the needle, wipe it off with a sterile gauze pad.

• Drawing up an air bubble is not recommended.

• The 'z-track' technique is recommended.[2]

• Insert the needle at an angle of 90 degrees.[11]

• Quick darting movement while inserting the needle.

• Insure intramuscular positioning of the needle via confirming restricted side-to-side movement of the needle as opposed to when the needle is in the subcutaneous plane.

• Aspirate for at least 5 to 10 seconds during dorsogluteal injections prior to injecting the medication.

• Slow injection (10 seconds per milliliter) allows stretching of the muscle fibers for retention of the drug, which minimizes the risk of leakage along the needle track.

• Wait for 10 seconds to allow the drug to diffuse within the muscle bulk.

• Withdraw the needle with a smooth and steady movement.

• ‘Scoop method’ of replacing the needle cap to prevent inadvertent prick injuries.

• Safe disposal of the needles and other wastes.[2][12]

• Assessment of the injection site for probable early and late complications.[2][1][13]

Complications

Common complications:

1. Persistent pain at the site of injection

2. Muscle fibrosis and contracture

3. Abscess at the injection site

4. Nerve injury -the sciatic nerve in gluteal injection, the femoral nerve in vastus lateralis injection, the superior gluteal nerve in dorsogluteal injection, the femoral nerve in vastus lateralis injection, radial nerve in deltoid injection

5. Periostitis, osteomyelitis

6. Transmission of HIV, hepatitis virus

7. Inadvertent injection of glass particles while using glass vials and ampoules.

Pain

Pain is one of the common complications of intramuscular injection.

Effective interventions to relieve pain include:

• Buzzy was more effective than ShotBlocker.[14][15]

• Topical eutectic mixture of local anesthetics (EMLA).[19][20]

• Manual pressure, rhythmic tapping, acupressure.[22]

• Virtual reality glasses, distraction cards, optical illusion pictures.[23][24]

• Ventrogluteal site compared to the dorsogluteal site.[25]

• Internally rotated foot and Z-track techniques.[26]

• A slow rate of injection at 10 s/cc.[27]

• Performing a rapid intramuscular injection without aspiration.[28]

Methods found not effective in relieving pain:

• Vapocoolant, ice packs in pediatric.[29]

• Warming of the injectate[30]

The simple step of asking the patient to cough vigorously immediately prior to injection also helps in reducing the pain associated with the procedure. The transmission of the cough impulse is faster than that of the pain impulse traveling through the slow conducting nerve fibers; thereby, it helps in minimizing the impact of the pain threshold perceived by the brain. A systematic review has shown that gender is the only major variable influencing pain during intramuscular injection.[31]

Neuropathy

The incidence of injection-related neuropathy observed during a national vaccination campaign in Pakistan was 7.1 per 1,000,00.[32] The ventrogluteal region has a better safety profile than the dorsogluteal region.[9][33][34]

Mechanisms governing nerve injury:

• Compression from external hematoma

Variables governing the risk of injury include:

• Anatomical site of injection

• Positioning of the patient during injection and

• The expertise of the health personnel[9]

The sciatic nerve, particularly its peroneal division, is the most common nerve injury, with an intrafascicular pattern the most common subtype. Dorsogluteal injections account for a majority of the same. Smaller gluteal muscle volume to sciatic nerve size ratio is a risk variable governing the same. Nearly 90% of patients with sciatic nerve injury are preset with an immediate foot drop. Magnetic resonance neurography shows increased signal intensity and neuroma formation. Electromyography shows signs of acute denervation as well as chronic denervation with reinnervation.[9]

Sunderland classification and treatment algorithm:

• First degree showing reversible conduction block wherein conservative management will suffice,

• Second-degree showing Wallerian degeneration with reactive fibrosis. They often show slow and incomplete recovery, and therefore neurolysis is often indicated, and

• Third-degree comprises necrosis and fibrosis, and the chances of recovery are dismal[9]

Surgical exploration is recommended only for cohorts with incapacitating or complete deficits without recovery, even at 3 to 6 months. Early surgical intervention prevents fibrosis. If an action potential is observed beyond the lesion, only neurolysis is advised; otherwise, suture or graft repair is advocated.[9]

Radial nerve palsy, most occurring above the radial groove, is the second most common form of traumatic injection neuropathy.[10][35]

Safe Landmarks

The intersection between the anteroposterior axillary lines and the perpendicular line from the mid-acromion point is safe for IM in the deltoid.[36] The safest anatomical point is approximately 7 to 13 cm below the mid-acromion, midway between the acromion and the deltoid tuberosity. The middle of the vastus lateralis is considered safe for injection in the vastus lateralis.[5]

Clinical Significance

Advantages

• Rapid and uniform absorption of the drug, especially the aqueous solutions

• Rapid onset of the action compared to that of the oral and the subcutaneous routes

• IM injection bypasses the first-pass metabolism of the drug

• It also avoids the gastric factors governing drug absorption

• Has efficacy and potency comparable to that of the intravenous drug delivery system

• Highly effective for emergency scenarios such as acute psychosis and status epilepticus

• Depot injections allow slow, sustained, and prolonged drug action

• A large volume of the drug can be administered compared to the subcutaneous route

 Disadvantages

• An expert and a trained person are necessary for administrating the drug by IM route

• The absorption of the drug is determined by the bulk of the muscle and its vascularity

• The onset and duration of the action of the drug are not adjustable

• In case of inadvertent scenarios such as anaphylaxis or neurovascular injuries, additional intravenous (IV) routes for emergency drug administration need to be secured

• IM injection at the appropriate landmarks may be difficult in a child as well as in patients requiring physical restrains

• Inadvertent injection within the subcutaneous plane can lead to delayed action of the drug

• Suspensions, as well as oily drugs, cannot be administered

• This can lead to anxiety in the patient, especially among children

• Self-administration of the drug can be difficult

• The precipitation of the drug following faster absorption of the solvent may lead to delayed or prolonged action of the drug

• Unintended prolonged sequelae following delayed release from the muscular compartment

• Need for temporary restraint of the patients, especially in crying children

Enhancing Healthcare Team Outcomes

The strict adherence to recommended guidelines and procedural algorithms for IM injections is of paramount importance in assuring effective pharmacokinetics and the pharmacodynamics of the drugs.[7]

Thorough knowledge of the specific anatomical landmarks helps minimize the neurovascular complications that harbinger the IM procedures.

The strict adherence to aseptic precautionary measures and safe disposal of the used equipment helps minimize the transmission of blood-borne infections.

The ventrogluteal site is considered the safest for IM injection due to the thin plane of subcutaneous tissues and the relatively thick bulk of the gluteus medius.[33]

Nursing, Allied Health, and Interprofessional Team Monitoring

Issues of True IM Injections

True intramuscular injections are observed only in 32 to 52%, with the incidence even falling to 8% among females.[37] Female sex, obesity, subcutaneous fat thickness, and injection site play significant roles in governing the same.[4][38][39][40] Ultrasound guidance and proper needle length are key factors in ensuring true IM injections among patients with increased body mass index[BMI].[41] However, there is still ongoing debate over this point.[42]

The Practice of Aspiration Prior to Drug Administration

Though nurses continue practicing aspirations, most do it for a short duration than the recommended time of 5 to 10 seconds.[6][7][8] Blood aspiration is observed mainly in the dorsal gluteal (15%) and deltoid (12%) injections.[43] The World Health Organization and Centers for Disease Control and Prevention do not recommend it. Aspiration is unnecessary and is now reserved only for dorsogluteal site injections.[7]

Use of Filter Needles

The syringe filters significantly minimize the risk of glass particle contamination.[44] However, economic constraints, time consumption, and workforce shortages are significant hindrances to its routine practice.[45] The risk increases with larger bore, unfiltered needles (safe with 23G).[46] Vial breakage by neck wrapping with a cotton ball from an outward direction results in low glass particles than the entire ampoule neck wrapping with a gauze pad from an inward direction method.[45]

Some of the current nursing practices pertaining to IM injections seem to evolve more like a tradition passing from one generation to the next and based upon Schön’s and Benner's learning concepts.[2][47] Evidence-based nursing practice is pivotal in ensuring patient safety, and regular updates, monitoring, and intervention mapping strategies may help improve practitioners' adherence to clinical recommendations.[6][7][8][48]

Figure

IM Injection, Buttocks, Intramuscular. Contributed by Steve Bhimji, MS, MD, PhD

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Why is ventrogluteal considered best practice?

Why is the ventrogluteal site the preferred site for IM injection?

Why is the ventrogluteal site preferred over Dorsogluteal?

What is best practice for IM injections?