Vaccine administration
women who weigh more then 200 lb 90 kg
, a 1½-inch needle is recommended.
• Vaccinating Persons with Bleeding Disorder.
- Individuals with a bleeding disorder or who are receiving anticoagulant therapy may develop hematomas in IM injection sites. When any intramuscularly administered vaccine is indicated for a patient with a bleeding disorder, the vaccine should be administered intramuscularly if a physician familiar with the patient's bleeding risk determines that the vaccine can be administered by this route with reasonable safety
Subcutaneous (subcut) Route. Subcutaneous injections are administered into the fatty tissue found below the dermis and above muscle tissue.
- Site - The recommended subcutaneous sites for vaccine administration are the thigh (for infants younger than 12 months of age) and the upper outer triceps of the arm (for persons 12 months of age and older). If necessary, the upper outer triceps area can be used to administer subcutaneous injections to infants.
There are only two routinely recommended IM sites for administration of vaccines,
- the vastus lateralis muscle (anterolateral thigh) and the deltoid muscle (upper arm). -Injection at these sites reduces the chance of involving neural or vascular structures. The site depends on the age of the individual and the degree of muscle development.
. The muscles of the buttock are not used for administration of vaccines in infants and children because of concern about .
-potential injury to the sciatic nerve, which is well documented after injection of antimicrobial agents into the buttock -If the gluteal muscle must be used, care should be taken to define the anatomic landmarks.*
• Intramuscular (IM) Route
. Intramuscular injections are administered into muscle tissue below the dermis and subcutaneous tissue.
The injection sites should be separated by
1 inch or more, if possible, so that any local reactions can be differentiated. Vaccines that are the most reactive (e.g., tetanus-containing and PCV) should be administered in different limbs if possible. Use of combination vaccines can reduce the number of inject
The vastus lateralis muscle in the anterolateral thigh is an alternative site if the deltoid sites cannot be used.
1- or 1¼-inch needle will be sufficient to reach muscle tissue in most older children and adolescents.
Patient Prep and Care
1. Screening 2. Vaccine safety and Risk communication 3. Atraumatic Care 4. positioning and comforting restraint 5. comfort measures 6.
Decisions on needle size and site of injection must be made for each person on the basis of
1. the size of the muscle, 2. the thickness of adipose tissue at the injection site, 3. the volume of the material to be administered, and 4. injection technique.
The recommended subcutaneous sites for vaccine administration are the thigh (for infants younger than 12 months of age) and the upper outer triceps of the arm (for persons 12 months of age and older). If necessary, the upper outer triceps area can be used to administer subcutaneous injections to infants.
1. thigh for infants younger than 12 months of age 2. upper outer triceps of the arm- 12 month of age or older
who weigh more than 260 lbs (more than 118 kg)
1.5 inch needle
For men and women who weigh d.
130-152 lbs (60-70 kg), a 1-inch needle is sufficient.
For women who weigh 1
152-200 lbs (70-90 kg) 152-260 lbs (70-118 kg), ------a 1- to 1½-inch needle is recommende
Needle Gauge -
22- to 25-gauge needle -
For men and women weighing less than 130 lbs (60 kg) a
5/8- to 1-inch needle is sufficient to ensure intramuscular injection into the deltoid if a 90-degree angle is used and the tissue is not bunched.
Needle Gauge & Length -
5/8-inch, 23- to 25-gauge needle - 45 degree angle
preterm infants, a
A 5/8 inch needle usually is adequate if the skin is stretched flat between thumb and forefinger and the needle inserted at a 90-degree angle to the skin.
Needle Gauge and Length -
A manufacturer prefilled microinjection syringe is used to administer a 0.1 mL dose into the dermal layer of the skin. The syringe contains a 30-gauge, 1.5 milliliter microneedl
Which immunizations are administered in this IM route
All inactivated vaccines, with the exception of one formulation of meningococcal polysaccharide vaccine (MPSV4), are administered by the intramuscular route. Many inactivated vaccines contain an adjuvant, which is a vaccine component that enhances the immune response to the antigen. Adjuvants can cause an exaggerated local reaction (e.g., pain, swelling, redness) if not injected into the muscle, so proper technique is critical
Screening
All patients should be screened for contraindications and precautions every time a vaccine is administered, even if the patient has previously received a dose of that vaccine. The patient's status can change from one visit to the next or a new contraindication or precaution may have been added.
• Intradermal (ID) Route. -
Fluzone Intradermal is the only U.S.-licensed vaccine that is administered by the intradermal route. It is approved only for use in persons 18 through 64 years of age. This Fluzone formulation is not the same as intramuscular formulations of inactivated influenza vaccine (TIV). Other TIV formulations should NOT be administered by the intradermal route.
If a vaccine and an immune globulin preparation are administered simultaneously for example
Td/Tdap and tetanus immune globulin [TIG] or hepatitis B vaccine and hepatitis B immune globulin [HBIG]), separate anatomic sites should be used. -The location of all injection sites should be documented in the patient's medical record. -Healthcare practices should consider using a vaccination site map so that all persons -administering vaccines routinely use the same anatomic site for each different vaccine.
Technique
Technique - Follow standard medication administration guidelines for site assessment/selection and site preparation. - To avoid injection into subcutaneous tissue, spread the skin of the selected vaccine administration site taut between the thumb and forefinger, isolating the muscle. Another technique, acceptable mostly for pediatric and geriatric patients, is to grasp the tissue and "bunch up" the muscle. - Insert the needle fully into the muscle at a 90° angle and inject the vaccine into the tissue. - Withdraw the needle and apply light pressure to the injection site for several seconds with a dry cotton ball or gauze.
Site - - e
The site of administration is the deltoid region of the upper arm. The patient should be seated with the arm bent at the elbow and the hand on the hip to ensure that the site of administration is prominent.
Vaccine Safety & Risk Communication -
There have been safety concerns about vaccines since the 18th century when the first smallpox vaccination campaigns began. Specific vaccine concerns have changed through time. An increasing number of parents, even those who support vaccination, are beginning to raise vaccine safety concerns. Parents/guardians and patients are exposed to information about vaccines through the media, internet, family members, and friends. Some of this information is inaccurate and misleading.
Injection technique is the most important parameter to ensure efficient intramuscular vaccine delivery. If the subcutaneous and muscle tissue are bunched to minimize the chance of striking bone,
a 1-inch needle is required to ensure intramuscular administration
in infants aged 1 month and older. For the majority of infants,and
a 1-inch, 22-25-gauge needle is sufficient to penetrate muscle in an infant's thigh. For neonates (first 28 days of life)
A provider's recommendation for vaccination is a powerful motivator. Healthcare providers are consistently identified as the most trusted source of vaccine information by parents and patients. Immunization providers should be prepared to discuss the benefits and risks of vaccines,
as well as the risks of vaccine-preventable diseases (VPD), using Vaccine Information Statements (VIS) and other reliable resources. Establishing an open dialogue promotes a safe, trust-building environment in which individuals can freely evaluate information, discuss vaccine concerns and make informed decisions regarding immunizations. Providers are also encouraged to discuss after care instructions with patients or parents/guardians (see additional information in Chapter 4 and Appendices E and F).
Hepatitis B vaccine administered by any route other than the intramuscular route, or in adults at any site other than the
deltoid or anterolateral thigh, should not be counted as valid and should be repeated.
Many inactivated vaccines contain an adjuvant, which is a vaccine component that enhances the immune response to the antigen. Adjuvants can cause an
exaggerated local reaction (e.g., pain, swelling, redness) if not injected into the muscle, so proper technique is critical
Larger than recommended dosages can be hazardous because of
excessive local or systemic concentrations of antigens or other vaccine constituents deposited into the tissue.
Children/Adolescents (3 through 18 Years) The deltoid muscle is preferred for children a on technique.
ged 3 through 18 years of age. The needle size for deltoid injections can range from 22-25 gauge and from 5/8- to 1-inch, depending
If multiple vaccines are administered at a single visit, administration of each preparation at a different anatomic site is desirable. For infants and younger children,
if more than two vaccines are injected in a single limb, the thigh is the preferred site because of the greater muscle mass.
*If the gluteal muscle is chosen,
injection should be administered lateral and superior to a line between the posterior superior iliac spine and the greater trochanter or in the ventrogluteal site, the center of a triangle bounded by the anterior superior iliac spine, the tubercle of the iliac crest, and the upper border of the greater trochanter
exception
meningococcal polysaccharide vaccine (MPSV4
The deltoid muscle can be used if the muscle mass is adequate. A 5/8-inch
needle is adequate only for the deltoid muscle and only if the skin is stretched flat between thumb and forefinger and the needle inserted at a 90° angle to the skin.
Doses of rabies vaccine administered in the gluteal site should
not be counted as valid doses and should be repeated. All vaccines should be administered by the manufacturer's recommended route, but there are no ACIP recommendations to repeat doses of other vaccines administered by another route. (See ACIP General Recommendations for more detail).
In general, older children and adolescents
require a 1-inch needle. One study found that obese adolescents may need a 1½-inch needle in order to reach muscle tissue. If there is any doubt, knowledge of body mass may be helpful in estimating the appropriate needle length.
Infants (Younger Than 12 Months) For the majority of infants,
the anterolateral aspect of the thigh is the recommended site for injection because it provides a large muscle mass
For older children and adults, .
the deltoid muscle can be used for more than one intramuscular injection
The "Rights of Medication Administration" should be applied to each encounter when vaccines are administered. These rights include:
the right patient; the right vaccine or diluent; the right time*; the right dosage; the right route, needle length, and technique; the right site; and, the right documentation. *(includes administering at the correct age, the appropriate interval, and before vaccine or diluent expires)
Toddlers (12 Months through 2 Years) For toddlers,
the vastus lateralis muscle in the anterolateral thigh is preferred. The needle should be at least 1-inch long.
• Atraumatic Care - Vaccine safety issues and the need for multiple injections have increased the concerns and anxiety associated with immunizations. Healthcare providers need to display confidence and establish an environment that promotes a sense of security and trust for the patient and family, utilizing a variety of techniques to minimize the stress and discomfort associated with receiving injections. This is particularly important when administering vaccines to children. Although pain from immunizations is, to some extent, unavoidable, there are some things that parents and healthcare providers can do to help when children need vaccines. Everyone involved should work to provide immunizations in the safest and least stressful way possible. Simple strategies that can be used by both parents and providers to make the process of receiving vaccines easier include:
• displaying a positive attitude through facial expressions, body language, and comments; • using a soft and calm tone of voice; • making eye contact, even with small children; • explaining why vaccines are needed (e.g., "this medicine will protect you from getting sick" or "this shot is a shield to protect your body against infection"); and, • being honest and explaining what to expect (e.g., do not say that the injection will not hurt).
