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Abbocillin, Abboject, Abbo-Liter, Abbo-Vial, Bejectal, Butterfly-16, Butlerfly-19, Butlerfly-21, Butlerfly-23, Butlerfly-25, Cly-Q-Pak, Erythrocin, Hyazyme, lon-o-trate, Metaphen, Microdrip, Panheprin, Pentothal, Soluset, Twin-Site, Venopak, Venotube Color-Break, registered trademark, Kimble Glass Co. Fiberglas, registered trademark, E. I. du Pont de Nemours & Co. (Inc.) Gold-Band, registered trademark, Wheaton Glass Co. Teflon, registered trademark, Owens-Corning Fiberglas Corp. Zephiran, registered trademark, Winthrop Laboratories
4 4 9 9 11 12 14
Selecting and Preparing the Site for Injection Making the Venipuncture The Bevel The Needle Basic Venipuncture Other Techniques
ABOUT THE INFUSION
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Selecting and Preparing the Equipment for Venoclysis Temperature of Solution at Time of Administration Assembling the Apparatus Rate of Infusion Mechanical Difficulties Adding Supplemental Medication Terminating the Infusion
ABBOTT EQUIPMENT FOR INFUSIONS
18 18 19 19 19 20 20
The Abbo-Liter The Venopak The Surgical Venopak The Venopak Microdrip The Secondary Venopak The Y-Type Venopak Soluset Venocath The Butterfly Infusion Set Venovalve 30 with "T" Connector "T" Connector Set Venotube 20, Venovalve 30, and Venotube 20 Sterile Pack The Venotube Twin-Site The Cly-Q-Pak for Hypodermoclysis
FROM THE SYRINGE
22 22 24 25 25 26 27 29 31 32 32 32 33 33
Transfer from the Ampoule and from the Multi-dose Vial. From the Ampoule From the Vial From the Two Compartment Vial. How to Prepare Solution Into the Vein Into the Muscle Into the Subcutaneous Tissues Into the Skin (Intradermal)
38 38 39 40 40 41 42 46 47
Frequently in clinical practice drugs or solutions are administered by other than the oral or rectal route. Such administration is called parenteral (meaning apart from the intestine) and usually refers to injection of drugs. Parenteral injection is employed for a number of reasons, among which are the following: 1. The patient may be unconscious. 2. The patient may be nauseated or vomiting. 3. Some drugs cannot be absorbed from the gastrointestinal tract (for instance, some antibiotics have too large a molecular size). 4. Some drugs are partially or completely destroyed by the gastric and other digestive juices. 5. A drug's action may be needed instantly (as during anaphylaxis, an asthmatic attack, or other emergency). 6. A drug's action may be needed only in a prescribed area (for instance, a local anesthetic). 7. A physician may wish to prolong the action of a drug by injecting a repository form or a concentrated aqueous solution. 8. Severe disturbance of fluid and electrolyte balance may require intravenous infusion (or subcutaneous infusion when a suitable vein is not available). Parenteral injection encompasses several routes of administration such as injection into a joint, into the spinal canal, into an artery, into the brain, or (in an emergency) into the heart itself. In fact, injections may be made into almost any organ or area of the body. However, it is our aim here to describe only those injeCtions which are administered more routinely. These are: 1. intravenous (into the vein) 2. intradermal (into the skin) 3. subcutaneous (under the skin) 4. intramuscular (into a muscle) Abbott intravenous equipment will be described, and a number of drawings will serve to illustrate the points made, the techniques described, and the equipment used.
SELECTING AND PREPARING THE SITE FOR INJECTION.
should be made, and precautions
observed, to insure as fossa (median
safe and painless an entry as possible. Although most superficial veins are suitable for venipuncture, veins in the antecubital basilic and median cephalic) are most frequently for all occasions. Other suitable alternatives with advantage. lies in the antecubital tionships). Other available network
chosen because they sometimes
are usually large and easily accessible. However, this site is not the best are available, Also, one should keep in mind that the median nerve fossa and that, in some patients, the brachial artery rela-
may lie superficially (see figure 9, page 11, for possible anatomical
veins include the cephalic and basilic veins in the fossa, the metacarpal and the dorsal venous
arm above the antecubital antebrachial movement,
the back of the hand. The accessory cephalic and median veins of the forearm are favored by many clinicians for long in the antecubital fossa precludes arm in a forearm especially flexion at the elbow, venipuncture
infusions. Whereas venipuncture
vein and securing of the needle and tubing allow the patient some movement without the risk of puncturing surface. The legs present the great saphenous and femoral veins in the thigh, and the great saphenous at the ankle. On the foot are the venous plexus of the dorsum, the dorsal venous arch, the medial marginal vein, and the lateral marginal vein. Ordinarily at least one or two of these veins will be suitable for injection. Also, with careful attention ment of the tourniquet, be utilized. To avoid the difficulties described later on page 10 (figure 8), the operator generally is urged to "use as small a needle as possible, and to insert it into the largest convenient 4 vein just distal to a venous junction, securing it by some means which does not occlude the vein distal to the point of insertion. Thus, he should try to enter large veins at the to the application of heat and placeeven veins that are small and poorly filled may the posterior wall of the vein. Here, again, one should be aware that aberrant arteries sometimes lie near the
antibrachii Vv. metacarpeae dorsales
V. ext. sup. femoralis,
V. saphena V. saphena
Figure 1. The superficial veins used in blood transfusion or intravenous (From Proceedings Staff meetings. Mayo Clinic, 12:122-125, 1937.)
end of a limb, and avoid the small veins at the distal end."1 the operator should ascerdegrees of varicosity of infused do not exist at or above the proof flow in such areas can there. untoward When this reactions delay solution
When using veins of the lower extremities, tain that marked posed point of injection. result il~ a collection accumulated the intravenous The partial stagnation or injected the general
may occur. Also, when an immediate the onset. However, if varicosities
effect is desired (as is usual when cannot be avoided, the point of into increase care should
route is chosen) varicose veins may considerably and the veins massaged has been determined, centrally utmost
jection should be elevated
the blood flow. When the site for injection measure, let the extremity
be given to the proper distention
of the vein. As a simple preliminary
in which the vein is located hang dependent compression above the site, as The tourniquet can A blood presconstriction used for tube held by a
for a time. This action alone may serve to make the veins more apparent. If the veins stand with a tourniquet, sure cuff is probably and of providing hemostat this purpose. If a vein in the antecubital sufficiently 6 to obstruct venous fossa is chosen, tighten return without stopping and will maintain the tourniquet arterial flow. arterial flow. At out well, manual will be sufficient to fill them.
vary from a twisted bandage
the most efficient means of applying
a quick smooth release. A soft rubber
or tied in a slip knot
(figure 2) is most frequently
This will fill the veins to capacity the same time, the patient
open and close his hand,
Figure 3. Shaded portions represent congestion from correct and incorrect application of heat. (From Proceedings Staff Meetings, Mayo Clinic, 12:122-126, 1937.)
finally keeping it closed until the needle is in the vein. When the veins are small or deep, constriction alone may not produce adequate dilatation. In this event, lightly slapping the veins at the wrist may cause additional dilatation of the vein. Application of heat to the and may be extremity is a valuable aid prior to applying the tourniquet administered,
necessary should the other means mentioned be unsuccessful. Properly this heat can mean the difference between a routine inby a venous cut-down. For example, jection and an involved administration
As illustrated in figures 3 and 4, heat must be applied not only to the area around, but also distal to, the site of venipuncture. if a vein of the upper extremity is to be used, the hand, wrist, forearm and arm (to a point above the elbow) should be enveloped in a warm,
Figure 4. Method of applying moist heat to dilate poorly filled veins. The arm is wrapped with a Turkish towel wrung out of hot water, over which is placed a'rubber sheet enclosed in turn by a dry Turkish towel. This is left in place 10 to 20 minutes.
Figure 5. Small or deeply set veins in the antecubital space are outlined cation of heat and before application of the tourniquet.
moist Turkish towel with an outer water-resistant Alternatively,
wrapping. Hot water controlled
bottles laid against the covering will sustain the heat. hospitals are employing a thermostatically electric blanket as a convenient means of promoting vasodilatation. When
a vein in the ankle is to be employed, the entire foot, ankle and leg should be similarly wrapped. In 10 to 20 minutes, the entire area will be congested with blood, so that the veins may be outlined and the tourniquet applied (figure 5, above; figure 6, page 9). Lundy2 has suggested the use of a common hair dryer (figure 5, above) as a quick convenient method to produce vasodilatation at almost any site. The only precaution is that the dryer not be employed when explosive hazards are present. When a vein of the upper extremity has been selected, an arm board may facilitate the puncture by restraining the patient from jerking his arm. The wrist can be secured to the board (not rigidly enough to stop free circulation) by a broad strip of adhesive tape or gauze. An arm board is particularly useful when administering parenteral fluids to children. Lundy3 points out the necessity of warming the sponge and antiseptic solution, at least to body temperature, puncture. before cleansing the site of the Because the arm is warm, it is more than usually sensitive to
cold, so that the reflex resulting from sudden contact with a cold solution causes the blood vessels to contract almost immediately. For infants and other persons with very small veins, or for unusually sensitive patients, venipuncture can be made painless by the simple 1.0 per cent solution. The expediency of raising a wheal in the skin overlying the vein. This is done by injecting 0.5 ml. of Procaine Hydrochloride, 8 needle used for making the wheal should be advanced close to the wall of the vein so that the vein and the skin covering it will be anesthetized.
Figure 6. Tourniquet
has been tightened
and patient has been instructed
to make a fist.
For an excitable or nervous patient a small dose of sedative at least thirty minutes before infusion may calm the patient and minimize and premovement of his extremities.
MAKING THE VENIPUNCTURE.
All the previous preparations
cautions lead directly to getting the needle safely and as painlessly as possible into the vein and keeping it there until the injection or infusion is completed. The Bevel: Whenever the lumen of the vein to be entered is sufficiently large in relation to the size of the needle (as in most cases) venipuncture should be made with the bevel of the needle facing upward (figure 7). This attitude of the needle to the vein will facilitate entry and will cause the least injury to the skin being pierced and the vein being entered. However, when the vein is small and the lumen is estimated to approach the size of the needle, entry should be made with the bevel facing downward (figure 8, drawing e). The angle at which the bevel is cut (long, intermediate, resistance to venipuncture to inadvertent finer gauges. or short) affects the function of the needle. A long bevel presents somewhat less than a short bevel, but is more susceptible penetration of the opposing vein wall. Improved methods
of sharpening have made short bevel needles popular, especially in the
Figure 7. A Relatively Small Needle Entering a Relatively Large Vein. This illustrates a satisfactory relationship of the lumen of the vein to the size of the needle.
%""ij~'' ' ' ',~
Figure 8. A Relatively Large Needle Entering a Relatively Small Vein. (a) A hematoma may form if the bevel faces upward. (b) In other cases, with the vein properly dilated, satisfactory entry may be made with the bevel facing upward. (c) However, when the tourniquet is released the vein tends to collapse and occlude the lumen of the needle. (d) Readjusting the needle without a tourniquet may lead to perforation of the posterior wall of the vein and a subsequent hematoma. (e) With the patient carefully prepared a relativeiy large needle may be introduced into a relatively small vein if the bevel faces downward. (From Surgery, 2:590, 1937).
.VEIN 1. basilic 2. median basiIic 3. cephalic 4. median cephalic 5. median cubital
Figure 9. Two common arrangements of the veins of the cubital fossa of the left arm, showing relationship to arteries and nerves. (Adapted from Adriani, J., Techniques and Procedures of Anesthesia, Charles C Thomas, Springfield, Illinois, 1956, p. 263.)
Figure 10. (below) Diagram
of a needle
lumen (inside diameter) -~===.~~be.vel
The Needle: Although not all physicians use the same size of needle for intravenous infusions, generally they prefer an 18-, 19-, or 20-gauge needle which is 1 or 1~ inches long. However, in certain instances, when fluids must be given at the most rapid rate possible, a 15-gauge needle may be employed. A "thinwall" needle.has a lumen (inside diameter) one size larger than its gauge. Thus a 19-9auge thinwall needle has the same lumen as an 18-gauge standard walled needle. Regardless of size, the needle should be sharp. A broken tip or the slightest hook on the end of the needle (figure 11) can result in mechanical difficulty for the operator and injury or unnecessary discomfort to the patient.
Figure 11. A simple test, such as passing the needle back and forth through sterile gauze orexamining the tip under a magnifying glass, will quickly demonstrate whether or not the needle is suitable for use.
(closed technique for intravenous
infusion): After is
the site has been prepared
(with heat if necessary) the tourniquet
applied and tightened as directed on pages 6 and 7, and venipuncture proceeds with these basic steps as illustrated 1. Apply antiseptic (figure 12). 2. Clear the infusion tubing of air and fasten the pinch clamp. 3. Hold the limb with the left hand, using the thumb to place the skin on stretch and to anchor the vein. 4. Point the needle in the direction of the course of the vein at the proposed site of entry. The angle of the needle to the surface of the skin should be about 45 degrees. 5. Place the tip of the needle slightly to one side of the vein (figure 13) and about one-half inch below the point where the needle will enter the vein itself. (Most operators do not attempt and vein in the same thrust.) 6. Firmly pierce the skin and underlying tissues to the depth of the vem. 7. Depress the needle (decrease its angle) so that the needle is almost to pierce the skin in figures 12, 13, 14, 15: solution to the area involving the injection
flush with the skin. Move the tip of the needle directly above the vein (figure 14). 8. Slowly send the needle into the vein. A backflow of blood into the clear plastic tubing will indicate satisfactory bottle holding fluid to be administered entry. (In some cases will have to be lowered.)
9. When the blood appears, cautiously advance the needle until it lies well within the lumen of the vein. This should be done by lifting the vein on the needle with a slight upward pressure to prevent the needle's passing through the posterior wall of the vein. 10. Release the tourniquet and relax the tension of the skin. 11. Adjust pinch clamp and start infusion. 12. Be sure fluid is flowing freely in the vein. (Signs of swelling may indicate extravasation. tinued immediately In this event, the infusion should be disconand a new site selected.)
13. To protect the skin under the needle, place sterile gauze under and over the needle. 14. Tape the needle firmly in place with adhesive. 15. To minimize movement of the needle in the vein, tape a looped portion of the tubing to the forearm (figure 15).
The "closed" technique is outlined above because assembled disposable equipment is the same. for by several
of the growing use of previously intravenous other techniques,
infusions. However, infusions may be started although the basic venipuncture
One method employs a needle attached to a 2-ml. dry syringe ("separate syringe" technique). Again, the infusion tubing is filled with fluid proceeds by the method outlined and cleared of air, and venipuncture
under Basic Venipuncture. The syringe (if it has no lock) should be held so that the little finger prevents movement of the plunger during piercing of the skin. After the skin is pierced the little finger should exert a slight backward pull on the plunger. The negative pressure thus induced will allow blood from the vein to enter the syringe. After blood appears freely in the syringe the needle is advanced into the vein as in step #9. The tourniquet tubing attached. In a variation containing venipuncture. is then eased, the syringe detached, syringe" technique and the Steps #11 through #14 are then performed. of the "separate a larger syringe
3 or 4 ml. of isotonic saline solution may be used for the This minimizes the danger of clotting which may occur
with a dry syringe, especially if there is difficulty in entering the vein. In infants and other subjects with exceedingly small veins only a small
amount of blood may be aspirated
before the vein collapses. It is then
Figure 16. Venipuncture at antecubital fossa. Arm has been prepared with antiseptic solution, draped and tourniquet tightened. Needle is aimed parallel to long axis of vein.
necessary to remove the tourniquet
and inject saline solution to be sure proceeds as outlined,
the vein has been entered properly. Venipuncture
the syringe being held as shown in figures 16, 17, 18. For piercing the skin, the syringe should be held by both the plunger and the barrel (figure 16). After the skin is pierced the syringe should be held by the plunger with the thumb against the barrel to create negative pressure (figure 17). Thus, when the vein is entered blood will be aspirated into the syringe. After blood appears freely in the syringe, the needle is advanced into the vein as in step #9. The tourniquet the syringe is detached, #14 are performed. the tubing is attached, is then eased, and the contents of the syringe are injected into the vein (figure 18). Finally, and steps #11 through
One other method of beginning an infusion is called the "connected syringe" technique. Here the syringe is assembled with a sidearm outlet from the barrel, and the tubing (cleared of air) is attached to this outlet before venipuncture. Venipuncture proceeds as with the basic "separate
syringe" method. After blood appears freely in the syringe the needle is
Figure 17. Thumb of left hand tenses skin back of needle. Position of right hand and thumb against the barrel of syringe permits slight aspiration duirng venipuncture.
advanced into the vein. The plunger is withdrawn
past the opening of
the sidearm and the tourniquet is eased, thus starting the infusion. Steps #11 through #14 are then performed. This technique eases the task of the operator but may be a burden to the patient, since the syringe remains attached throughout the infusion. Even though a pad of sterile cotton is placed under the syringe, the extra weight may lead to severe discomfort during an infusion lasting several hours. For this reason the technique is not used often.
Figure 18. Method of holding syringe with needle inserted
into median cephalic
SELECTION AND PREPARATION OF EQUIPMENT FOR VENOCLYSIS:
there are mechanical differences between the equipment 1. A bottle or other administered, 2. A dispensing cap, 3. A drip chamber, 4. A length of tubing, 5. A pinch clamp, 6. An air filter, 7. A needle adapter, 8. A needle. A small syringe is sometimes employed ("separate nected syringe" techniques, needle is in the vein (by aspiration of blood). reservoir containing
manufactured to be
by different firms, a basic unit usually consists of the following: the solution
syringe" and "conthat the
pages 14 and 15) to determine
Despite a similarity of component parts, there are two distinctly different types of equipment available: disposable and permanent. Selection of one type or other determines the amount of preparatory work to be done. A disposable unit (such as the Venopak, shown on page 23) is delivered to the hospital sterile and ready for immediate use. After a single infusion the complete unit is then discarded. According to Lundy4: "Most pyrogenic reactions following blood and fluid infusions seem to arise from improperly cleansed and unsterile equipment. This is particularly true with reference to rubber tubing. Tubing should be used only once for blood transfusions. Disposable tubing is to be preferred. It might be well if there were a member of the hospital staff designated as a 'snatcher' whose function it would be to snatch up and dispose of all tubing once used for transfusion or infusion purposes. The 'snatcher' the preparation would save us many needless reactions." The need for strictly aseptic techniques throughout is permanent equipment) and infusion is well established. When the same equipment is reused (as it should be carefully cleansed, thoroughly rinsed with triple-distilled water, packed in sterile gauze, and sterilized by autoclaving.
TEMPERATURE OF SOLUTION AT TIME OF ADMINISTRATION:
solutions are administered
without regard to the temperature.
cally all commercial intravenous
solutions are stable at room temperaA rather wide temperature
ture and are not stored under refrigeration.
range is tolerable to the patient, because the small volume infused with each drop is quickly diluted and brought to the temperature of the circulating blood. ASSEMBLING THE APPARATUS: Attach the tubing to the bottle (or other reservoir) according to the.manufacturer's directions. Suspend the bottle on a stand two to three feet above the level of the bed. Adjusting the height of the bottle is one means of controlling the rate of infusion. RATE OF INFUSION: This is one of the most important factors in the successful administration of fluids. Usually (except in emergency procedures) the rate should be slow. Specific rate of flow must be determined by the clinician who orders the medication. As indications may vary with the kind and concentration of solution being administered, condition of patient and other factors, no attempt is made to discuss them here. Before venipuncture, the operator determines the maximum rate of flow by his choice of needle-size. For most infusions, an 18-, 19-, or 20-gauge needle (lor 172 inches long) is used. Occasionally, when parenteral solutions are given too rapidly "speed shock" may occur. Usually, the patient is flushed, uncomfortable and complains of a pounding headache or constriction of the chest. There may be pulse irregularity and, in extreme instances, there is a cessation of respiration or disappearance of the radial pulse. The best preventive of speed shock is slow infusion. More commonly, too rapid administration of fluids may cause subcutaneous edema. MECHANICAL DIFFICULTIES: Relatively few things will inhibit the flow of an infusion properly assembled and started. However, flowis altered occasionally, usually from one of four causes- a kink in the tubing, a plugged air filter, displacement of the needle or an obstruction in the needle. A simple preventive or remedy is to flush the needle every half hour or so. This reduces considerably the possibility of clogging the needle. If the needle is not clogged, the tubing should be checked to be sure that there are no obstructions. Should difficulties still be encountered after the needle and tubing have been checked, the infusion should be terminated (page 20) before any major adjustment .is made.
ADDING SUPPLEMENTAL MEDICATION: With the versatility of parenteral equipment currently available, the physician may administer several medications through the same infusion needle simultaneously or sepa-
rately. Several mechanical devices may facilitate stance, a three-way stopcock attached when one or more supplemental course of an infusion. The usual venoclysis apparatus changes in therapy. operator
this process. For in-
to the needle provides the oper-
ator with two inlets to the blood stream. This is especially desirable medicaments must be given during the itself allows ample range for routine effect is desired the insert with needle (and attached
When a drug for immediate
may pierce a gum-rubber
syringe) and make the injection. With the commercial sets and special tubing with multiple injection sites now available, additional fluids may be introduced into the bottle or injected into the tubirig,'Finally, the infusion of a separate solution may be facilitated with a series hook-up or a tandem hook-up. Regardless of the means employed for supplemental medication or
the point at which it enters the primary infusion system, one should be alert for signs of leakage or for air bubbles in the tubing. Any opening introduced into the tubing may permit air to be pulled into the moving fluid, and air embolism may result. Stopcocks may also be a point of entry for air.
TERMINATING THE INFUSION:
an infusion (before or at
the end of the procedure) : 1. Stop" the flow of fluid by means of the clamp nearest the needle. 2. With the needle held firmly in place, gently remove the adhesive tape by which the needle and adapter were secured. 3. With one hand, place and hold a small wad of sterile cotton over the site of injection. 4. With the other hand keep the hub of the needle flush with the skin and slowly withdraw the needle, taking care not to drag the tip against the posterior wall of the vein. 5. Secure the wad of cotton over the injection site with a piece of adhesive tape, Since the patient's not attempt arm has "recovered." arm has been immobilized for a period of time, do do so himself when his
to flex it for him. Let the patient
ABBOTT EQUIPMENT FOR INFUSIONS
ABBOTT EQUIPMENT FOR INFUSIONS
Abbo-Liter is the registered trademark of the special container in which Abbott solutions for infusion are offered. The Abbo-Liter is graduated and labeled for reading in the standing or hanging positions. Solutions are sterile and pyrogen-free and are packaged at atmospheric pressure. Modern techniques of preparation, sterilization, and packaging have replaced the need to bottle solutions under vacuum. Thus, in principle the Abba-Liter is an enlarged ampoule. An operator need only open the Abbo-Liter, connect the appropriate apparatus, and begin venoclysis or hypodermoclysis. With aseptic techniques no contamination will occur. Since there is no vacuum to be relieved before the solution is administered, there can be no inrush of air and possible air-borne contaminants. Additional selected electrolytes may be added to the Abbo-Liter from the Abbo-Vial which contains Ion-o-trate, Abbott's line of concentrated electrolyte solutions. Simply unscrew the plastic hood of the Abbo-Vial to break the seal; then aseptically pour the calculated amount of the selected Ion-o-trate into the standard Abbott bulk solution. Abbott equipment for infusions has many unique features. For instance, the Secondary Venopak may be connected in series with the Venopak to change fluid therapy during the course of an infusion. Alternatively, two Abbo-Liter containers may be connected by means of a Y-type tubing. Other sets are designed for extension, for administration by syringe, for micro-administration, or for administration from several sites on the same tubing. All sets are packaged with complete operating instructions.
VENOPAK for Simple Venoclysis
The Venopak is a completely disposable set for administering intravenous fluids from the Abbo-Liter. Important to this all-plastic unit are the following features: The drip chamber is flexible. One squeeze primes it (or clears it if ever flooded). It is oversize for improved performance and visibility. The air filter is made of woven Fiberglas discs, coated with Teflon. The filter is non-wettable virtually eliminating leakage or interruption of air flow. The screw clamp can be operated with one hand permitting close regulation of the flow rate. Two lengths are available: Venopak (60 inches) and Venopak-78 (78 inches).
VENOPAK-List No. 4622; (With 20-G Needle-List [18-G I.D.] Siliconed Needle-List No. 4638) VENOPAK-78-List No. 4631; (With 20-G Needle-List [18-G I.D.] Siliconed Needle-List No. 4621)
No. 4615); (With
No. 4644); (With 19-G Thinwall
and operating the Venopak
1. Remove protective lid from dispensing cap, and fit cap to Abbo-Liter by turning container against it. 2. Suspend bottle. Hold the coiled tubing in one hand. Half fill drip chamber by squeezing chamber.* Close clamp. 3. Remove protective cover from needle adapter, and attach sterile vein needle. 4. Open clamp and clear tubing of air by filling with fluid. Close clamp. 5. Make venipuncture of flow. Injecting supplementary in prepared site, and adjust rate
Screw clamp is easily adjusted with one hand.
medication medication, sterilize the gum rubber insert using a syringe and
To inject supplementary by applying Metaphen
(nitromersol, Abbott) Tincture or other suitable
antiseptic solution and allowing to dry. Inject, 25-gauge needle. Compatible medication by removing the air filter and attaching
may also be added directly to the solution the syringe without needle to
the air vent. Inject, remove syringe, and replace filter. The procedure
*If drip chamber ever floods. simply close" clamp and turn Abbo-Liter back to the upright inverted) position. Squeeze drip chamber to clear the excess fluid, then resuspend. (non-
takes only a few seconds. Medications can be added while the infusion is in progress. Although mixing is accomplished by air bubbles rising during the infusion, it may be well to swirl the bottle immediately the supplementary medication. after adding
SURGICAL VENOPAK to Provide Extra Injection Sites
CLAMP-~ -76" PLASTIC TUBING
VENOPAK-List No. 4557 VENOPAK with 18-G Thinwall
(17-G 1.0.) Siliconed
Needle List No. 4666
The Surgical Venopak differs from the Venopak in having a 76-inch tubing with three injection sites. Two are Y-type sites. The third site (immediately preceding the needle adapter) ble of withstanding is heavy gum rubber capainterrupted with the multiple needle punctures. Both a screw clamp and a the adjustment of the screw clamp.
slide clamp are provided. Flow may be temporarily slide clamp without disturbing
(List No. 4740) for Precision Drop Control
For a slower rate of administration rate, the Venopak Microdrip
or for more precise control of the solu-
is offered for use with Abbo-Liter
tions. This special disposable set consists of a dispensing cap with air filter, the Microdrip and flexible drip chamber, clear plastic tubing with inside diameter of 0.100 inch, a screw-type pinch clamp, a metal pinch clamp, a multiple-injection site, and a needle adapter. The screw-type pinch clamp affords the control desired. Approximately 60 drops from the Microdrip This will vary slightly with individual
deliver one milliliter.
sets, viscosity of the solution,
and the flow rate.
CLAMP INJECTION SITE
The infusion rate should be checked periodically and, if necessary, adjusted to maintain the desired rate.
VENOPAK (List No. 4613) for Series Hookup
Venopak provides a simple and economical means of
adding more fluid, or of changing fluids, while an infusion continues. This disposable unit is similar to the primary Venopak, but has no drip chamber. It permits attaching primary container. a secondary container in series to the without The Secondary Venopak can be attached
stopping flow from the primary container. If specific gravity of the secondary fluid is greater than that of the primary fluid, it will tend to layer under, and will mainly infuse first. Otherwise the two fluids will intermingle to varying degrees, and infuse simultaneously. The secondary container always empties first. Air from is always possible, we recommend bottle containing that the secondary tubing rises to the top of the primary container. Because some degree of mixing drug (e.g., intravenous secondary infusion. secondary hookup never be made into a primary hazard of an overdose of primary fluid a potent the 25
anesthetics or muscle relaxants).
This avoids any
which may mix in during
Assembling and operating the Secondary
1. Remove protective lid from dispensing cap, and fit cap by turning Abbo-Liter secondary container against it. Place secondary container upright, or hold it as shown in sketch below. 2. Remove air filter from primary Venopak, uncover adapter of Secondary Venopak, and plug adapter tightly into exposed vent. 3. Suspend the secondary container.
Convenient way to hold secondary container and attached set. Hold adapter between thumb and forefinger. Then suspend secondary container by its bail from last two fingers of same hand. This allows both hands free movement for plugging in and avoids spillage, since adapter is higher than secondary container.
(List No. 4656) for Alternate
This set is for alternate
venoclysis from two Abbo-Liter
exclusively. Completely disposable, it contains two dispensing caps with
air filters and drip chambers, two slide clamps, a screw clamp, clear plastic tubing, a gum rubber injection site, and a needle adapter. Assembling and operating the Y - Type Venopak lid from one dispensing cap, and fit cap to by turning container against it. Repeat with other con-
1. Remove protective Abbo-Liter tainer.
2. Close both slide clamps and suspend containers. 3. Holding coiled tubing in one hand, half fill each drip chamber by squeezing chamber. 4. Remove protective vein needle. cover from needle adapter, and attach sterile
5. Expel air as follows: Open one slide clamp, and allow fluid to fill tubing to a point below the Y; close the clamp. Open other slide clamp, and fill all remaining 6. Make venipuncture tubing and needle; close the clamp. in prepared site.
7. Fully open slide clamp below the desired container, regulating the rate of flow with the screw clamp below the Y. 8. To switch to the alternate container, tightly close the slide clamp below the first container; then fully open slide clamp below second container, regulating rate of flow with screw clamp.
Do not allow either container to empty completely. Be sure slide
clamp closure is complete (no dripping in chamber). If either bottle empties completely, air may be drawn into main tubing and administered with fluid.
(List No. 4578) and SOLUSET
-250 (List No. 4680)
The Soluset isAbbott's chamber. solution
set with rigid calibrated limited amounts of use. It is
It permits the physician to administer in precise volumes.
It is well suited to pediatric
complete, requiring no other parts except a vein needle, Major feature of the set is a rigid cylinder of 100-ml. or 250-ml. level, the operator capacity. By filling the cylinder to an appropriate
can give any precise volume desired. Amounts larger than capacity may be given simply by refilling the cylinder. Because the cylinder is rigid, it permits positive reading of the fluid level. The graduations 5-ml. intervals, spaced equidistantly. A hinged valve abruptly the cylinder when the fluid level reaches the 0 mark. Soluset-lOO is fitted with a Microdrip orifice, which provides approximately 60 drops per ml. Soluset-250 is calibrated at 15 drops per ml. 27 Both sets provide a screw clamp for precise control of flow rate. Conveniently, it is not necessary to close this clamp during refilling. are in seals off
Supplemental medication may be injected (1) at the top of the cylinder, (2) at a Y-type site on the tubing, and (3) at the gum rubber preceding the needle adapter. The cylinder is connected to the bottle by two lengths of tubing, one side for movement of fluids, the other side for air. A single slide clamp closes both.
5 mi. SCALE
MICRODRIP DRIP CHAMBER INJECTION ~-SCREW SITE CLAMP
Note: Toshowthat the set is outof service between infusions, and yet leave it completely connected, the cylinder may be looped over the stand. .
and operating the Soluset
1. TO ASSEMBLE. Close both clamps. Fit dispensing cap by turning Abbo-Liter container against it. Invert and suspend container. 2. TO PRIME TUBING. Open slide clamp, fill calibrated chamber about one-third, and close slide clamp again tightly. Gently squeeze drip chamber until about one third full. Without removing needle adapter
cover, open screw clamp to fill tubing with fluid, expelling all air from tubing. Close screw clamp. 3. TO FILL. Open slide clamp and fill calibrated chamber to desired level. Tightly close slide clamp. 4. TO ADMINISTER. Attach vein needle. Proceed with venipuncture, taking caution to avoid air bubbles in tubing prior to venipuncture. Adjust flow rate with screw clamp; 60 drops equal one milliliter. The set will shut off automatically at pre-set volume. 5. TO REFILL. It is not necessary to close screw clamp for refilling. Simply open slide clamp, fill calibrated chamber to desired level, and tightly close slide clamp. Gently squeeze lower part of drip chamber just enough to open rubber diaphragm. Slowlyrelease finger pressure.
VENOCATH Sterile Peel. Pack (Intravenous catheter inside the needle)
VENOCATH-14-List VENOCATH-16-List VENOCATH-18-List
No. 4614; 11)1," catheter, No. 4816; 11X" catheter, No. 4718; 11)1," catheter,
15-G. bore; needle 13.G. bore. 18-G. bore; needle 15-G. bore. 21-G. bore; needle 17-G. bore.
The Venocath is a flexible intravenous catheter inside a needle. This catheter is radio-opaque; its position in the vein is always readily visible in X-ray films. A removable stainless steel wire stylet prevents the catheter from buckling while being threaded into the vein. After the needle is withdrawn from the vein, a unique folding guard shields the entire length of the needle. The catheter may be left indwelling during repeated infusions, and the limb usually need not be immobilized. Use of the pliant catheter is more comfortable for the patient than administration via a rigid needle, especially if therapy is prolonged. It also obviates surgical cutdown and sacrifice of the vein.
and operating the Venocath
1. To open-Leave the sterile inner sheath intact until immediately before use. Then grasp base of blue needle guard and strip sheath down enough to expose only two-thirds of guard.
2. Expose Needle-Slide back clear plastic ring on needle guard, and open guard wings. Discard inner white cover, exposing needle.
Enter Vein-Make venipuncture, holding needle bevel up. Grasping catheter through its protective sheath, slowly push catheter well into vein. (If during this maneuver, it becomes necessary to withdraw catheter, always withdraw needle simultaneously; this prevents severing of catheter by needle.)
4. Withdraw Needle-After blood fills catheter, apply finger pressure over catheter in vein. Hold it thus while withdrawing needle. Discard sheath. Snap hub of needle guard into white adapter at catheter end.
5. Withdraw Stylet-Remove protective cap from white adapter, and withdraw wire stylet. Immediately connect administration set to adapter.
6. Close Needle Guard-Close wings of guard in place over needle, and slide ring back to distal end of wings, to lock them in place. Tape catheter, needle guard, and end of administration set for proper immobilization.
Vein Infusion Set")
Butterfly sets serve as extensions for infusion of blood or solutions from the Venopak or any standard needle manipulation. syringe. They have flexible plastic wings that can be folded upward to provide a fingergrip for more accurate This allows the needle to be held flat against the in difficult patients-for example, elderly perskin and inserted into the vein with a sliding motion. The same feature facilitates venipuncture sons with fragile, rolling veins. When released, the wings fold flat against the skin, where two short strips of tape suffice for stable anchorage. To eliminate any possibility of separation, tubing and needle are permanently joined at the time of manufacture. The short needle, compact anchorage, and flexible tubing contribute to greater patient comfort-with reduced chance of phlebitis, or of pressure necrosis beneath a bulky taped hub connection. The sets are sterile inside and out, come in sterile peel-pack envelopes, complete with stainless needle.
BUTTERFLY-16-List No. 4716 with 16-G. thinwall needle (15-G. bore)
Designed primarily as a surgical infusion set, the Butterfly-16 is supplied with a 16-gauge thin wall needle (15-G. bore) for rapid infusion and pressure administration. The .100" r.D. tubing is 3D-inches long, which set at a clearly visible location allows connection to the administration outside the surgical drapes.
BUTTERFLY-19-List No. 4590 with 19-G. thinwall needle (18-G. bore) and .054" 1.0. tubing BUTTERFLY-21-List No. 4492 with 21-G. thinwall needle (20-G. bore) a[ld .040" 1.0. tubing BUTTERFLY-23-List No. 4565 with 23-G. needle and .040" 1.0. tubing BUTTERFLY-25-List No. 4506 with 25-G. needle and .040" 1.0. tubing
These sets are supplied with small J.D. ultra flexible tubing, 12-inches long. The 19- and 21-gauge sets are adaptable for infusions at many sites, and on patients of all ages. The 23- and 25-gauge sets are pediatric sizes, especially convenient when working with infant scalp veins.
VENOVALVE List No. 4730
30" with "T"
This is a syringe administration site (latex-covered)
set, 30 inches long. A check valve at injection this
the terminal female adapter prevents backflow. An additional site may be uncovered to expose a female adapter.
"T" CONNECTOR List No. 4612 SET-
is provided at the T -type male needle adapter;
Use this connecting unit to join any two pieces of equipment four inches of plastic tubing, slide clamp, and attached
or syringes. T-type male
with or without needles to a common outlet. It provides a female adapter, needle adapter with injection site (with latex cover which may be removed to expose a female adapter).
VENOTUBE VENOTUBE VENOTUBE
20-List No. 4429 30-List No. 4481 30 Sterile Peel-Pack-List
These sets consist of tubing connections Pentothal between syringe
(20 and 30 inches long respectively) and needle during administration
pinch clamp and male and female adapters. Sodium (Sodium Thiopental
They are used as flexible or as extensions
where added length is needed. The inside sterility of No. 4429 and 4481 is maintained
by air filters and hoods at each end. No. 4610 is supplied
in a sterile peel-open envelope, and is sterile inside and out; it has a smaller lumen tubing than 4481, and is without air filters and hoods.
(List No. 4522) for Versatility
-TO MALE ADAPTER
This 30-inch assembly with two injection infusions, tra'nsfusions, (Sodium Thiopental female adapters. I t is disposable.
sites is designed to be used for of Pentothal Sodium
or the administration injection
The set consists of 30 inches of clear sites, two pinch clamps, and male and
plastic tubing, multiple
This is a versatile set offering a number of combinations.
When a suitable vein is unusually or obese patients) lysis (subcutaneous equipment important parenteral infusion).
difficult to find or enter (as in infants by hypodermocof as
fluids may be administered of aseptic techniques
The same rigi<;l precautions-sterility throughout-are infusion. infusion as for intravenous furnishes
and employment for subcutaneous
Needle size: For general use the Cly-Q-Pak
two 22-gauge the
needles two inches long. Where another size needle is preferred, Cly-Q-Pak is also available without needles. Other factors: Patients, throughout the infusion, especially children, since a sudden movement until the equipment of the patient
should be well attended may
dislodge a needle or disconnect should be discontinued or reassembled. Selecting the equipment: for hypodermoclysis
a tubing. Should this happen, the infusion can be properly adjusted
When one needle is employed, to hasten administration,
the basic unit (for instance, two needles
is the same as that used in venoclysis
the Venopak, page 23). However,
are generally utilized. This can be accomplished
by use of the Cly-Q-Pak
_PLASTIC "Y" TUBE
Unit) With two Needles, List No. 4617; Without
which is basically the same as the Venopak except that an inverted plastic "Y" joins two separate arms of tubing to the primary tube. Each arm is 14 inches long. Cly-Q-Pak (see illustration) carton, is completely assembled, is delivered in a sterile individual and is ready for immediate
use. A pinch clamp on each arm allows the operator to control the flow to each site. Cly-Q-Pak is assembled in the same manner as the Venopak and operates on the same principles. Discard the entire unit after one use. Selecting and preparing the site: The best site for hypodermoclysis is the outer middle surface of the thighs. The anterior surfaces of the
thighs, the flanks, and the loose tissues at the sides of the chest below the axillae are also suitable. The injection is into the fatty tissues just beneath the skin. Adequate cleansing of the skin can be accomplished by applying Tincture of Metaphen within a five-inch radius of the proposed site of injecinjection of 0.5 m!. of 1%. In a few moments the fluid: the needle for hypothe tion. A wheal is then raised by intradermal procaine hydrochloride,
dermoclysis can be inserted through the center of the wheal. Introducing needle and infusing As with venipuncture
clysis tubing should be cleared of air before' insertion To guard against inadvertent be introduced either unattached intravascular
of the needle.
injection, the needle should
or attached to a syringe. The technique:
• With thumb and index finger pinch a fold of the skin and hold firmly. • Through the center of the wheal plunge the needle to about threefourths of its length at an angle of about 30 degrees to the skin. • Watch for the flow of blood or (if syringe is attached) aspirate. If none appears, connect the clysis tubing to the needle by means of the adapter. • Place sterile gauze under and over the needle; tape the needle, adapter, and tube securely to the skin. Adjust the pinch clamp and start the flow of liquid. Rate of flow: The rate at which such an infusion can be administered will vary from person to person and must be adjusted accordingly. Ability to absorb fluids is variable, and tissues may become unduly distended and painful if the rate is too fast. The flow should be stopped from time to time in order to gauge the rate of absorption. If an individual's absorption is found to be very slow, a new site (or sites) should be considered. Hyazyme (hyaluronidase for injection, Abbott) is also available for For this Absorption increasing the rate of absorption. and absorption reason, it is used frequently This enzyme accelerates the diffusion
of fluids and drugs injected subcutaneously. as an aid in hypodermoclysis.
may be enhanced considerably, so usual time for this type of infusion can be reduced to one-half or one-third. Hyazyme is supplied as a lyophilized powder in one-milliliter vials, each containing 150 U.S.P. units of hyaluronidase. The powder is reconstituted by addition of 1.0 ml. of sterile water for injection, U.S.P., or sodium chloride injection, U.S.P. (isotonic). This solution is then injected through the wall of the gum rubber insert or is injected directly into the site chosen for hypodermoclysis be determined by the attending immediately preceding the infusion. by subcutaneous infusion will physician according to the patient's The exact solutions to be administered
needs and general condition. Those usually given by this route are isotonic solutions containing some electrolytes. Care should be taken during the administration of hypertonic solutions or of isotonic solutions containing only a sugar, since these may cause pain by drawing fluid from the surrounding tissues. If the patient is salt-deficient, or is in the beginning stage of shock, or has impaired kidney function, fluid may be drawn from the circulating volume, thus, leading to circulatory diffi35 culties. The operator should be alert for signs of unusual swelling or edema in the area of clysis.
FROM THE SYRINGE
FROM THE SYRINGE
Solutions or other liquid preparations may be administered from a syringe by any of several routes, the exact volume depending on the route chosen by the operator or dictated by other factors. Thus, medications or diagnostic materials may commonly be injected intravenously (into the vein), intramuscularly (into a muscle or muscle-mass), subcutaneously (under the skin), or intradermally (into the superficial layer of skin).
Transfer from the Abbott ampoule and from the multi-dose vial
Both the ampoule (for a single dose) and the vial (for multiple doses) are designed specifically for delivering a solution to the syringe. For maximum ease of operation many Abbott sterile ampoules are offered with Color-Break or Gold-Band to eliminate the necessity for filing, sawing, or scoring by the operator. The neck of the ampoule breaks cleanly and evenly with only slight pressure.
From the ampoule
1. Always read the label of the ampoule to be certain it contains the drug
and dosage which were prescribed. Never use the contents of an un-
labeled ampoule. 2. Cleanse the neck of the ampoule with an antiseptic sponge or swab: A. Abbott ampoules with paper labels may be sterilized externally by immersion in alcohol (70 per cent) or in Zephiran (benzalkonium chloride). They should not be immersed in
Metaphen (nitromersol, Abbott), since the adhesive is attacked by alkaline solutions. B. Abbott ampoules labeled with a silk-screen printing process may be immersed in water, alcohol, or other antiseptic solutions. 3. Grasp both ends of the ampoule as shown below and bend the stem until it snaps. No filing, scoring, or sawing is required.
4. Insert the needle deep into the ampoule and aspirate the solution. 5. Holding the syringe vertically with the needle pointed up, expel the air and check the dosage. 6. Proceed with the injection. 7. If the drug is not to be injected immediately, place the empty ampoule on the sterile tray with the full syringe to identify its contents. Use the neck of the ampoule as a cover for the needle.
From the vial
1. Remove the safety seal and dust-cap. 2. Cleanse the top of the vial with antiseptic sponge or applicator. The cleansing solutions for Abbott vials are the same as for the ampoules (described immediately above). 3. Place the plunger of the syringe at the desired volume, insert the needle through the center of the rubber stopper, and force air from the syringe into the vial. 4. Holding the vial upside down, withdraw the desired volume into the syringe and withdraw the needle from the vial. 5. Proceed with the injection. 6. Replace the dust-proof cap on the vial and store for future use. 7. If the injection is not to be given immediately, wrap the syringe and needle in sterile gauze or place in a sterile container, leaving the vial nearby for identification.
From the TWO
A unique container for parenteral solids, the other containing in the Two Compartment
is the Two Compartment (injec-
Vial, a sterile vial with one compartment
containing lyophilized (dried)
the diluent. For instance, Bejectal
table vitamin B complex, Abbott) improved with Vitamin C is offered Vial. Solids and diluent are mixed just prior Vial to the injection by pressing the top (exposed) rubber stopper. The dry solids are stable indefinitely, and the Two Compartment eliminates many steps usually required in reconstituting ing is accomplished internally
How to prepare solution:
by a closed sterile technique.
1. Remove plastic dust-cap
by pushing off with thumb. Press top
of rubber stopper with firm, steady pressure to dislodge rubber plug which separates the two compartments. 2. Shake Two Compartment syringe, pierce stopper desired volume. Vial until all solids have been dissolved. vial. Using needle attached through center to ring. Withdraw 3. Sterilize top of stopper, invert squarely
Into the vein
In contrast to the larger volumes administered by infusion, relatively small volumes of solutions or liquid suspensions are injected into the vein from a syringe. Reasons for this route include the following: 1. An immediate effect is desired, 2. The drug may not be capable of absorption from the gastrointestinal tract or from the tissues, 3. A drug may be too irritating for other parenteral routes, 4. Tests of circulatory function may be desired. The size of the syringe should be in proportion to the volume of solution to be administered. The availability of 2-ml., 5-ml., and 20-ml. syringes usually provides adequate latitude for all routine injections. Ideally a small syringe will be calibrated in both cubic milliliters and minims, and a darkened plunger will aid in the measurement of small doses. The needle should be chosen for the occasion. Hence, when a drug must be administered slowly a 24- or 26-gauge needle can be used advantageously if the vein is easily accessible. However, in most cases a larger needle is generally preferred, such as a 20-gauge needle which is 1 or 1~ inches long. Aseptic techniques should be employed throughout the preparation and injection. The syringe and needle must be properly sterilized before use. A dry syringe and needle are preferred, since some preparations are affected by water or are incompatible with it.
SELECTING AND PREPARING THE SYRINGE AND NEEDLE: PREPARING THE SITE AND PERFORMING THE INJECTION: The general comments on pages 4 to 11 apply here as does the "separate syringe" technique (page 14). To complete the injection, proceed with the following steps:
1. With the needle satisfactorily located in the vein and the tourniquet released, slowly depress the plunger of the syringe. 2. When the contents have been injected, aspirate a small amount of blood to be sure the needle is still in the vein. 3. With one hand, place and hold a small wad of sterile cotton over the site of injection. 4. With the other hand, keep the syringe flush with the skin and slowly withdraw the needle. 5. Instruct the subject to hold the cotton in place by manual pressure for two minutes.
inJectwn. When aspirating in order to deter-
mine whether the needle has entered the vein (described page 15), the operator should also be alert for signs of inadvertent arterial puncture. The presence of bright red blood within the syringe and evidence of pulsation are strong indications that an artery has been entered. If arterial entry is not detected during aspiration, then partial or complete injection of the contents of the syringe may cause arterial spasm and pain down the length of the arm (in the direction of arterial flow). In either event the procedure should be terminated and appropriate measures instituted. Thrombophlebitis. Excessive trauma to the vein (as from multiple punctures), injection of very irritating agents, or injection of relatively high concentrations of certain drugs may cause complications in the vein at or above the site of the injection. A hardening of the vein and pain up the length of the arm (in the direction of venous flow)are signs of this complication. The procedure should be terminated and proper treatment begun. Pain. Certain agents are known to cause pain on injection. Occasionally this pain may be accompanied by venous spasm which will greatly inhibit the injection. If any difficulty is encountered during administration of such material, the procedure should be discontinued. Swelling. Occasionally, despite care, the posterior wall of the vein may be pierced and the contents of the syringe injected into the subcutaneous tissues. Thus, throughout the injection the operator should watch closely for signs of swelling or of tissue irritation. Should these occur, the injection should be stopped at once and suitable measures taken.
Into the muscle
Whenever practicable, the intramuscular route is utilized, since it is more convenient to both the patient and the operator than is the intravenous route. Also, when prolonged action is preferred to immediate, a drug may be injected into the muscle and gradually absorbed by the blood stream. For example, prolonged blood levels of penicillin may be obtained by intramuscular injection of penicillin G procaine. Similarly, the action of heparin may be prolonged considerably by intramuscular injection of a very concentrated aqueous solution. For the operator, intramuscular injections are much easier to administer-no tourniquet, less equipment, a minimum of mechanical maneuvers. The technique is straightforward and remains constant, within limits, from person to person. Nevertheless, precautions are necessary to insure that a blood vessel
has not been entered. The equipment, must be sterile, the medication must be sterile and pyrogen-free, and aseptic techniques should be employed throughout.
SELECTING THE SYRINGE AND NEEDLE:
of a drug are
seldom injected into the muscles, and a 5-ml. syringe is the largest which will be required. Generally a 2-m1. syringe will suffice. The needle should be small, sharp, and strong with a gauge of 20 to 23 and a length not less than 172 inches, preferably about 272 inches. In addition to the standard syringes available, Abbott offers the Abboject syringe, a completely disposable unit containing accepted doses of certain medications. of a standard siderable popularity thus eliminating improper sterilization. Currently offered in this unit are: Abbocillin-DC Erythrocin-I.M. (penicillin G procaine), 600,000 Units, in Abboject Dis(erythromycin, Abbott), 100 mg., in Abboject DisPreparing it for use requires only the attachment Luer hub needle. This type of equipment has gained conbecause it is delivered sterile and is used but once, or the possibility of cross infection, serum reactions,
posable Syringe with Needle, List No. 6310. posable Syringe, List No. 6350. Penicillin G Procaine in Aqueous Suspension, 300,000 Units, in Abboject Disposable Syringe with Needle, List No. 6332.
SELECTING AND PREPARING THE SITE FOR INJECTION:
As with intrainand vastus
venous injections, a variety jection. The gluteal
of sites is available for intramuscular triceps, deltoid, pectoral,
lateralis of the quadriceps femoris are all suitable. However, the gluteal muscles are usually considered to be the site of choice, especially when the medication is irritating administered. or when relatively large volumes are to be a definite psychological Lying prone, the patient advantage does not The overlying skin in the area is thin and easily pierced.
Also, this site offers the operator when the patient is apprehensive. see the approach of the needle. Nevertheless,
one should remember that under the gluteal muscles lie a drug into the gluteal muscles if the 43
the sciatic nerve and the superior gluteal artery. Although the hazards of introducing are real, they can be considerably minimized, if not eliminated,
Figure 19. The gluteal muscle-site of choice for intramuscular injections. Upper outer quadrant lies well away from great sciatic nerve and superior gluteal artery.
Figure 20. Patient should lie relaxedface down, feeUoeing in, arms hanging over sides of table.
operator is cognizant of this fact: the inner angle of the upper outer quadrant (see figure 19, above) is the safest point for injection. This area lies well away from the sciatic nerve and has a good thickness of muscle.
PREPARING THE PATIENT:
Instruct the patient to lie face down on the table. Cleanse the upper outer quadrant with a suitable antiseptic and allow it to dry. If injection is made while the skin is still wet, the antiseptic may be carried into the tissues with the injection, thus leading to irritation.
PERFORMING THE INJECTION:
1. With the left hand, tense the skin by pulling down on the buttock. 2. With the right hand, hold the syringe by the index finger and thumb, steadying it by the second finger of the right hand. 3. By one quick thrust introduce the needle almost perpendicularly to the skin. The depth of insertion varies and depends on the individual's size.For example, an obese patient may require a penetration as deep as 2 or 27i inches, while a child's muscle may be reached at a depth of 72 to 1 inch. In any event, the needle should be advanced only about three-fourths of its length. Thus, should the needle break (usually at the hub), the cannula may be removed without dissection or probing. An experienced operator can usually tell when the needle is in the muscle by "feel," since the muscle will offer more resistance to passage of the needle.
4. Grasp the syringe with the left hand and, using the thumb and index finger of the right hand, draw back on the plunger. If no blood or exudate appears, return the left hand to its former position tensing the skin. (If blood appears in the syringe, the needle is in a vein or artery and should be withdrawn immediately.) 5. Inject slowly. The solution should flow freely without force. 6. Pinch the area of injection with the free hand and withdraw the needle. 7. When rapid absorption is desirable, massage the site vigorously the drug in the muscle at one point. When slow absorption is for about two minutes. This will distribute and prevent an accumulation
indicated, do not massage. Simply sponge the area with an antiseptic. If several injections are to be given at relatively site is close intervals, different sites should be selected for each puncture-
preferably in the gluteal, deltoid, or triceps groups. Whatever chosen, the technique of injection remains almost the same.
ALTERNATIVES TO THE GLUTEAL MUSCLES.
As an alternative
injections, the lateral aspect of the thigh has been suggested as a safe and convenient site.5,6 The muscle mass involved is the vastus lateralis of the quadriceps femoris group. The attitude should be perpendicular of the syringe and needle plane. The injections including to the skin and on a horizontal
procedure is the same as for other intramuscular aspiration. In adults, a needle
inches long is usually suitable, while
a shorter needle should be employed for infants. Gilles7 recommends that infants receive the injection in the distal third of the thigh. The ventrogluteal to dorso-intragluteal site has also been recommended as an alternative injection.s,9,lo For one methods,9 of locating the stands. The anterior iliac spine is taken as a is palpated. In the other method
proper site the patient
reference point and the trochanter
of locating the site the patient is recumbent.
The site is defined with
index and middle fingers, usually of the left hand which rests on the patient's hip. The ventral index finger rests on the iliac, and the middle finger (stretching dorsally) palpates the crest of the ilium. Then the top of this finger presses exactly below the iliac crest. The triangle between the index finger, middle finger and the iliac crest confines the injection site (figure 21). Curtis and Tuckerll believe that this approach will work well for infants. Combes12 recommends the mid anterior thigh (vastus medialis) (figure 45
22) as the preferable site for intramuscular young children.
Into the subcutaneous tissues
When a drug is to be administered subcutaneous intravenously,
in small amounts, the determinant of the
route may be utilized. When drugs are given other than the rate of absorption is an important
intensity and duration of their activity. The speed of absorption, in turn, is dependent on the physiochemical properties of the drug and the local blood supply of the injected Unfortunately, area. Water-soluble drugs are absorbed rapidly; fat-soluble and insoluble drugs, slowly. however, irritating drugs or drugs in heavy vehicles sloughing, or or suspensions so administered abscess formation-and may produce induration, injection. parenterally, drugs in-
are extremely painful to the patient. As a result,
not all medications are suitable for subcutaneous In common with all substances administered jected subcutaneously nique previously parenteral outlined should be employed.
must be sterile. The same exacting aseptic techVariations from other
procedures can be found in the following three basic steps:
1) Selecting the syringe and needle. 2) Selecting and preparing the site for injection. 3) Performing the injection.
SELECTING THE SYRINGE AND NEEDLE.
The volume of a subcutaneous
injection is seldom greater than 2.0 ml. Thus, a 2-ml. syringe, calibrated in minims or fractional 46 milliliters, should usually be employed. The length of the needle should be ~ or ~ inch and the gauge should be 26, although any needle ranging in size from 22- to 26-gauge may be used.
SELECTING AND PREPARING THE SITE FOR INJECTION.
The injection of a drug beneath the surface of the skin is usually made in the loose interstitial tissues of the arm, forearm, thigh, interscapular region, or the buttocks. Edematous tissues, where absorption is poor, should be avoided. The site of entry should be changed when injections are to be made frequently. To prepare the site, simply cleanse skin with an antiseptic solution and allow to dry. PERFORMING THE INJECTION. With the thumb and index finger, pinch up a fold of the skin and hold firmly. Plunge the needle boldly into fold at 45-degree angle to the long axis of the extremity or part. As explained on page 44, the needle should be inserted only about three-fourths of its length. Aspirate. If blood appears in the syringe, select a new site. If there is no show of blood, inject the contents of the syringe. Then withdraw the needle and massage site gently with an antiseptic sponge. DEEP SUBCUTANEOUS INJECTION. The usual sites for subcutaneous injection mentioned above often do not provide the deep administration which is sometimes desirable. For instance, concentrated aqueous solutions of heparin* willproduce a prolonged therapeutic effectwith the least likelihood of local irritation if they are injected into deep subcutaneous tissues. A prolonged effect for as long as twelve hours may be obtained by injection deep into the subcutaneous tissues. Best sites are immediately above and below the iliac crest, in the lower abdominal wall, and, in some patients, in the thigh. Absorption and effect are prompt. There is little or no pain, and local reactions are rare and minor. The patient himself may be taught to make these injections.
Into the skin (Intradermal)
For diagnostic purposes, desensitization, or immunization, a number of substances may be injected into the corium, the more vascular layer of skin just beneath the epidermis. By intradermal administration of certain antigens, the body's response or lack of response to specific allergens can be evaluated and the need for prophylactic therapy indicated. A tuberculin syringe with 26-gauge needle % inch long is usually employed. The usual site of intradermal injection is the anterior (volar) surface of the forearm. TECHNIQUE OF ADMINISTRATION. Holding the forearm with one hand, use the thumb to place the skin on stretch. Holding the syringe between
'Sodium heparin, U.S.P., supplied by Abbott Laboratories as Panheprin; professional literature availabie on request from Abbott Laboratories, North Chicago, illinois.
the thumb and forefinger of the other hand, seat the plunger against the heel of the palm. First, expel the air from the needle by slightly contracting the thumb and forefinger. Then, at an angle to the long axis of the forearm, place the syringe and needle horizontally flat against the skin with the bevel of the needle facing upward. Depress the syringe and needle until there is no more give and advance the syringe and needle until the bevel just disappears into the corium. Contract the hand slowly so that the thenar eminence advances the plunger and the desired amount (usually about 0.1 ml.) of fluid is injected Remove the needle and wipe the site. to raise a wheal.
1. Thrombophlebitis after Infusions, Lancet, 2:541, September 10, 1955. 2. Lundy, J. S., An Excellent Method for Obtaining Speedy Vasodilation for Venipuncture, Proc. Staff Meet. Mayo Clin., 34:550, November 11, 1959. 3. Lundy, J. S., Suggestions to Facilitate Venipuncture in Blood Transfusion, Intravenous Therapy and Intravenous Anesthesia, Proc. Staff Meet. Mayo Clinic, 12:122, February 24, 1937. 4. Lundy, J. S., Remarks at 93rd Annual Session of Minnesota Medical Association, St. Paul, Minnesota, May 1946. 5. Levi, W. M., Jr., and Ferrari, B. E., The Preferred Site of Intramuscular Injection, J. South Carolina M. A., 54:44, February 1958. 6. Augustine, R. W., Landmesser, W. E., Jr., Parker, M. V., and Vaden, O. L., Site for Intramuscular Injection, U.S. Armed Forces M. J., 3:1787, December 1952. 7. Gilles, F. H. and French, J. H., Postinjection Sciatic Nerve Palsies in Infants and Children, J. Pediat., 58:195, February 1961. 8. von Hochstetter, A., tiber Probleme und Technik der Intraglutaalen Injecktion, Teil I, Schweiz. med. Wchnschr., 85:1138, November 19, 1955. 9. von Hochstetter, A., tiber Probleme und Technik der Intraglutaalen Injecktion, Teil II, Schweiz. med. Wchnschr., 86:69, January 21, 1956. 10. Schmidt, R., Beitrag zur Intramuscularen Inj ecktion : Anatomische Untersuchung und Klinische Prufung der Neuen Intraglutaalen Injecktionstechnik nach von Hochstetter, Helvetica med. Acta, 24:561, Fasc. 5, November 1957. 11. Curtiss, P. H., Jr., and Tucker, H. J., Sciatic Palsy in Premature Infants, J.A.M.A., 174:1586, November 19,1960. 12. Combes, M. A., Clark, W. K., Gregory, C. F., and James, J. A., Sciatic Nerve Injury in Infants: Recognition and Prevention of Impairment Resulting from Intragluteal Injections, J.A.M.A., 173:1336, July 23, 1960.
This Little Booklet on the parenteral administration of medicines probably has very little useful information in it for anyone in the United States; it is more of a History of Medicine Document for two reasons. First, it was a “detail” pamphlet provided by a manufacture of medical supplies of the old type that had some educational information in it. It demonstrated how to use the item while pushing there sale. Booklets such as this were fairly common in the 1960’s and early 70’s, were readily provided to students, interns, nurses, doctor’s in the hope that the use of this particular product would catch on. They were really kind of ambitious and expensive, which really doomed them. They did provide useful information. Second, here in the United States we no longer use hung bottles, bags having replaced them as being easier to use, easier to dispose of. Nor do we usually use Drip Chambers to control the rate of infusion, but usually use electronic metering devices. Yes I am sure there are still hospitals even here in the U.S. that cannot afford such. If one should find oneself in a third world country or if the world should degenerate to such a point, It might be good to know this material, either as a practitioner or to know if the job is being done correctly. Such materials are still used in a good part of the world at large.
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