Overview
A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin.
In this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the muscle. Medication given this way is usually absorbed more slowly than if injected into a vein, sometimes over a period of 24 hours.
This type of injection is used when other methods of administration might be less effective. For example, some medications can’t be given by mouth because acid and enzymes in the stomach would destroy them.
Other methods, like intravenous injection, can be difficult and costly. For small amounts of delicate drugs, a subcutaneous injection can be a useful, safe, and convenient method of getting a medication into your body.
Medications administered by subcutaneous injection include drugs that can be given in small volumes (usually less than 1 mL but up to 2 mL is safe). Insulin and some hormones are commonly administered as subcutaneous injections.
Other drugs that need to be given very quickly can also be administered via subcutaneous injection. Epinephrine comes in an automated injector form, called an EpiPen, that’s used to quickly treat severe allergic reactions. While it’s intended to be given intramuscularly, epinephrine will also work if given subcutaneously.
Some pain medications like morphine and hydromorphone (Dilaudid) can be given this way as well. Drugs that prevent nausea and vomiting like metoclopramide (Reglan) or dexamethasone (DexPak) can also be given via subcutaneous injection.
Some vaccines and allergy shots are administered as a subcutaneous injection. Many other vaccines are administered as an intramuscular injection — into muscle tissue rather than under the skin.
The location of injection is important for subcutaneous injections. The drug needs to be injected into the fatty tissue just below the skin. Some areas of the body have a more easily accessible layer of tissue, where a needle injected under the skin will not hit muscle, bone, or blood vessels.
The most common injection sites are:
- Abdomen: at or under the level of the belly button, about two inches away from the navel
- Arm: back or side of the upper arm
- Thigh: front of the thigh
Equipment used for subcutaneous injections includes:
- Medication: Vials of liquid medication can be single-use or multiuse. Vials can also be filled with a powder to which liquid needs to be added.
- Syringes: The needles are short, at 5/8 inches long. The thickness of the needle is usually 25 or 27 gauge. There may be other options for doses more than 1 mL or for children or people with visual impairments.
- Auto-injector pen: Some medications are available in a “pen” with a short single-use needle screwed onto the end of a pen-shaped, multiuse vial. The amount of medication needed is then dialed in at the end. As mentioned earlier, emergency medications like epinephrine can also come in this form.
1. Wash your hands. Wash your hands with soap and warm water to prevent potential infection. Be sure to thoroughly scrub between fingers, on the backs of hands, and under fingernails. The Centers for Disease Control and Prevention (CDC) recommends lathering for 20 seconds — the time it takes to sing “Happy Birthday” twice.
2. Gather supplies. Assemble the following supplies:
- needle and syringe with medication or auto-injector pen
- alcohol pads
- gauze
- puncture-resistant container to discard the used needles and syringe (typically a red, plastic “sharp’s container”)
- bandages
3. Clean and inspect the injection site. Before injecting medication, inspect your skin to make sure there’s no bruising, burns, swelling, hardness, or irritation in the area. Alternate injection sites to prevent damage to an area with repeated injections. Then you should clean the skin with an alcohol swab. Let the alcohol dry thoroughly before doing the injection.
4. Prepare the syringe with medication. Before withdrawing medication from a vial and injecting yourself or someone else, make sure you’re using the correct medication, at the correct dose, at the correct time, and in the right manner. Use a new needle and syringe with every injection.
Preparing a syringe:
Remove the cap from the vial. If the vial is multidose, make a note about when the vial was first opened. The rubber stopper should be cleaned with an alcohol swab.
Draw air into the syringe. Draw back the plunger to fill the syringe with air up to the dose that you’ll be injecting. This is done because the vial is a vacuum, and you need to add an equal amount of air to regulate the pressure. This makes it easier to draw the medication into the syringe. Don’t worry, though — if you forget this step, you can still get the medication out of the vial.
Insert air into the vial. Remove the cap from the needle and push the needle through the rubber stopper at the top of the vial. Inject all the air into the vial. Be careful to not touch the needle to keep it clean.
Withdraw the medication. Turn the vial and syringe upside down so the needle points upward. Then pull back on the plunger to withdraw the correct amount of medication.
Remove any air bubbles. Tap the syringe to push any bubbles to the top and gently depress the plunger to push the air bubbles out.
Preparing an auto-injector:
- If you’re using a pen delivery system, attach the needle to the pen.
- The first time you use the pen, you’ll need to prime it to push out extra air in the delivery system.
- Dial a small dose (usually 2 units or 0.02 mL, or as indicated by the package instructions) and push the button to expel the primer.
- Dial the correct dose and prepare for your injection.
5. Inject the medication.
Pinch your skin. Take a big pinch of skin between your thumb and index finger and hold it. (Your thumb and forefinger should be about an inch and a half apart.) This pulls the fatty tissue away from the muscle and makes the injection easier.
Inject the needle. Inject the needle into the pinched skin at a 90-degree angle. You should do this quickly, but without great force. If you have very little fat on your body, you may need to inject the needle at a 45-degree angle to the skin.
Insert the medication. Slowly push the plunger to inject the medication. You should inject the entire amount of medication.
Withdraw the needle. Let go of the pinched skin and withdraw the needle. Discard the used needle in a puncture-resistant sharp’s container.
Apply pressure to the site. Use gauze to apply light pressure to the injection site. If there’s any bleeding, it should be very minor. You may notice a little bruising later. This is common and nothing to be concerned about.
If you’ll be doing this type of injection for more than one dose or for multiple days, you’ll need to rotate the injection sites. This means that you shouldn’t inject medicine into the same spot twice in a row.
For example, if you injected medicine into your left thigh this morning, use your right thigh this afternoon. Using the same injection site over and over again can cause discomfort and even tissue damage.
As with any injection procedure, infection at the site of injection is a possibility. Signs of infection at the injection site include:
- severe pain
- redness
- swelling
- warmth or drainage
These symptoms should be reported to your physician immediately.
Intramuscular injection (IM) is installing medications into the depth of specifically selected muscles. The bulky muscles have good vascularity, and therefore the injected drug quickly reaches the systemic circulation and thereafter into the specific region of action, bypassing the first-pass metabolism. It is one of the most common medical procedures to be performed annually. This activity outlines and highlights the role of the interprofessional team in improving care for patients who undergo an intramuscular injection. This activity also summarizes the anatomic landmarks, safety precautionary checklists, the recommended procedural steps, and the complications to be aware of following the procedure.
Objectives:
Identify the safe anatomical landmarks for intramuscular injection.
Describe the technique of intramuscular injections.
Summarize the potential complications of intramuscular injection.
Review interprofessional team strategies for improving care coordination and communication to advance intramuscular injection and improve outcomes.
Intramuscular injection (IM) is installing medications into the depth of specifically selected muscles.[1] The bulky muscles have good vascularity, and therefore the injected drug quickly reaches the systemic circulation and thereafter into the specific region of action, bypassing the first-pass metabolism.[2] It is one of the most common medical procedures to be performed annually.[3] However, there is still a lack of adherence to recommended guidelines and an algorithm for giving IM among health professionals worldwide.[2]
Drugs may be given intramuscularly both for prophylactic (around 5% for immunization) as well as curative purposes (accounting for more than 95% of IM injections).[2]
The most common medications given by IM route include:
Antibiotics- penicillin G benzathine penicillin, streptomycin
Biologicals- immunoglobins, vaccines, and toxoids
Hormonal agents- testosterone, medroxyprogesterone[2]
Any nonirritant and soluble drugs may be given IM during an emergency scenario.
Anatomical Landmarks
There are specific landmarks to be considered while giving IM injections to avoid any neurovascular complications. The specific landmarks for the most commonly used sites are discussed below.
Dorsogluteal Region
5 to 7.5 cm below the iliac crest
Upper outer quadrant within the buttocks[4]
Ventrogluteal Region
The heel of the opposing hand is placed in the greater trochanter, the index finger in the anterior superior iliac spine, and the middle finger below the iliac crest - the drug is injected into the triangle formed by the index, middle finger, and the iliac crest[4]
Deltoid
2.5 to 5 cm below the acromion process[1]
Vastus Lateralis
The middle third of the line joining the greater trochanter of the femur and the lateral femoral condyle of the knee[5]
IM for therapeutic purposes is indicated for the following patients:
Noncompliant
Uncooperative
Reluctant
Unable to receive drugs through other common routes
Do not tolerate oral medications[2]
Contraindications
Active infection, cellulitis, or dermatitis at the site of administration.
Known allergy or hypersensitivity to the drug.
Acute myocardial infarction- the release of muscle enzymes complicate the management strategy.
Hypovolemic shock - the drug's absorption may be hampered due to compromised vascularity of the muscle.
Associated muscular atrophy - leads to delayed drug absorption and increases the risk of neurovascular complications.
Equipment
An appropriately sized syringe with a correct needle length;
For infants, vastus lateralis, 22 and 25 mm during ‘bunching,’ 16-mm needle while stretching the skin
For toddlers and older children, deltoid, or VL, is preferred, 25mm to 38.[6][7][8]
Alcohol-based antiseptic solution
The correct drug in an appropriate dose
The safe needle and waste disposal unit
Personnel
A trained nurse, pharmacist, or a paramedic
Evaluate the Need for IM Injection [2]
Out of 12 billion injections administered on the global front annually, 50% of them have been found to be administered by an inadequately trained staff. Furthermore,75% of them are being injected unnecessarily.[9]
Review and Confirmation from the “Medication Administration Record” [2]
Comply with the “Rights of Medication Administration”
Right patient
Right drug
Right dose
Right site
Counseling the Patient
Consent
Choose an Appropriate Site for Injection
Infants-vastus lateralis
Children-vastus lateralis and deltoid
Adults-ventrogluteal and deltoid[2]
Sequential Method of IM Injection
Thoroughly clean the hands and wear gloves.
70% isopropyl swab for 30 seconds and allow the skin to dry.[10]
Use of filter needle and change the needle prior to injection under aseptic precautions.
To prevent bent or dulling of the needle due to coring by the rubber, insert the needle in the bevel up fashion.
When withdrawing the injectate, the container should be held down and avoid withdrawing the last drops.
If medication drips on the needle, wipe it off with a sterile gauze pad.
Drawing up an air bubble is not recommended.
The 'z-track' technique is recommended.[2]
Insert the needle at an angle of 90 degrees.[11]
Quick darting movement while inserting the needle.
Insure intramuscular positioning of the needle via confirming restricted side-to-side movement of the needle as opposed to when the needle is in the subcutaneous plane.
Aspirate for at least 5 to 10 seconds during dorsogluteal injections prior to injecting the medication.
Slow injection (10 seconds per milliliter) allows stretching of the muscle fibers for retention of the drug, which minimizes the risk of leakage along the needle track.
Wait for 10 seconds to allow the drug to diffuse within the muscle bulk.
Withdraw the needle with a smooth and steady movement.
‘Scoop method’ of replacing the needle cap to prevent inadvertent prick injuries.
Safe disposal of the needles and other wastes.[2][12]
Assessment of the injection site for probable early and late complications.[2][1][13]
Common complications:
Persistent pain at the site of injection
Muscle fibrosis and contracture
Abscess at the injection site
Gangrene
Nerve injury -the sciatic nerve in gluteal injection, the femoral nerve in vastus lateralis injection, the superior gluteal nerve in dorsogluteal injection, the femoral nerve in vastus lateralis injection, radial nerve in deltoid injection
Skin slough
Periostitis, osteomyelitis
Transmission of HIV, hepatitis virus
Inadvertent injection of glass particles while using glass vials and ampoules.
Pain
Pain is one of the common complications of intramuscular injection.
Effective interventions to relieve pain include:
Buzzy was more effective than ShotBlocker.[14][15]
Topical eutectic mixture of local anesthetics (EMLA).[19][20]
Manual pressure, rhythmic tapping, acupressure.[22]
Virtual reality glasses, distraction cards, optical illusion pictures.[23][24]
Ventrogluteal site compared to the dorsogluteal site.[25]
Internally rotated foot and Z-track techniques.[26]
A slow rate of injection at 10 s/cc.[27]
Performing a rapid intramuscular injection without aspiration.[28]
Methods found not effective in relieving pain:
Vapocoolant, ice packs in pediatric.[29]
Cold needle technique.
Warming of the injectate[30]
The simple step of asking the patient to cough vigorously immediately prior to injection also helps in reducing the pain associated with the procedure. The transmission of the cough impulse is faster than that of the pain impulse traveling through the slow conducting nerve fibers; thereby, it helps in minimizing the impact of the pain threshold perceived by the brain. A systematic review has shown that gender is the only major variable influencing pain during intramuscular injection.[31]
Neuropathy
The incidence of injection-related neuropathy observed during a national vaccination campaign in Pakistan was 7.1 per 1,000,00.[32] The ventrogluteal region has a better safety profile than the dorsogluteal region.[9][33][34]
Mechanisms governing nerve injury:
Direct needle injury
Compression from external hematoma
Ischaemia
Variables governing the risk of injury include:
Anatomical site of injection
The length of the needle
The angle of injection
Positioning of the patient during injection and
The expertise of the health personnel[9]
The sciatic nerve, particularly its peroneal division, is the most common nerve injury, with an intrafascicular pattern the most common subtype. Dorsogluteal injections account for a majority of the same. Smaller gluteal muscle volume to sciatic nerve size ratio is a risk variable governing the same. Nearly 90% of patients with sciatic nerve injury are preset with an immediate foot drop. Magnetic resonance neurography shows increased signal intensity and neuroma formation. Electromyography shows signs of acute denervation as well as chronic denervation with reinnervation.[9]
Sunderland classification and treatment algorithm:
First degree showing reversible conduction block wherein conservative management will suffice,
Second-degree showing Wallerian degeneration with reactive fibrosis. They often show slow and incomplete recovery, and therefore neurolysis is often indicated, and
Third-degree comprises necrosis and fibrosis, and the chances of recovery are dismal[9]
Surgical exploration is recommended only for cohorts with incapacitating or complete deficits without recovery, even at 3 to 6 months. Early surgical intervention prevents fibrosis. If an action potential is observed beyond the lesion, only neurolysis is advised; otherwise, suture or graft repair is advocated.[9]
Radial nerve palsy, most occurring above the radial groove, is the second most common form of traumatic injection neuropathy.[10][35]
Safe Landmarks
The intersection between the anteroposterior axillary lines and the perpendicular line from the mid-acromion point is safe for IM in the deltoid.[36] The safest anatomical point is approximately 7 to 13 cm below the mid-acromion, midway between the acromion and the deltoid tuberosity. The middle of the vastus lateralis is considered safe for injection in the vastus lateralis.[5]
Advantages
Rapid and uniform absorption of the drug, especially the aqueous solutions
Rapid onset of the action compared to that of the oral and the subcutaneous routes
IM injection bypasses the first-pass metabolism of the drug
It also avoids the gastric factors governing drug absorption
Has efficacy and potency comparable to that of the intravenous drug delivery system
Highly effective for emergency scenarios such as acute psychosis and status epilepticus
Depot injections allow slow, sustained, and prolonged drug action
A large volume of the drug can be administered compared to the subcutaneous route
Disadvantages
An expert and a trained person are necessary for administrating the drug by IM route
The absorption of the drug is determined by the bulk of the muscle and its vascularity
The onset and duration of the action of the drug are not adjustable
In case of inadvertent scenarios such as anaphylaxis or neurovascular injuries, additional intravenous (IV) routes for emergency drug administration need to be secured
IM injection at the appropriate landmarks may be difficult in a child as well as in patients requiring physical restrains
Inadvertent injection within the subcutaneous plane can lead to delayed action of the drug
Painful procedure
Suspensions, as well as oily drugs, cannot be administered
This can lead to anxiety in the patient, especially among children
Self-administration of the drug can be difficult
The precipitation of the drug following faster absorption of the solvent may lead to delayed or prolonged action of the drug
Unintended prolonged sequelae following delayed release from the muscular compartment
Need for temporary restraint of the patients, especially in crying children
The strict adherence to recommended guidelines and procedural algorithms for IM injections is of paramount importance in assuring effective pharmacokinetics and the pharmacodynamics of the drugs.[7]
Thorough knowledge of the specific anatomical landmarks helps minimize the neurovascular complications that harbinger the IM procedures.
The strict adherence to aseptic precautionary measures and safe disposal of the used equipment helps minimize the transmission of blood-borne infections.
The ventrogluteal site is considered the safest for IM injection due to the thin plane of subcutaneous tissues and the relatively thick bulk of the gluteus medius.[33]
Issues of True IM Injections
True intramuscular injections are observed only in 32 to 52%, with the incidence even falling to 8% among females.[37] Female sex, obesity, subcutaneous fat thickness, and injection site play significant roles in governing the same.[4][38][39][40] Ultrasound guidance and proper needle length are key factors in ensuring true IM injections among patients with increased body mass index[BMI].[41] However, there is still ongoing debate over this point.[42]
The Practice of Aspiration Prior to Drug Administration
Though nurses continue practicing aspirations, most do it for a short duration than the recommended time of 5 to 10 seconds.[6][7][8] Blood aspiration is observed mainly in the dorsal gluteal (15%) and deltoid (12%) injections.[43] The World Health Organization and Centers for Disease Control and Prevention do not recommend it. Aspiration is unnecessary and is now reserved only for dorsogluteal site injections.[7]
Use of Filter Needles
The syringe filters significantly minimize the risk of glass particle contamination.[44] However, economic constraints, time consumption, and workforce shortages are significant hindrances to its routine practice.[45] The risk increases with larger bore, unfiltered needles (safe with 23G).[46] Vial breakage by neck wrapping with a cotton ball from an outward direction results in low glass particles than the entire ampoule neck wrapping with a gauze pad from an inward direction method.[45]
Some of the current nursing practices pertaining to IM injections seem to evolve more like a tradition passing from one generation to the next and based upon Schön’s and Benner's learning concepts.[2][47] Evidence-based nursing practice is pivotal in ensuring patient safety, and regular updates, monitoring, and intervention mapping strategies may help improve practitioners' adherence to clinical recommendations.[6][7][8][48]
Review Questions
IM Injection, Buttocks, Intramuscular. Contributed by Steve Bhimji, MS, MD, PhD
1.
Shaw H. Intramuscular injection. Nurs Stand. 2015 Oct 07;30(6):61-2. [PubMed: 26443178]
2.Nicoll LH, Hesby A. Intramuscular injection: an integrative research review and guideline for evidence-based practice. Appl Nurs Res. 2002 Aug;15(3):149-62. [PubMed: 12173166]
3.Dincer B, Yildirim D. The effect of vibration stimulation on intramuscular injection pain and patient satisfaction: Single-blind, randomised controlled study. J Clin Nurs. 2021 Jun;30(11-12):1615-1622. [PubMed: 33590594]
4.Soliman E, Ranjan S, Xu T, Gee C, Harker A, Barrera A, Geddes J. A narrative review of the success of intramuscular gluteal injections and its impact in psychiatry. Biodes Manuf. 2018;1(3):161-170. [PMC free article: PMC6267269] [PubMed: 30546922]
5.Nakajima Y, Fujii T, Mukai K, Ishida A, Kato M, Takahashi M, Tsuda M, Hashiba N, Mori N, Yamanaka A, Ozaki N, Nakatani T. Anatomically safe sites for intramuscular injections: a cross-sectional study on young adults and cadavers with a focus on the thigh. Hum Vaccin Immunother. 2020;16(1):189-196. [PMC free article: PMC7012163] [PubMed: 31403356]
6.Rishovd A. Pediatric intramuscular injections: guidelines for best practice. MCN Am J Matern Child Nurs. 2014 Mar-Apr;39(2):107-12; quiz 113-4. [PubMed: 24201242]
7.Sisson H. Aspirating during the intramuscular injection procedure: a systematic literature review. J Clin Nurs. 2015 Sep;24(17-18):2368-75. [PubMed: 25871949]
8.Sepah Y, Samad L, Altaf A, Halim MS, Rajagopalan N, Javed Khan A. Aspiration in injections: should we continue or abandon the practice? F1000Res. 2014;3:157. [PMC free article: PMC5333604] [PubMed: 28344770]
9.Jung Kim H, Hyun Park S. Sciatic nerve injection injury. J Int Med Res. 2014 Aug;42(4):887-97. [PubMed: 24920643]
10.Cook IF. Best vaccination practice and medically attended injection site events following deltoid intramuscular injection. Hum Vaccin Immunother. 2015;11(5):1184-91. [PMC free article: PMC4514326] [PubMed: 25868476]
11.Warren BL. Intramuscular injection angle: evidence for practice? Nurs Prax N Z. 2002 Jul;18(2):42-51. [PubMed: 12238797]
12.Al Awaidy S, Bawikar S, Duclos P. Safe injection practices in a primary health care setting in Oman. East Mediterr Health J. 2006;12 Suppl 2:S207-16. [PubMed: 17361692]
13.Rodger MA, King L. Drawing up and administering intramuscular injections: a review of the literature. J Adv Nurs. 2000 Mar;31(3):574-82. [PubMed: 10718876]
14.Sivri Bilgen B, Balcı S. The Effect on Pain of Buzzy® and ShotBlocker® during the Administration of Intramuscular Injections to Children: A Randomized Controlled Trial. J Korean Acad Nurs. 2019 Aug;49(4):486-494. [PubMed: 31477677]
15.Yilmaz G, Alemdar DK. Using Buzzy, Shotblocker, and Bubble Blowing in a Pediatric Emergency Department to Reduce the Pain and Fear Caused by Intramuscular Injection: A Randomized Controlled Trial. J Emerg Nurs. 2019 Sep;45(5):502-511. [PubMed: 31257044]
16.Bilge S, Aydin A, Gun C, Aldinc H, Acar YA, Yaylaci S, Cinar O, Balci V. Comparison of the efficacy of ShotBlocker and cold spray in reducing intramuscular injection-related pain in adults. A prospective, randomized, controlled trial. Saudi Med J. 2019 Oct;40(10):996-1002. [PMC free article: PMC6887882] [PubMed: 31588477]
17.Yildirim D, Dinçer B. Shotblocker Use in Emergency Care: A Randomized Clinical Trial. 2021 Jan-Mar 01Adv Emerg Nurs J. 43(1):39-47. [PubMed: 33952876]
18.Zengin M, Yayan EH. A Comparison of Two Different Tactile Stimulus Methods on Reducing Pain of Children During Intramuscular Injection: A Randomized Controlled Study. J Emerg Nurs. 2022 Mar;48(2):167-180. [PubMed: 34952709]
19.Sridharan K, Sivaramakrishnan G. Pharmacological interventions for reducing pain related to immunization or intramuscular injection in children: A mixed treatment comparison network meta-analysis of randomized controlled clinical trials. J Child Health Care. 2018 Sep;22(3):393-405. [PubMed: 29486590]
20.Cassidy KL, Reid GJ, McGrath PJ, Smith DJ, Brown TL, Finley GA. A randomized double-blind, placebo-controlled trial of the EMLA patch for the reduction of pain associated with intramuscular injection in four to six-year-old children. Acta Paediatr. 2001 Nov;90(11):1329-36. [PubMed: 11808908]
21.Kashaninia Z, Sajedi F, Rahgozar M, Noghabi FA. The effect of Kangaroo Care on behavioral responses to pain of an intramuscular injection in neonates. J Spec Pediatr Nurs. 2008 Oct;13(4):275-80. [PubMed: 19238715]
22.Öztürk D, Baykara ZG, Karadag A, Eyikara E. The effect of the application of manual pressure before the administration of intramuscular injections on students' perceptions of postinjection pain: a semi-experimental study. J Clin Nurs. 2017 Jun;26(11-12):1632-1638. [PubMed: 27535654]
23.Basak T, Demirtas A, Yorubulut SM. Virtual reality and distraction cards to reduce pain during intramuscular benzathine penicillin injection procedure in adults: A randomized controlled trial. J Adv Nurs. 2021 May;77(5):2511-2518. [PubMed: 33608955]
24.Canbulat Şahiner N, Türkmen AS. The Effect of Distraction Cards on Reducing Pain and Anxiety During Intramuscular Injection in Children. Worldviews Evid Based Nurs. 2019 Jun;16(3):230-235. [PubMed: 30997744]
25.Sahebkar M, Khosrojerdi A, Rad M, Stewart JJ, Rastaghi S, Assarroudi A. Evaluation of the effect of selecting gluteal injection site on the pain injection based on anthropometric indices and body shape pattern: A randomised controlled trial study. J Clin Nurs. 2021 Jun;30(11-12):1556-1563. [PubMed: 33559212]
26.Kara D, Yapucu Güneş Ü. The effect on pain of three different methods of intramuscular injection: A randomized controlled trial. Int J Nurs Pract. 2016 Apr;22(2):152-9. [PubMed: 25039702]
27.Mitchell JR, Whitney FW. The effect of injection speed on the perception of intramuscular injection pain. A clinical update. AAOHN J. 2001 Jun;49(6):286-92. [PubMed: 11760527]
28.Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V., HELPinKIDS Team. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin Ther. 2009;31 Suppl 2:S48-76. [PubMed: 19781436]
29.Hall LM, Ediriweera Y, Banks J, Nambiar A, Heal C. Cooling to reduce the pain associated with vaccination: A systematic review. Vaccine. 2020 Dec 03;38(51):8082-8089. [PubMed: 33189429]
30.Ayinde O, Hayward RS, Ross JDC. The effect of intramuscular injection technique on injection associated pain; a systematic review and meta-analysis. PLoS One. 2021;16(5):e0250883. [PMC free article: PMC8092782] [PubMed: 33939726]
31.Nahm FS, Lee PB, Park SY, Kim YC, Lee SC, Shin HY, Lee CJ. Pain from intramuscular vaccine injection in adults. Rev Med Chil. 2012 Feb;140(2):192-7. [PubMed: 22739948]
32.Mansoor F, Hamid S, Mir T, Abdul Hafiz R, Mounts A. Incidence of traumatic injection neuropathy among children in Pakistan. East Mediterr Health J. 2005 Jul;11(4):798-804. [PubMed: 16700396]
33.Donaldson C, Green J. Using the ventrogluteal site for intramuscular injections. Nurs Times. 2005 Apr 19-25;101(16):36-8. [PubMed: 15871375]
34.Small SP. Preventing sciatic nerve injury from intramuscular injections: literature review. J Adv Nurs. 2004 Aug;47(3):287-96. [PubMed: 15238123]
35.Shoemaker S. Preventing Shoulder Injury Related to Vaccine Administration. Am J Nurs. 2021 Jun 01;121(6):45-47. [PubMed: 34009164]
36.Nakajima Y, Mukai K, Takaoka K, Hirose T, Morishita K, Yamamoto T, Yoshida Y, Urai T, Nakatani T. Establishing a new appropriate intramuscular injection site in the deltoid muscle. Hum Vaccin Immunother. 2017 Sep 02;13(9):2123-2129. [PMC free article: PMC5612213] [PubMed: 28604191]
37.Chan VO, Colville J, Persaud T, Buckley O, Hamilton S, Torreggiani WC. Intramuscular injections into the buttocks: are they truly intramuscular? Eur J Radiol. 2006 Jun;58(3):480-4. [PubMed: 16495027]
38.White S, Goodwin J, Behan L. Nurses' Use of Appropriate Needle Sizes When Administering Intramuscular Injections. J Contin Educ Nurs. 2018 Nov 01;49(11):519-525. [PubMed: 30376144]
39.Ozen O, Gunaydin M, Tosun A, Coskun ZU, Aytekin K, Takir S. Assessment rate of true dorsogluteal intramuscular drug injection using ultrasonography. Pak J Med Sci. 2019 Jul-Aug;35(4):1132-1137. [PMC free article: PMC6659072] [PubMed: 31372156]
40.Dayananda L, Belaval VV, Raina A, Chandana R. Intended intramuscular gluteal injections: are they truly intramuscular? J Postgrad Med. 2014 Apr-Jun;60(2):175-8. [PubMed: 24823517]
41.Strohfus P, Palma S, Wallace CT. Dorsogluteal intramuscular injection depth needed to reach muscle tissue according to body mass index and gender: A systematic review. J Clin Nurs. 2022 Oct;31(19-20):2943-2958. [PubMed: 34791732]
42.Herraiz-Adillo Á, Martínez-Vizcaíno V, Pozuelo-Carrascosa DP. Aspiration before intramuscular vaccines injection, should the debate continue? Enferm Clin (Engl Ed). 2022 Jan-Feb;32(1):65-66. [PMC free article: PMC8783631] [PubMed: 35078751]
43.Thomas CM, Mraz M, Rajcan L. Blood Aspiration During IM Injection. Clin Nurs Res. 2016 Oct;25(5):549-59. [PubMed: 25784149]
44.Erkoc Hut A, Yazici ZA. Glass particle contamination threat in nursing practice: A pilot study. J Adv Nurs. 2021 Jul;77(7):3189-3191. [PubMed: 33855755]
45.Chiannilkulchai N, Kejkornkaew S. Safety concerns with glass particle contamination: improving the standard guidelines for preparing medication injections. Int J Qual Health Care. 2021 Jun 23;33(2) [PMC free article: PMC8221140] [PubMed: 34101800]
46.Preston ST, Hegadoren K. Glass contamination in parenterally administered medication. J Adv Nurs. 2004 Nov;48(3):266-70. [PubMed: 15488040]
47.Noyes J. An explanation of the differences between expert and novice performance in the administration of an intramuscular injection of an analgesic agent to a patient in pain. J Adv Nurs. 1995 Oct;22(4):800-7. [PubMed: 8708202]
48.Cassista J, Payne-Gagnon J, Martel B, Gagnon MP. Applying Theory to Understand and Modify Nurse Intention to Adhere to Recommendations regarding the Use of Filter Needles: An Intervention Mapping Approach. Nurs Res Pract. 2014;2014:356153. [PMC free article: PMC4121269] [PubMed: 25120927]