INJECTON COURSE

For second year student

By
Prof. Dr. Nirvana Ahmed
Elshalakany
Head of Anesthesia department

Faculty of medicine
Six October University
Defination:

An injection is an infusion method of putting fluid into the body

, usually with a syringe and a hollow needle which is pierced
through the skin to a sufficient depth for the material to be
parenteral route of administration; that is, administration via a
route other than through the digestive tract.
Since the process involves a small puncture wound to the body
(with varying degrees of pain depending on injection type and
location, medication type, needle gauge and the skill of the
individual administering the injection), fear of needles is a
common phobia.
There are several methods of injection or infusion used in
humans, including:
intradermal, subcutaneous, intramuscular, intravenous, intraosse
ous, intraperitoneal, intrathecal, epidural, intracardiac, intraartic
ular , intracavernous , and intravitreal . A depot injection is an
injection, usually subcutaneous, intradermal, or intramuscular,
that deposits a drug in a localized mass, called a depot, from
which it is gradually absorbed by surrounding tissue. Such
injection allows the active compound to be released in a
consistent way over a long period

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 I) Intramuscular injection:

In an intramuscular injection, the medication is delivered

directly into a muscle. Many vaccines are administered
intramuscularly. Many drugs as codeine, metoclopramide, and
many other medications when injected intramuscularly are
absorbed into the muscle fairly quickly, while others are more
gradual. Injections to the buttocks are known to reach the

Blood stream quickly due to the large amount of muscular tissue

and corresponding blood.

Sites of intramuscular injection:

1) Deltoid muscle of the arm is the site most typically used for
vaccines. However, this site is not common for self-injection,
because its small muscle mass limits the volume of medication that
can be injected — typically no more than 1 milliliter.

2) Vastus lateralis muscle of the thigh: The thigh may be used when
the other sites aren’t available or if you need to administer the
medication on your own. Divide the upper thigh into three equal
parts. Locate the middle of these three sections. The injection
should go into the outer top portion of this section.

3) Ventrogluteal muscle of the hip (most common): The

Ventrogluteal muscle is the safest site for adults and children older
than 7 months. It’s deep and not close to any major blood vessels
and nerves. This site is difficult for self-injection, and may require
the help of a friend, family member, or caregiver. Place the heel of
your hand on the hip of the person receiving the injection, with the
fingers pointing towards their head. Position the fingers so the
thumb points toward the groin and you feel the pelvis under your
pinky finger. Spread your index and middle fingers in a slight V
shape, and inject the needle into the middle of that V.

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How to Give an Intramuscular Injection
1) Wash your hands prior to starting the procedure. Good hygiene is
important to minimize the risk of infection

2) Reassure the patient and explain the procedure to him.

3) Sanitize the area with an alcohol swab.

4)Insert syringe needle smoothly and quickly at an angle of 90 degrees to

the skin.

5) After injecting the needle but before injecting the medication, start by
pulling back on the plunger.

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6) Inject the medication slowly. While it is best to insert the needle
quickly to minimize pain, injecting the medication slowly helps to
minimize pain.

7) Pull the needle out at the same angle as you injected it. Do this once
you're confident all the medicine has been injected.

Complications of intramuscular injections?

It’s normal to experience some discomfort after an intramuscular

injection. But certain symptoms may be a sign of a more serious
complication. Call your doctor or healthcare provider right away if you
experience:

 severe pain at the injection site

 tingling or numbness
 redness, swelling, or warmth at the injection site
 drainage at the injection site
 prolonged bleeding
 signs of an allergic reaction, such as difficulty breathing or facial
swelling

It’s also normal to have some anxiety about performing or receiving an

injection, especially an intramuscular injection due to the long needle.
Read through the steps several times until you feel comfortable with the
procedure, and take your time. Don’t hesitate to ask your provider or
pharmacist to go through the procedure with you beforehand.

They’re more than willing to help you understand how to perform a safe,
proper injection.

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 II) Subcutaneous injection
A subcutaneous injection is an injection administered into the fatty area
just under the skin (as opposed to an intravenous injection, which is
administered directly into the bloodstream). Because they give a slower,
more gradual release than intravenous injections, subcutaneous injections
are frequently used as a way to administer both vaccines and medications.

Medications given using a subcutaneous injection:

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

Where can I give a subcutaneous injection?

The following are sites where you can give a subcutaneous injection:
 Abdomen: Uncover your abdomen. You may give an injection
below the waist to just above the hip bone and from the side to
about 2 inches from the belly button. Avoid the belly button.

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  Thigh: Uncover the entire leg. Find the area halfway between
the knee and hip and slightly to the side. Gently grasp the area
to make sure you can pinch 1 to 2 inches of skin.
 Lower back: Uncover the back from the waist to the top of the
buttocks. Imagine a line that runs across the back just above the
crack between the buttocks. An injection may be given below
the waist and above this line. Give the injection halfway
between the spine and the side.
 Upper Arm: Uncover the arm to the shoulder. Have the person
getting the injection stand with his hand on his hip. Stand next
to and a little behind the person. Find the area halfway between
the elbow and shoulder. Gently grasp the skin at the back of the
arm between your thumb and first 2 fingers. You should be able
to grasp 1 to 2 inches of skin

How to give subcutaneous Injection?

1) Prepare a clean, ordered work area.

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 2) Remove the tamper resistance tab from the vial of medication

3) Hold the syringe firmly in your dominant hand , Grasp the cap over
the needle with the thumb and forefinger of your other hand and pull
the cap off the needle.

4) Carefully use your non-dominant hand to grab the vial of medication,

Insert the needle into the rubber stopper.

5) Draw medication into your syringe. Making sure the needle tip is
submerged in the liquid medicine; pull back on the plunger slowly and
gently until you have reached your desired dosage.

6) Ready the syringe in your dominant hand, gently "pinch" the injection
site with the other hand, Insert the syringe into the skin at 90 degrees
(straight up and down, relative to the skin) to ensure that the medication
is injected into the fatty tissue.

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7) Push down on the plunger without applying extra pressure onto the
patient until all of the medication has been injected. Uses one controlled,
steady motion, gently press a piece of gauze or a cotton ball next to the
needle at the injection site, and then remove the needle from the skin in
one smooth motion.

Complications of subcutaneous injection

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

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 III) Intravenous Injection (I.V)
An intravenous (or IV for short) line is one of the most common,
important tools in modern medicine. IVs allow healthcare professionals to
administer fluids, blood products, and medications directly into a
patient's.

Uses of IV medications

IV medication is often used because of the control it provides over

dosage. For instance, in some situations, people must receive medication
very quickly. This includes emergencies, such as a heart attack, stroke, or
poisoning. In these instances, taking pills or liquids by mouth may not be
fast enough to get these drugs into the bloodstream. IV administration, on
the other hand, quickly sends a medication directly into the bloodstream.

Other times, medications may need to be given slowly but constantly. IV

administration can also be a controlled way to give drugs over time.

Certain drugs may be given by IV administration because if you took

them orally (by mouth), enzymes in your stomach or liver would break
them down. This would prevent the drugs from working well when
they’re finally sent to your bloodstream. Therefore, these drugs would be
much more effective if sent directly into your bloodstream by IV
administration.

Drugs typically given by IV

Many different types of medications can be given by IV. Some of the

drugs more commonly given by this method include:

 chemotherapy drugs such as doxorubicin, vincristine, cisplatin, and

paclitaxel
 antibiotics such as vancomycin, meropenem, and gentamicin
 antifungal drugs such as micafungin and amphotericin
 pain medications such as hydromorphone and morphine
 drugs for low blood pressure such as dopamine, epinephrine,
norepinephrine, and dobutamine

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 Immunoglobulin medications (IVIG).

Standard IV lines

A standard IV catheter is used for two kinds of IV medication

administration:

IV push

An IV “push” or “bolus” is a rapid injection of medication. A syringe is

inserted into your catheter to quickly send a one-time dose of drug into
your bloodstream.

IV infusion

An IV infusion is a controlled administration of medication into your

bloodstream over time. The two main methods of IV infusion use either
gravity or a pump to send medication into your catheter:

Pump infusion: In the United States, a pump infusion is the most

common method used. The pump is attached to your IV line and sends
medication and a solution, such as sterile saline, into your catheter in a
slow, steady manner. Pumps may be used when the medication dosage
must be precise and controlled.

Drip infusion: This method uses gravity to deliver a constant amount of

medication over a set period of time. With a drip, the medication and
solution drip from a bag through a tube and into your catheter.

Types of central venous catheters

Long-term medication treatment, such as chemotherapy or total

parenteral nutrition, usually requires a central venous catheter (CVC)
instead of a standard IV catheter. A CVC is inserted into a vein in your
neck, chest, arm, or groin area.

CVCs can be used for a longer period of time than a standard IV line. A
CVC can stay in place for several weeks or even months.

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The three main types of CVCs include:

Peripherally inserted central catheter (PICC)

A PICC has a long line that sends medication from the area of insertion,
through your blood vessels, all the way to a vein near your heart. A PICC
is typically placed in a vein above your elbow in your upper arm.

Tunneled catheter

With a tunneled catheter, medication can be sent directly into blood

vessels in the heart. One end of the catheter is placed into a vein in the
neck or chest during a short surgical procedure. The rest of the catheter is
tunneled through the body, with the other end coming out through the
skin. Medications can then be given into that end of the catheter.

Implanted port

Like a tunneled catheter, an implanted port inserts a catheter into a vein in

the neck or chest. This device is also placed during a short surgical
procedure. But unlike a tunneled catheter, an implanted port is located
completely beneath the skin. To use this device, a healthcare provider
injects medication through the skin into the port, which sends the
medication into the bloodstream.

How to Insert an IV:

1) Prepare the IV tubing by suspending the IV bag from an elevated
stand, filling the tubing with saline solution, and checking for any
bubbles

2) Choose a suitable-gauge catheter for the situation.

3) Put on sterile gloves.

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4) Look for prominent veins

5) To get your chosen veins to swell up for easy insertion, apply a

tourniquet behind the intended IV site.

6) If you're having a hard time finding suitable veins, it can be helpful to

palpate the patient's skin in the area of the IV site.

7) Disinfect the IV site

8) Remove the catheter from its sterile packaging. Briefly inspect it to

ensure that it is intact and working. .

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9) Take the catheter in your dominant hand and insert the needle (bevel
facing up) through the skin. Reduce the angle of insertion as you advance
the needle into the vein.

10) Maintaining pressure on the skin, pull the needle (only the needle —
not the catheter) back out of the vein. Slowly advance the catheter into
the vein while maintaining pressure on the vein and skin. When the
cannula is seated in the vein, remove the tourniquet and secure the
catheter by placing a sterile bandage or dressing over the lower half of the
catheter hub.

11) Remove the protective cover from the end of the IV tubing and
carefully insert it into the catheter hub. Secure it in the catheter by
screwing and locking in place.

12) Open the IV roller clamp and look for drips forming in the drip
chamber. Check that the IV is infusing into the vein.

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Side effects

While IV medication use is generally safe, it can cause both mild and
dangerous side effects. Medications given intravenously act on the body
very quickly, so side effects, allergic reactions, and other effects can
happen fast. In most cases, a healthcare provider will observe you
throughout your infusion and sometimes for a period afterward. Examples
of IV side effects include:

Infection: Infection can occur at the injection site. To help prevent

infection, the administration process must be done carefully using sterile
(germ-free) equipment. An infection from the injection site can also
travel into the bloodstream. This can cause a severe infection throughout
the body. Infection symptoms can include fever and chills, as well as
redness, pain, and swelling at the injection site. If you have any
symptoms of infection, call your doctor right away.

Damage to blood vessels and injection site: A vein can be damaged

during injection or by the use of an IV catheter line. This can cause
infiltration. When this occurs, medication leaks into surrounding tissue
instead of going into the bloodstream. Infiltration can cause tissue
damage.

IV administration can also cause phlebitis, or inflammation of the veins.

Symptoms of both infiltration and phlebitis include warmth, pain, and
swelling at the injection site. Call your doctor right away if you have any
of these symptoms.

Air embolism: If air gets into the syringe or the IV medication bag and the
line runs dry, air bubbles can enter your vein. These air bubbles can then
travel to your heart or lungs and block your blood flow. An air
embolism can cause severe problems such as heart attack or stroke.

Blood clots: IV therapy can cause blood clots to form. Clots can block
important blood vessels and cause problems such as tissue damage or
death. Deep vein thrombosis is one type of dangerous blood clot that IV
treatment can cause.

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 IV) Intradermal injection
It is the injection of a substance into the dermis, just below the epidermis.
This route has the longest absorption time as compared to
subcutaneous injections and intramuscular injections. As a result, it is
used for sensitivity tests, like tuberculin and allergy tests, and for local
anesthesia.

What are the sites for intradermal injections?

Intradermal injection is one of the routes of administration used for

vaccination. The three main routes are intradermal (ID) injection,
subcutaneous (SC) injection and intramuscular (IM) injection. Each type
targets a different skin layer: Subcutaneous injections are administered in
the fat layer, underneath the skin.

What angle is used when giving an intradermal injection?

Hold syringe at a 5- to 15-degree angle from the site. Place the needle
almost flat against the patient's skin, bevel side up, and insert needle into
the skin. Insert the needle only about 1/4 inch , with the entire bevel
under the skin.

What size needle is used for intradermal injection?

Equipment include syringes calibrated in tenths and hundredths of

a milliliter. The dosage given is usually less than 0.5 mL, less than given
subcutaneously or intramuscularly. A 1/4" to 1/2" long and 26 or 27
gauge thick needle is used

What degree is intradermal injection?

Simple drawing of cross section of skin with three needles

administering injectionsat different angles. Intramuscular at
90 degrees (left), subcutaneous at 45degrees (center), and intradermal at
15 degrees (right).

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How is intradermal injection given?

Intradermal injection is the injection of a substance into the dermis, just

below the epidermis. This route has the longest absorption time as
compared to subcutaneous injections and intramuscular injections. As a
result, it is used for sensitivity tests, like tuberculin and allergy tests, and
for local anesthesia.

Intra dermal injection

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