Injection technique 1: Administering drugs via the Intramuscular Route

Part 1 of this two-part series on injection techniques describes the evidence base and procedure for administering an Intramuscular Injection

Injecting any drugs INCLUDING Androgenic and Anabolic Steriods is potentially very dangerous, make sure you read the next chapter entitled ” The Risks of performing an Intramuscular Injection – Read this, Important ! before you attempt self-administration of an Intramuscular Injection.  

Using the correct injection technique and selecting the correct site for administration and following best practice hygiene will minimize your risk of complications. 

Disclaimer: I am NOT your Doctor, this information is my opinion and intended for those qualified to perform such a procedure. 

This is part 1 of a two-part series on injection techniques, part 2 – a separate module will cover the Subcutaneous Administration route.

Introduction

Drugs administered by the intramuscular (IM) route are deposited into vascular muscle tissue, which allows for rapid absorption into the circulation

What an Intramuscular Injection Depot looks like in an MRI

No it’s not a ” ball shape” as many assume 


Site selection

Traditionally the dorsogluteal (DG) muscle has been used by our tribe for IM injections but this muscle is in close proximity to a major blood vessel and nerves, with Sciatic Nerve Injection Iinjury SNII a recognised complication of performing Intramuscular Injections.  

As such the dorsogluteal  ( DG ) muscle is no longer recommended for IM injections 

In spite of this, many in our tribe ( including myself ) continue to use it as the ” go to” location for IM administration.  Caution if you are going do dorsogluteal injections be very very careful with placement of the point of administration and make yourself aware of the risks, see Chapter 2.  

In Clinical best practice, four muscle sites are recommended for IM administration

Vastus lateralis, Rectus femoris, Deltoid, Ventrogluteal.

Deltoid

Vastus Lateralis, Rectus Femoris

Ventrogluteal.

Equipment required to perform an IM Injection 

Needles – Please see the Chapter below for information on Needle Selection 

Syringe – Please see the Chapter below for information on Syringe Selection 

Drug for administration

Alcohol Swabs 

Sharps container – Please dispose of your used Needles safely ! 

Procedure

Before drug administration, confirm that you do not have any allergies to or a contraindication for use of the Compound you intend to administer.   

Check the bottle label to confirm the compound and concentration is as you believed. 

Wash and dry your hands to reduce the risk of infection.

Hold your ampoule up to the light and take a good look. If the liquid is discolored or there are bits floating in it then it could be dangerous or faulty and you should not use it. 

If the Hormone has ” crashed” out of suspension we will deal with how you can fix that in Master Class. 

Oil-based solutions will be easier to inject if warmed to body temperature – you can do this in a number of ways just be sure whatever method you use does not risk ” contamination” of the product – eg do not fully immerse an opened multiuse vial in warm water. 

If you are satisfied the drug looks OK then assemble the syringe and needle, push the needle through the seal, inject a little air to balance the pressure

Then draw back the plunger until the dose you want is in the syringe and withdraw the required amount of drug from the ampoule or multiuse vial. 

Remove the air bubbles. 

If you can, get rid of any big bubbles in the syringe so that you can be sure of your dose. Flick the barrel and then press the plunger until the solution reaches the top of the syringe.

Pushing a needle through the seal will make it blunt and a blunt needle will cause more damage to your muscle. 

Best practice says you should use 2 needles for each administration. One needle to draw up your product from the vial and another new needle for the actual administration. 


Discard the used ” draw needle” (use your sharps box) and replace it with a new sterile needle – see the chapter on needles for recommendations on needle selection 

Don’t uncap the new ” administration needle” until the last moment ie right before you are ready to inject.

Check the intended site of administration for signs of edema, infection or skin lesions, if any of these are present, select a different site.

Skin preparation

There is some debate about using alcohol-impregnated swabs to clean injection sites. PHE (2013) suggests that, if a patient is physically clean and generally in good health, swabbing the skin is not required.

I, however, recommend that you always, always clean the skin at the point of administration using an alcohol-impregnated swab (70% isopropyl alcohol)

When you have used the alcohol swab on the injection site, allow a few seconds for your skin to dry before injecting. 

A Z-track technique can be used to prevent backtracking and leakage from the injection site. 

Hold the syringe and needle in your dominant hand and gently stretch the skin around the injection site using the non-dominant hand. This displaces the subcutaneous tissue and aids needle entry


Insert the needle at a 90-degree angle using a dart-like action. This prevents accidental depression of the plunger during insertion of the needle. 

Aspiration

Do I need to aspirate when doing IM injections ?

Aspiration is the process of pulling back on the syringe plunger by applying negative pressure for 5-10 seconds after the needle has been inserted into tissue, but before administration of the medication (CDC, 2017; Sepah et al, 2017).

I have included lots of references here because it’s going to be questioned by some.

The rationale for aspiration has traditionally been to avoid inadvertent intravenous administration of the medication. This concern is based on tradition, but not supported by evidence (CDC, 2017; Sepah et al, 2017). Indeed many of the new auto-disable safety syringes prevent aspiration, making the process impossible during medication administration (Sepah et al, 2017).

In clinical practice the dorsogluteal site ( the only site that has high density of major nerves and blood vessel ) is not generally recommended and therefore aspiration is not necessary in routine clinical practice.

However rather ironically in our tribe the dorsogluteal site is the default go to for AAS depot

For our tribe … aspiration is not required except for highly vascular areas such as the dorsogluteal site (WHO 2004, DH 2013).

Ventrogluteal versus dorsogluteal admin

In the past decade, greater emphasis has been placed on using the ventrogluteal site for deep intramuscular injections, compared with the dorsogluteal site (Bolander 1994, Cook and Murtagh 2003, King 2003, Greenway 2004, Donaldson and Green 2005, Cocoman and Murray 2006, Nisbet 2006, Zaybak et al 2007).

There is sufficient evidence to promote the use of the ventrogluteal site wherever possible (Small 2004).

There are risks associated with the dorsogluteal site, with sciatic nerve injury identified as a serious complication of iatrogenic injury associated with dorsogluteal injections (Small 2004); and this site has major nerves and blood vessels (Bolander 1994, Tortora and Derrickson 2008).

The ventrogluteal site offers the greatest thickness of muscle, it is free of nerves and blood vessels, with a narrower layer of fat (Cocoman and Murray 2006) and is therefore the recommended site for intramuscular injections (Workman 1999, Rodger and King 2000, Greenway 2004).

The DH (2013) and the World Health Organization (WHO) (2004) report no advantages in using the dorsogluteal site.

So takeaway ?

Do I need to aspirate when doing IM injections ?

Only on the dorsogluteal site.

How fast do I press the Plunger ? 

Depress the plunger slowly to deliver the drug at a rate of 1ml/10 seconds; this aids absorption of the drug and reduces pain.

When all of the drug has been deposited 

Wait for 10 seconds to allow the drug to diffuse into the tissue and then quickly withdraw the needle.

Discard the used ” draw needle” (use your sharps box)

Every single piece of equipment used in an injection must be considered lethally contaminated and disposed of safely into a specially designed sharps box


Wash your hands.

Record administration, as well as the administration site as repeated injections into the same site can lead to induration and abscesses.

Complications of poorly performed IM injection can include:

Pain, Bleeding, Abscess formation, Cellulitis, Muscle fibrosis, Injuries to nerves and blood vessels, Inadvertent intravenous (IV) access.

These complications can be avoided if the site for injection is accurately identified and a skilled evidence-based technique is used. 

Strategies to reduce Pain at the point of Administration are outlined in a separate Chapter below

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