Principles of Injection Technique Table of contents Introduction . 4 Selection . 6 • Selecting the devices • Anatomy of the BD needle • Anatomy of the syringe • Anatomy of the medication pen • BD recommendations for needle length and gauge selectionn Preparation . 16 • Considerations before device assembly • Devices and equipment • Filling the syringe Administration . 22 • Skin preparation • Injection routes – Intramuscular – Subcutaneous – Intradermal The information in this manual is intended for use Disposal . 32 as a reference for proper injection technique and is • Safe use and disposal of sharps intended for healthcare professionals. • Selecting, evaluating and using It is not intended as a substitute for medical education sharps disposal containers or training. The medical devices discussed in this manual should not be used by untrained individuals and are designed for healthcare professional use. References . 36 Appendix . 37 Refer to manufacturer’s Instructions for Use • Needlestick prevention – Needlestick Safety and Prevention Act For information about other educational offerings, please – Safety-engineered device technologies contact the BD Education Center at 800.255.6334 – Safety injection device evaluation form or email [email protected] This booklet is intended to educate healthcare Introduction workers with information on how to prepare and The process for giving an injection includes some basic steps . This manual administer skin injections safely and correctly. divides the injection process into four categories . Upon completion of this booklet, the participant should have an understanding of: The basic topics, standard for all injections, discussed in the following pages are: • Assessment of patient – This manual Selection assumes that the healthcare worker has basic knowledge and education on proper List factors that need to be considered when patient assessment. selecting a syringe and needle for an injection . • Type of injection • Site selection • Selection and assembly of supplies Preparation and devices Describe the following components of medication • Injection administration preparation, assembling, preparing and checking . • Safe disposal of waste materials Administration List the medication volumes that can safely be injected into the following areas: intramuscular, subcutaneous and intradermal . Disposal Describe the four safety performance criteria for sharps disposal containers . 4 Selection Selection Selecting the devices There are many different syringes and needles suiting many different procedures . It is important to choose the needles and syringes carefully according to the type of injection to be administered . For example, the length and gauge of needle and type of syringe must be suitable for the injection site, viscosity and volume of medication . The BMI, age and condition of the patient are other key factors in the selection process . 6 7 The anatomy of the BD needle Bevel Needle The sharpened angular tip at the end of the needle . There are typically four types of bevels used for skin injections . Most needles are made of stainless steel, which is siliconized to allow easier penetration force . Available in different lengths and gauges to suit Regular bevel: The most common bevel, used for a vast individual clinical and patient needs . majority of applications . Typically used for intramuscular and subcutaneous injections . There are three types of needle walls1: Regular wall: This is the most common wall thickness . The thickness of the steel wall minimizes flexing when the needle is inserted into a vial stopper or patient . Short bevel: Used for specialty applications such as arterial blood gas sampling and nerve blocks . Thin wall: As shown in the diagram, the thin wall needle has a narrower steel wall, allowing a greater volume of fluid to pass through it . The flow rate is typically equivalent to that of a regular wall needle one gauge larger . This is especially important with very thin needles . Intradermal bevel: This needle bevel is used primarily for skin testing (e .g ., allergy tests) . Extra thin wall: This has the Regular Thin thinnest steel wall wall wall, designed 5-bevel: The two additional bevels create a flatter, thinner to increase the *,2 surface that is perceived to have less pain . benefits of the thin wall needle . Extra thin wall Hub Allows user to attach the needle to a syringe by either a luer lock or a luer slip connection . Safety mechanism All safety-engineered needles are color coded to denote the gauge of the needle . (See chart on Designed to protect the user from pages 14 and 15 .) accidental needlestick injuries . Safety technology for injection needles include retracting syringes, shielding needles and sliding sleeve syringes . 8 * Study was not conducted on all needle sizes . Product photo enlarged, not actual size 9 The anatomy of the syringe Generally used for injections requiring 1. Stopper: Prevents leakage of medication a secure connection of the syringe to around the plunger, and acts as an indicator another device . The tip is threaded for Luer lock tip for measuring the syringe’s contents (see a “locking” fit and is compatible with diagram) . a variety of needles, catheters and other devices . 1 1.1 1.2 1.3 A friction-fit connection that requires 1.4 Align intended the clinician to insert the tip of the 1.5 1.6 dosage here syringe into the needle hub or other luer 1.7 connection in a push-and-twist manner . 1.8 Luer slip tip 1 1.9 This will ensure a connection that is 2 less likely to detach . Simply sliding the attaching device onto the syringe tip 2. Scale markings: Scale markings are typically may not ensure a secure fitting . in milliliter (mL) units . On insulin syringes, however, graduations are displayed in “units” based on the insulin concentration prescribed . (Example: U-100 means 100 units Allows for work requiring closer of insulin suspended within 1 mL of fluid . Eccentric luer proximity to the skin . Generally used for 2 A 3/10 mL insulin syringe will accommodate slip tip venipunctures and aspiration of fluids . up to 30 units when using U-100 insulin .) (Also see luer slip instructions above .) 3. Barrel: Reservoir for holding liquid, clearly graduated to allow accurate and visual measurement of the syringe’s contents . 3 Used for flushing (cleaning) catheters, gastrostomy tubes and other devices . 4. Flanges: The “wings” that extend out from Catheter tip Insert catheter tip securely into catheter 4 the side of the syringe barrel that provide or gastrostomy tube . If leakage occurs, an area or surface for the index finger and refer to your facility’s guidelines . 5 middle finger to grasp during aspiration or administration . 6 5. Plunger rod: A piston-like device inside the barrel . Most commonly found in insulin and tuberculin syringes . Permanently Permanently attached needles, also known as attached needle 6. Thumb press: Area where clinician presses integral needles, reduce the amount to push plunger rod down into barrel to expel of medication waste . contents . 10 11 The anatomy of the medication pen Types of pen needles Needle (cannula) • Conventional pen needles (without safety engineering) used by self-injecting patients . Pen needles Outer Needle Teardrop 3 should be used once . cover Inner hub label needle shield Pen cap • Safety-engineered pen needles used by healthcare providers (this example shows protective shields at both ends of the pen needle after use) . Attach pen needle here Insulin cartridge Important: Pen injector • Pen injectors can be used for one person only—“one pen, one patient.”3 • Pen injectors, often the size and shape of a large marker, carry medication in self-contained cartridges. The most commonly used pens contain insulin. Outer pen needle cover * Intended primarily for self-injection, medication pens are now also used in healthcare settings. Dose window • Another type of pen injectors is single use with a preattached needle. Inner pen needle shield* Dosage Injection knob Insulin pens button • Insulin pens: After attaching pen needle, the needle needs to be always primed following the manufacturer’s directions. Pen needle • Insulin pens fall into one of two groups: reusable pens and disposable. Reusable insulin pens have cartridges of insulin that are replaced when empty. Disposable insulin pens (used in healthcare settings) come prefilled with insulin and are thrown away when empty. • Insulin pens are used with pen needles that are sold separately. Insulin pen needles should only be used once. 12 * Remove after attaching pen needle to pen . 13 BD recommendations for needle length and Needle length dependent on gauge selection4 age, physical condition and medication requirements. INTRAMUSCULAR (IM)* Location of injection Needle length Needle gauge Needle angle Pediatric Infants < 12 months Vastus lateralis muscle (< 0 .5 mL vol .) 22 mm – 25 mm 25 – 27 G 90˚ Deltoid muscle Toddlers and children Ventrogluteal site 22 mm – 30 mm 22 – 25 G 90˚ (12 months to 18 years) Dorsogluteal site (not recommended for < 3 years) Vastus lateralis muscle Adult Deltoid muscle Ventrogluteal site (may be best site for 25 mm – 40 mm (up to 76 mm > 18 years cachectic adults) 19 – 25 G 90˚ for large adults) Dorsogluteal site (avoid in obese adults) Vastus lateralis muscle SUBCUTANEOUS (SubQ) Location of injection Needle length Needle gauge Needle angle Insulin delivery: Anterolateral thigh Insulin delivery: 4 mm – 13 mm 29 – 32 G Pediatric to adult Upper outer tricep area; upper buttocks 45° –