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

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(2,9,10,11,12)

The Science of Blood Aspiration

The practice of aspiration has been added and eliminated based on anecdote, assumption, and arbitrary choice for decades and is not based on scientific evidence(1,3,8,11) No studies confirm or reject current aspiration techniques & no data currently exists to document the necessity for aspiration(1,5,8,11)

Integrative Review Search Strategy

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

Synthesis of the Evidence

Synthesis of the Evidence

Adapted from: Canadian Medical Association & Centre for Evidence-Based Medicine (2001)

17

Strength of the Evidence

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

Strength of the Evidence

Review limitations relatively narrow focus of administered medications, mainly vaccines, immunizations, insulin and penicillin

Clinical Expert Critique

Dr. Linda Diggle (3)
Immunisation Nurse Specialist Public Health Dept, States of Jersey, l.diggle@health.gov.je

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

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(2,7,8,11,14) 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

Fears of adverse reactions following nonaspiration of intramuscular injections mainly center on intraarterial injection of penicillin and other large molecule medications
(4,6,9,10,13)

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?

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.bizhosting.com/injbygun.html

Recommendations for Consideration

Aspiration is not indicated for SC injections of vaccines, immunizations and insulin(2,8) Aspiration is not indicated for IM injections of vaccines and immunizations(2,5)
Aspiration may be indicated for IM injections of large molecule medications, such as penicillin(4,10,13)

Recommendations for Consideration

Until a standard can be determined, injection techniques must be individualized to the patient, the equipment, and the medication being administered in order to decrease the risk of incorrect needle placement(3,11,13,14,15)

Significance to Patient Care

These aspects are particularly important in the pediatric population, which receives the majority of vaccines and immunizations(5) Elimination of the aspiration technique has the potential to(2,5,14):
Reduce injection, duration time & decrease injection pain Increase medication injection compliance

Significance to Patient Care

Although the practice of aspiration is advocated by some experts, the procedure is not required because no large blood vessels exist at the recommended injection sites(3,8,15) Organizations which state aspiration is not necessary for immunizations & vaccines are(1,3,15):
Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) Department of Health Services (DHS) American Academy of Family Physicians (AAFP) U.K. Department of Health (DoH) World Health Organization (WHO)

Further Research
The primary reliance on conflicting best practice guidelines reflects the need for more research in this deceptively routine patient care procedure However, it is highly unlikely a randomized control trial will answer this question, 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

Acknowledgements
We wish to thank
Anna Omery, RN, DNSc, CNAA-BC Terry Bream, RN, MN

for their support of this project

For More Information

Cecelia L. Crawford, RN, MSN
Project Manager III, Translational Research KP SCAL Nursing Research Program 626-405-5802 Cecelia.L.Crawford@kp.org

Joyce A. Johnson, PhD, RN-BC

Regional Director, Education and Research Southern California Permanente Medical Group 626-564-3254 Joyce.A.Johnson@kp.org

Questions?

References
1. Atkinson, W. L., Pickering, L. K., Schwartz, B., Weniger, B. G., Iskander, J. K., & Watson, J. C. (2002). General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). Morbidity and Mortality Weekly Report, 51, RR2. 1-33. 2. Chiodini, J. (2001). Best practice in vaccine administration. Nursing Standard, 16(7), 35-38. 3. Diggle, L. (2007). Injection technique for immunization. Practice Nurse, 33(1), 34-37. 4. Gammel, J. A. (1927). Arterial embolism: an unusual complication following the intramuscular administration of bismuth. Journal of the American Medical Association, 88, 998-1000. 5. Ipp, M., Taddio, A., Sam, J., Goldbach, M., & Parkin, P. C. (2007). Vaccine related pain: randomized controlled trial of two injection technique Archives of Disease in Childhood,92,1105-1108.

References
6. Li, J.T., Lockey, R. F., Bernstein, I. L., Portnoy, J. M., & Nicklas, R. A. (2003). Allergen immunotherapy: A practice parameter. Annuals of Allergy, Asthma, & Immunology, 1-40. 7. Livermore, P. (2003). Teaching home administration of sub-cutaneous methotrexate. Paediatric Nursing, 15(3), 28-32. 8. Middleton, D. B., Zimmerman, R. K., & Mitchell, K. B. (2003). Vaccine schedules and procedures, 2003. The Journal of Family Practice, 52(1), S36-S46. 9. Nicoli, L. H., & Hesby, A. (2002). Intramuscular injection: An integrative research review and guidelines for evidence-based practice. Applied Nursing Research, 16(2), 149-162. 10. Ozel, A., Yavuz, H., & Erkul, I. (1995). Gangrene after penicillin injection: A case report. The Turkish Journal of Pediatrics, 37(1), 567-71. 11. Peragallo-Dittko, V. (1995). Aspiration of the subcutaneous insulin injection: Clinical evaluation of needle size and amount of subcutaneous fat. The Diabetes Educator, 21(4), 291-296.

References
12. Roger, M. A., & King, L. (2000). Drawing up and administering intramuscular injections: A review of the literature. Journal of Advanced Nursing, 31(3), 574582. 13. Talbert, J. L., Haslam, R. H. & Haller, J. A. (1967). Gangrene of the foot following intramuscular injection in the lateral thigh: A case report with recommendations for prevention. The Journal of Pediatrics, 70(1), 110-114. 14. Workman, B. (1999). Safe injection techniques. Nursing Standard, 13 (39), 47-53. 15. World Health Organization (2004). Immunization in Practice, Module 6: Holding an immunization session. Immunization in Practice: A practical resource guide for health workers 2004 update, 1-29. 16. Center for Nursing History at Misericordia University: http://www.misericordia.edu 17. Levels of Evidence, Canadian Medical Association & Centre for Evidence-Based Medicine (2001). Available at: http://www.cebm.net/index 18. Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Lippincott, Williams & Wilkins