Holding it taut, quickly and smoothly insert the needle into the muscle at a 90-degree The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. 1,2 Even when alternate routes of administration are available, IM injections may be preferred when a patient cannot tolerate oral, Overall, 5 mL has been cited for adults as the maximum volume for a single IM injection, with lower maximums proposed for adult patients with less- developed or small muscle mass.3,13,14 iNTRAMUsCUlAR iNJECTiONs Once administered exclusively by physicians, IM injections became a primary-nurse responsibility during the 1960s.1. aspect, lateral to the midpoint of the thigh. Historic concerns about exposure to vaccine components are limited to non-parenteral vaccines in which some degree of environmental exposure is unavoidable (5, 8), or situations in which self-inoculation is likely due to the nature of the vaccine microbe [e.g. Administering volumes smaller than recommended (e.g., inappropriately divided doses) might result in inadequate protection. Assess the family for ways they can assist in the procedure. Different single-components of combination vaccines should never be mixed in the same syringe by an end-user unless specifically licensed for such use (4). Unused syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) should be discarded at the end of the clinic day. Follow the organizations practice for emergency response. static compliance and maximum expiratory flow at 50% of awake total lung capacity (V max) increase. The usual dose is 12.5 to 25 mg per kg (5.7 to 11.4 mg per pound) of body weight every six hours; or 16.7 to 33.3 mg per kg (7.6 to 15 mg per pound) of body weight every eight hours. A separate needle and syringe should be used for each injection. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. informed practice: Trauma-informed care is a way of approaching interactions with children and families in which providers remain cognizant of the impacts of trauma while also taking actions to prevent potentially traumatic experiences (Boles, 2017). The concern should be explored, the practitioner notified, and the order verified. Guidelines for subcutaneous and intramuscular injection Click here to proceed to intramuscular injection information . If not using the Z-track method, follow these steps for injection. Inactivated influenza vaccine is immunogenic when administered in a lower-than-standard dose by the intradermal route to healthy adult volunteers. We also use third-party cookies that help us analyze and understand how you use this website. Infants and children weighing up to 20 kg (44 pounds)Dose is based on body weight and must be determined by your doctor. Such practices increase the risk for infectious complications and neurovascular and muscle injuries. 1 mL in an older infant >1month. Contraindications Relative Known bleeding disorder or thrombocytopenia. Be sure to give the injection in the center of the muscles . 2 How many milliliters can be injected intramuscularly? For the majority of infants, the anterolateral aspect of the thigh is the recommended site for injection because it provides comparatively larger muscle mass than the deltoid (Figure 2) (23). The maximum amount of medication for a single injection is generally 1 ml. Hepatitis B administered intradermally might result in a lower seroconversion rate and final titer of hepatitis B surface antibody than when administered by the deltoid intramuscular route (53-54). 7. The angle of administration for an ID injection is 5 to 15 degrees. Source: Adapted from Immunization Action Coalition. This cookie is set by GDPR Cookie Consent plugin. If 2 vaccines are to be administered in a single limb, they should be spaced an inch apart (4, 24). The cookie is used to store the user consent for the cookies in the category "Other. Live attenuated influenza vaccine is approved for healthy nonpregnant persons aged 2-49 years and is the only vaccine administered by the intranasal route. The volume of medication will vary: for children under 2-years old, the maximum volume should be 1 mL; for adults, the maximum volume is 1 mL for the deltoid muscle and 3 mL . Hepatitis A vaccine and meningococcal conjugate vaccine do not need to be repeated if administered by the subcutaneous route (55-56). To receive email updates about this page, enter your email address: We take your privacy seriously. Prepare the needle: Hold the syringe with your writing hand and pull the cover off with your other hand. Immune responses generated by jet injectors against both attenuated and non-live viral and bacterial antigens are usually equivalent to, and occasionally greater than, immune responses induced by needle injection. The dorsogluteal is not the preferred site due to its proximity to the sciatic nerve and major blood vessels. & Greenberg, C. S. (2003). They help us to know which pages are the most and least popular and see how visitors move around the site. 50 Flemington Road Parkville Victoria 3052 Australia, Site Map | Copyright | Terms and Conditions, A great children's hospital, leading the way, Kids Health Info: Allergic and anaphylactic reactions, How to don and remove Personal Protective Equipment (PPE), The evidence table for this guideline can be accessed here, Preferred site in neonates and children under walking age but can be used in any age group (up to 5mls can be given in adults), Clinical judgement is used based on the size of the child and their development (see considerations above and below), Can be given in children >12 months if muscle mass is developed, Only recommended at The Royal Children's Hospital (RCH) if appropriately trained, Appropriate size needle for administration, Drawing up needle and syringe (if medication not pre-filled), Alcohol impregnated swab (if area visibly soiled), Personal Protective Equipment (PPE) for hazardous medications or infectious patients, Complete the six rights of medication administration, Don PPE if required (particularly for hazardous medications), Position patient in a safe and comfortable position, Consider the use of comfort techniques such as distraction, buzzy bee, ice or a countdown, Clean site with an alcohol swab (if required), Stretch the skin flat (Z-tracking if applicable), Inject the needle to the hub at a 90-degree angle, Do not aspirate or drawback as this can increase pain and discomfort in children, Inject the medication at a slow and steady pace, Remove the needle and apply a cotton ball, Monitor for immediate adverse reactions, e.g., fever, rash, vomiting, shortness of breath. Necessary cookies are absolutely essential for the website to function properly. (c) Do not withdraw more than 0.5 mL from the reconstituted product, even if some product is left in the vial. Evidence does not support use of antipyretics before or at the time of vaccination; however, they can be used for the treatment of fever and local discomfort that might occur following vaccination. Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state. Children 2 to 11 years of age and weighing 45 kg or more1 mg or 0.2 mL injected under . Studies of children with previous febrile seizures have not demonstrated antipyretics to be effective in the prevention of febrile seizures (48). Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. IM injection: Maximum recommended single IM dose is 2grams. Displace the skin and subcutaneous tissue by pulling the skin laterally or downward from the injection site. Vaccines should be drawn up in a designated clean medication area that is not adjacent to areas where potentially contaminated items are placed. Equipment For more than 150 additional . Best practice guidance for route, site, and dosage of immunobiologics is derived from data from clinical trials, practical experience, normal intervals of health care visits, and theoretical considerations. Persons administering ACAM 2000 smallpox vaccine to laboratory and health care personnel at risk for occupational exposure to orthopoxviruses can decrease the risk for inadvertent infection through recommended infection prevention measures. For deep IM injections, the recommended volume ranges from 2 to 5 ml. Small muscles absorb small volumes. Do not touch this area until you give the injection. Release the skin. What is the fastest way to get rid of a tight foreskin? An IM site is chosen based on the age and condition of the patient, and the volume and type of medication injected. This guideline aims to facilitate the administration of intramuscular injections to maximise the therapeutic effect while minimising potential complications and patient discomfort. Comfort measures, such as distraction (e.g., playing music or pretending to blow away the pain), cooling of the injection site(s), topical analgesia, ingestion of sweet liquids, breastfeeding, swaddling, and slow, lateral swaying can help infants or children cope with the discomfort associated with vaccination (40-42). Any vaccination using less than the standard dose should not be counted, and the person should be revaccinated according to age unless serologic testing indicates that an adequate response has developed. For older children and adults, the deltoid muscle can be used for more than one intramuscular injection. Intramuscularly (IM): An intramuscular injection is one that is given in the muscle. Multi-dose vials to be used for more than one patient should not be kept or accessed in the immediate patient treatment area. When to use an intramuscular ( IM ) injection? Persons administering vaccinations should follow appropriate precautions to minimize risk for disease exposure and spread. (4, 10) For toddlers, the anterolateral thigh muscle is preferred, and when this site is used, the needle should be at least 1 inch long. The purpose of IM injections is to administer medication safely into the muscle below the subcutaneous layer. Multiple use jet injectors using the same nozzle for consecutive injections without intervening sterilization were used in mass vaccination campaigns from the 1950s through the 1990s (33); however, these were found to be unsafe because of the possibility of bloodborne pathogen transmission (34-37) and should not be used. If no blood appears, inject the medication. For children: 7 through 10 years of age, use a 1- to 1.25-inch (25-32 mm) needle 11 through 18 years of age, use a 1- to 1.5-inch (25-38 mm) needle 2. d. Instruct the family regarding the potential adverse effects of the medication. Checklist 56 outlines the steps to administer an intradermal injection. Verify the correct patient using two identifiers. The method of administration of injectable vaccines is determined, in part, by the inclusion of adjuvants in some vaccines. When injecting into the deltoid muscle, for adults a measurement of body mass/weight is allowable prior to vaccination, understanding that resources to measure body mass/weight are not available in all clinical settings. (2022). The maximum volume for a single IM injection is 1 mL; any volume over this should be divided between multiple injection sites (7) The maximum single intramuscular dose is 2 g, doses greater than 2 g must be given in two divided doses or by intravenous administration. For women under 60 kg (130 lbs), a -inch (16 mm) needle is sufficient, while for women between 60 kg and 90 kg (130 to 200 lbs) a 1-inch (25 mm) needle is required. The recommended volume ranges from 2 to 5 ml for "deep" IM injections. Take steps to eliminate interruptions and distractions during medication preparation. Figure 7.13 TB syringe Intramuscular. NWCommons: Institutional Repository of Northwestern College Smoothly, quickly, and steadily withdraw the needle and release the skin. Chapter 20: Pediatric nursing interventions and skills. To locate the muscle, place the palm of a hand over the greater trochanter of the femur, facing the index finger and thumb towards the umbilicus, along the anterior iliac spine. Palpate the muscle below the greater trochanter and above the lateral femoral condyle (knee joint). Because the recommended sites for pediatric IM injections for vaccines have no large blood vessels, the practice of aspiration for immunization or toxoids is unnecessary.2 However, aspiration is routinely used and is recommended when medications other than vaccines or toxoids are administered. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. We also use third-party cookies that help us analyze and understand how you use this website. These cookies track visitors across websites and collect information to provide customized ads. If giving a larger shot, give 15 mls, pull the needle out until you are almost out if the skin, push it back in at a much different angle, check for blood, then complete the injection. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients (3). Your deltoid muscle is the large muscle in your upper arm, just below your shoulder. Jet injectors are needle-free devices that pressurize liquid medication, forcing it through a nozzle orifice into a narrow stream capable of penetrating skin to deliver a drug or vaccine into intradermal, subcutaneous, or intramuscular tissues (32-33). Place the middle finger toward the iliac crest creating a What is the maximum volume that can be injected intramuscularly? Pediatrics (1982) 70 (6): 944-948. Wolicki, J., Miller, E. (2021). If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. For administration of routinely recommended vaccines, there is no evidence of risk of exposure of vaccine components to the health care provider, so conditions in the provider labeled as contraindications and precautions to a vaccine components are not a reason to withdraw from this function of administering the vaccine to someone else. For an infant who is unable to breastfeed or for an infant who does not breastfeed, consider nonnutritive sucking, sucrose, and warmth. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. deficit of literature relating to administering intramuscular injection to children and adolescents. Give in the central and thickest portion of the deltoid muscle - above the level of the armpit and approximately 2-3 fingerbreadths (~2") Erythema or swelling at the injection site. There is no evidence the cream interferes with other vaccines (46-49). 2 What happens if you inject into muscle? Appropriate needle length depends on age and body mass. Large-volume injections (3 mL or greater), however, are not frequently administered; and many clinicians may not be familiar with their appropriate use, possible side effects, and potential efficacy. Children above 5 kg: 10 micrograms/kg (0.1 ml/kg of Adrenaline 1:10,000 solution) is given into a vein or into a bone every 3-5 minutes every 3-5 minutes until the heart starts to work. trochanter:A bony prominence at the top of the femur where the hip and thigh muscles are fixed. Label all medications, medication containers, and other solutions. Subcutaneous injection: injection of a biological product into the layer of fatty tissue between the skin and muscle. What is the maximum injectable amount for an ID injection? These federal regulations require the use of engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens. The development of this nursing guideline was coordinated by Mica Schneider, RN Specialist Clinics, and approved by the Nursing Clinical Effectiveness Committee. The cookies is used to store the user consent for the cookies in the category "Necessary". For non-live vaccines, manufacturers typically recommend use within the same day that a vaccine is withdrawn or reconstituted. Determine the familys desire to be present during the procedure. Overall, 5 mL has been cited for adults as the maximum volume for a single IM injection, with lower maximums proposed for adult patients with less-developed or small muscle mass. The maximum volume generally accepted for an SC injection is around 1.5 ml , although higher volumes (of up to 4 ml) can be administered if necessary . Deviation from the recommended route of administration might reduce vaccine efficacy (14-15) or increase the risk for local adverse reactions (16-18). The most appropriate sites for IM injections are the vastus lateralis (anterolateral thigh) for infants and toddlers and the deltoid muscle for pediatric patients 3 years and older.6 Selection of the injection site is based on the patients age, muscle mass, medication volume, and medication viscosity. If injecting medication into the deltoid muscle of an adult, the volume of solution should not exceed 1 mL. Intramuscular injections commonly result in pain, redness, and swelling or inflammation around the injection site. Place the syringe between your thumb and first finger. The patient can be positioned lying on their stomach or standing up. What is the maximum volume for subcutaneous injection? For serious infections, AAP recommends a dose of 100 mg/kg/day IV or IM divided every 12 to 24 hours (Max: 4 g/day). Use of a topical refrigerant (vapocoolant) spray immediately before vaccination can reduce the short-term pain associated with injections and can be as effective as lidocaine-prilocaine cream (51). Source: Adapted from Minnesota Department of Health and Immunize.org. ACIP discourages variations from the recommended route, site, volume, or number of doses of any vaccine. If multiple vaccines are administered at a single visit, administer each preparation at a different anatomic site (28). The ventrogluteal muscle can accommodate up to 2.5 ml, with a maximum volume of 3 ml. For men and women who weigh <130 lbs (<60 kg), a -inch needle is sufficient to ensure intramuscular injection in the deltoid muscle if the injection is made at a 90-degree angle and the tissue is not bunched. Many medications must be injected intramuscularly because of chemical properties, pharmacokinetics, desired onset, intensity and duration of the effect, and certain patient characteristics related to treatment compliance.