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Cecelia L. Crawford, RN, MSN
SCAL Patient Care Services
SCAL Nursing Research Program
Joyce A. Johnson, PhD, RN-BC
Southern California Permanente Medical Group
STTI International Nursing Research Congress
Vancouver, July 2009
To Aspirate or Not to
Aspirate
That is the Question: An Integrative Review of
the Evidence
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 ProjectQuestions 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?”
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)
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 Center for Nursing History Collection (16)
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 fairFinal 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, [email protected]
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 non-
aspiration of
intramuscular injections
mainly center on intra-
arterial 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
Elimination of the aspiration technique has the potential to(2,5,14):
Reduce injection, duration time & decrease injection pain
Increase medication injection compliance
These aspects are
particularly important in the
pediatric population, which
receives the majority of
vaccines and
immunizations(5)
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
Anna Omery, RN, DNSc,
CNAA-BC
Terry Bream, RN, MN
for their support of this project
We wish to thank
For More Information…
Cecelia L. Crawford, RN, MSNProject Manager III, Translational Research
KP SCAL Nursing Research Program
626-405-5802
Joyce A. Johnson, PhD, RN-BCRegional Director, Education and Research
Southern California Permanente Medical Group
626-564-3254
Questions?
References1. 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.
References6. 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.
References12. Roger, M. A., & King, L. (2000). Drawing up and administering intramuscular
injections: A review of the literature. Journal of Advanced Nursing, 31(3), 574-582.
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
