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Aspiration in Injections F1000Research 2017, 3:157 Last updated: 26 SEP 2018 REVIEW Aspiration in injections: should we continue or abandon the practice? [version 2; referees: 1 approved, 1 approved with reservations] Yasir Sepah1,2, Lubna Samad1,3, Arshad Altaf 4,5, Muhammad Sohail Halim2, Nithya Rajagopalan6, Aamir Javed Khan1,3 1Centre for Injection Safety Pakistan, Interactive Research & Development, Karachi, Pakistan 2Stanford University, Stanford, CA, USA 3The Indus Hospital, Karachi, 75190, Pakistan 4Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA 5Canada-Pakistan HIV/AIDS Surveillance Project, Sindh AIDS Control Programme, Karachi, Pakistan 6University of Nebraska Medical Center, Omaha, NE, USA v2 First published: 10 Jul 2014, 3:157 (doi: 10.12688/f1000research.1113.1) Open Peer Review Second version: 01 Feb 2017, 3:157 (doi: 10.12688/f1000research.1113.2) Latest published: 01 Mar 2017, 3:157 (doi: 10.12688/f1000research.1113.3) Referee Status: Abstract Aspiration during any kind of injection is meant to ensure that the needle tip is Invited Referees at the desired location during this blind procedure. While aspiration appears to 1 2 be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, version 3 report there is no evidence that this procedure is truly beneficial or unwarranted. published Keeping in view the huge number of injections given worldwide, it is important 01 Mar 2017 that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order version 2 report to provide not only an exhaustive review of the subject, but also a starting point published 01 Feb 2017 for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed version 1 service (including Medline), Google Scholar and Scopus. Guidelines provided published report report by the World Health Organization, Safe Injection Global Network, International 10 Jul 2014 Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical 1 Cees Smit Sibinga , IQM Consulting Association and International Organization of Standardization for International Development of Quality recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for Management in Transfusion Medicine, The relevant information. In addition, curricula of several medical/-nursing schools Netherlands from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events 2 Ankit Balani, Yashoda Hospitals, India as a result of not aspirating prior to injection delivery were reviewed. Curricula Sandhya Sarjare, Yashoda Hospital, India of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections Discuss this article were consulted as well. Comments (0) Keywords Page 1 of 15 F1000Research 2017, 3:157 Last updated: 26 SEP 2018 Keywords Aspiration, injection Corresponding authors: Yasir Sepah ([email protected]), Lubna Samad ([email protected]) Competing interests: No competing interests were disclosed. Grant information: This literature review was funded by Star Syringe Ltd UK. All decisions regarding the content of the manuscript and final responsibility for submission of the manuscript belong to the authors. Copyright: © 2017 Sepah Y et al. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication). How to cite this article: Sepah Y, Samad L, Altaf A et al. Aspiration in injections: should we continue or abandon the practice? [version 2; referees: 1 approved, 1 approved with reservations] F1000Research 2017, 3:157 (doi: 10.12688/f1000research.1113.2) First published: 10 Jul 2014, 3:157 (doi: 10.12688/f1000research.1113.1) Page 2 of 15 F1000Research 2017, 3:157 Last updated: 26 SEP 2018 English-language literature on aspiration from all published and REVISE D Amendments from Version 1 non-published sources in order to provide an overview on the sub- Errors that were identified by the two reviewers have been addressed ject. In particular, this review aims to highlight areas of debate and in this version. A conclusion section has been added to the draw attention to key questions that remain unanswered, thus provid- manuscript. ing a starting point for controlled studies on specific areas requiring See referee reports clarification. Methodology A literature review was conducted using the US National Institute Introduction of Health’s PubMed service (including Medline), archives An injection is defined by the World Health Organization (WHO) of SIGNpost, the weekly electronic newsletter of the World as parenteral administration of medication through a skin puncture Health Organization’s (WHO) Safe Injection Global Network via a syringe, while aspiration is defined as the pulling back of (SIGN), and International Organization of Standardization the plunger of a syringe (for 5–10 seconds) prior to injecting (ISO) recommendations 7886 parts 1–4 for sterile hypodermics. medicine1–4. Aspiration is most commonly performed during an Clarification on points of debate was sought by direct communication intramuscular (IM) or subcutaneous (SC) injection, and is meant with ISO. Google Scholar was also used to search for relevant to ensure that the needle tip is located at the desired site, and has information. Relevant search terms for PubMed and Google Scholar not accidentally punctured a blood vessel. literature searches are listed below. Despite the growing wealth of medical knowledge in recent dec- Guidelines from the WHO, International Council of Nursing (ICN), ades, the simple procedure of aspiration is still generating much US Center for Disease Control (CDC), US Federal Drug Agency controversy concerning its perceived benefits and indications5. (FDA), UK National Health Service (NHS), British Medical Asso- Advocates of aspiration contend that it is a technically easy maneu- ciation, UK Nursing and Midwifery Council (NMC), and Australian ver that is rapidly performed and well tolerated by patients with no Nursing and Midwifery Accreditation Council, Public Health increase in costs incurred. However, due to a paucity of available Agency Canada and the Pakistan Medical Association (PMA) were data, there is no evidence that this procedure is essential or truly extensively searched for information. Data from the WHO Program beneficial. This issue has been widely debated with specific regard for International Drug Monitoring network in regard to adverse to vaccination; there are no studies that have assessed the need for events as a result of not aspirating prior to injection delivery were aspiration prior to IM injection of vaccines in relation to vaccine reviewed. Curricula of selected major medical/nursing schools in safety. The widespread use of auto-disable (AD) syringes – most of India, Nigeria and Pakistan were also reviewed for relevant infor- which are not designed to aspirate6 – has not been linked to adverse mation to document the inclusion (or otherwise) of aspiration in effects due to the elimination of the aspiration procedure prior to teaching guidelines for injection technique. injection of vaccines7. This finding has intensified the debate and raised doubts over the necessity of aspiration in non-vaccine medi- National therapeutic manuals and formularies such as British cation administration as well. National Formulary (BNF), European Pharmacopeia (EP), United States Pharmacopeia (USP) and Pakistan Pharma Guide (PPG) were Conventional syringes are also used to aspirate materials other also consulted for information regarding aspiration before injec- than blood – synovial fluid, amniotic fluid, cells (via fine needle tion. Product inserts for all injectable drugs on the WHO Essential cytology), pericardial fluid, peritoneal fluid and cerebrospinal Drug List (EDL) were collected to determine if the manufacturer fluid (CSF) are examples8–19. This wide spectrum of applications had provided instructions on aspiration prior to injecting the drug. for conventional syringes is all the more interesting in view of These product inserts were collected from local pharmacies and the the fact that although used for both aspiration and injection, the international manufacturers for each drug. Drug inserts from multi- syringe is actually designed only for injection20. A number of stud- nationals were acquired either directly from their websites or from ies have concluded that a conventional syringe is a poorly control- other online resources including the Drug Index (www.Rxlist.com), led and non-ergonomic device during aspiration21,22. Possible lack Australian Prescription
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