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To Aspirate or Not to Aspirate That is the Question

An Integrative Review of the Evidence
Cecelia L. Crawford, RN, MSN SCAL Patient Care Services SCAL Nursing Research Program

PresentationHERE title Joyce A. Johnson, PhD, RN-BC SUB TITLE
Southern California Permanente Medical Group
STTI International Nursing Research Congress Vancouver, July 2009

Evidence Reviews
Integrative Review (18):
• A review via a systematic approach that uses a detailed search strategy to find relevant evidence to answer a targeted clinical question • Evidence can come from RCTs, observational studies, qualitative research, clinical experts, and other types of evidence • Does not use summary statistics

Triggers Questions by nurse educators: “Why am I still teaching blood aspiration during medication injection in nursing orientation?” “I was taught to aspirate in nursing school. Do I still need to do this?” Project Kirksville College of Osteopathic Medicine .

Integrative Review Purpose & Aim To determine the quality of the evidence for aspiration of blood during subcutaneous (SC) and intramuscular (IM) medication administration Ultimate aim of developing global best practice standards and guidelines for the ambulatory care setting .

12) .9.11.10.History & Facts about Aspiration The practice of aspiration of blood during injections is a tradition that has been taught in nursing for the past 40 years(9) The Center for Nursing History Collection (16) This precautionary technique is performed to ensure that a low flow blood vessel or artery has not been penetrated(2.

8.11) No studies confirm or reject current aspiration techniques & no data currently exists to document the necessity for aspiration(1.5. and arbitrary choice for decades and is not based on scientific evidence(1.3.11) .8. assumption.The Science of Blood Aspiration The practice of aspiration has been added and eliminated based on anecdote.

“intramuscular”. “subcutaneous”. in the ambulatory care setting A 2000-2008 review of the research evidence via electronic databases used the search terms of “aspiration”.Integrative Review Search Strategy Examined the aspiration technique for SC and IM injections. primarily involving vaccine and immunization administration. and “injections” .

Synthesis of the Evidence .

Synthesis of the Evidence Adapted from: Canadian Medical Association & Centre for Evidence-Based Medicine (2001) 17 .

the strength of the research evidence ranged from insufficient to fair Final grade for body of the evidence: Insufficient .Strength of the Evidence Using an internal KP quantitative grading schema.

immunizations. insulin and penicillin .Strength of the Evidence Review limitations – relatively narrow focus of administered medications. mainly vaccines.

Linda Diggle (3) Immunisation Nurse Specialist Public Health l. States of Jersey.Clinical Expert Critique  Internationally known expert in injection procedures & technique  Critiqued integrative review findings & recommendations  Her clinical judgment and expert opinion is validated by the evidence captured in this review .

14) There is no reported evidence that aspiration with or without blood return (8.11) • confirms needle placement • eliminates the possibility of an intramuscular injection into a non-subcutaneous blood vessel .Results: Key Summary of the Evidence Aspiration may not be a reliable indicator of correct needle placement(11) Aspiration during subcutaneous injection is not necessary(

10.6.13) .9.Results: Key Summary of the Evidence Fears of adverse reactions following nonaspiration of intramuscular injections mainly center on intraarterial injection of penicillin and other large molecule medications (4.

Results: Key Summary of the Evidence Most nurses do not follow slow aspiration guidelines and perform the procedure too quickly for it to be effective(5) Ten Second Rule:  Slow aspiration (5-10 seconds)  Slow injection (5-10 seconds)  Slow withdrawal. no rubbing How many nurses do this? .

com/injbygun.Results: Key Summary of the Evidence Use of jet injection for delivery of vaccines and immunizations does not involve the aspiration technique(1) http://501medmen.html .bizhosting.

such as penicillin(4.8) Aspiration is not indicated for IM injections of vaccines and immunizations(2.13) .10. immunizations and insulin(2.5) Aspiration may be indicated for IM injections of large molecule medications.Recommendations for Consideration Aspiration is not indicated for SC injections of vaccines.

11.13.15) . and the medication being administered in order to decrease the risk of incorrect needle placement(3. injection techniques must be individualized to the patient.14. the equipment.Recommendations for Consideration Until a standard can be determined.

which receives the majority of vaccines and immunizations(5) Elimination of the aspiration technique has the potential to(2.14):  Reduce injection. duration time & decrease injection pain  Increase medication injection compliance .Significance to Patient Care These aspects are particularly important in the pediatric population.5.

15) Organizations which state aspiration is not necessary for immunizations & vaccines are(1.15):       Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) Department of Health Services (DHS) American Academy of Family Physicians (AAFP) U.Significance to Patient Care Although the practice of aspiration is advocated by some experts.8. the procedure is not required because no large blood vessels exist at the recommended injection sites(3. Department of Health (DoH) World Health Organization (WHO) .K.3.

it is highly unlikely a randomized control trial will answer this question.Further Research The primary reliance on conflicting best practice guidelines reflects the need for more research in this deceptively routine patient care procedure However. due to patient safety issues and the extremely large sample size required to detect this rare major adverse event(5) .

Final Steps: Finish Line! Ultimate Goals KP Ambulatory Clinical Practice Committee Inclusion in KP Clinical Practice Guidelines  Incorporate changes throughout KP SCAL Region Ambulatory Care Disseminate information to ambulatory practice leaders & educators .

RN. MN for their support of this project . CNAA-BC Terry Bream. DNSc. RN.Acknowledgements We wish to thank Anna Omery.

Johnson@kp. MSN Project Manager III.Crawford@kp.For More Information… Cecelia .org Joyce A. Education and Research Southern California Permanente Medical Group 626-564-3254 Joyce.L. RN. Crawford. Johnson. PhD. RN-BC Regional Director. Translational Research KP SCAL Nursing Research Program 626-405-5802 Cecelia.

Questions? .

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