Intramuscular injection pain ppt

Dr. Kamlesh Lala/Dr. Mrudula lala 1

PAIN AFTER

INTRAMUSCULAR INJECTIONCauses and Measures to alleviate itDr. Kamlesh Lala MBBS

Dr. Mrudula Lala MD

Ahmedabad, [email protected]


Intramuscular Injection is the most widely practiced percutaneous procedure

Each child is compulsorily exposed to this in his early childhood by way of immunisation

The most common side effect is apprehension and pain


Pain is a subjective phenomenon influenced by multiple factors including

Age Anxiety level Previous experience Ambience Approach of a provider Culture


It is said that “Pain is inevitable”

But“Suffering is optional”

But here we try to reduce this suffering


Concern and anxiety about injections are common for all ages.

Several methods are found effective to relieve this apprehension and discomfort in different stages of injection procedure


Injection should not scare the child


Different Stages of intervention in alleviation of Pain

Before Injection Drug Equipment Site Selection Pre Injection During Injection Post Injection


1. Before Injection

Give age appropriate dose of NSAID. Avoid aspirin in children. Administer Paracetamol in dose of 15-20 mg/kg.

Local Anaesthetic (5% Xylocaine) can be applied at the site of injection an hour before

Administer sweet tasting liquid (2ml of 20% w/v sucrose or expressed breast milk) immediately before.

Child can even be breast fed immediately before


2. Drug

Shake Test for DTwP vaccine: Shake well the vaccine vial. After shaking, the vaccine sediment within 30 minutes leaving a deposit below a column of transparent fluid. This indicates that vaccine has been frozen in a cold chain. Discard such vial. Frozen vaccine increases the chances of local reaction and sterile abscess.


2. Drug (cont.)

Benzyl Alcohol (BA) is used to increase the lipid solubility of esterified compounds and to prevent bacteria growth. It can cause destruction of cells and localised pain and inflammation.

After injection of the drug, BA is absorbed from the site causing active drug to precipitate fine crystals within the muscle. This causes pain after 4-12 hours of injection characterised by pain and inuration.


2. Drug (cont.)Tissue Irritation

Tissue irritation is the most common cause of Post Injection Pain. It starts 12-24 hours after injection with warm, red, tender induration. This will fade after 72 hours.

Common with hormone injections. More common in a brand manufactured

by local drug company. (poor quality of raw material, excessive preservative, too much BA used)


2. Drug (cont.)

Addition of Benzyl Benzoate (BB) can reduce it.

Gently warm the oily injection by rubbing it in between two palms so as to improve the viscosity of the drug.

Larger than 5 ml volume is not advised for intramuscular injection. It should be divided into multiple injection at different sites.


3. Equipment

Use new syringe and needle every time. Longer needle reduces redness and

swelling, because medication is sure into the muscle. More so with Chloroquine and Diclofenac. So use 1.5” long needle for gluteal injection in adolescents and adults.

Use wide bore needle eg. 23g because narrow bore produces a jet under pressure causing muscle injury and pain.

For oily injection, use still wider bore needle (21g or 22g).


4. Site Selection

Use anterolateral thigh in children up to 2

years or even up to 5 years.

After that use deltoid muscle

In adults use gluteal muscle for oily

injection or if volume is greater than 2 ml.

Larger volumes are better tolerated in

larger muscle groups


4. Site Selection (cont.)

Do not use the same site over and over

again for days for multiple injections.

It may cause irritation and muscle injury;

and increases the chances of infection.

Rotate the site.


5. Pre Injection

After swabbing the site with spirit or alcohol, allow it to dry, or it may cause irritation.

Topical refrigerant (vapocoolant) spray immediately before the injection may reduce the short term pain.

Do not keep the air bubble inside the syringe.

Proper positioning of the patient allows to identify the site correctly.

Ensures patient’s comfort by muscle relaxation.


6. Techniques

1. Standard techniqueThe needle is introduced at 900 with steady pressure and aspiration to be performed for 5-10 seconds, drug is slowly injected over 5-10 secs., and the needle to be withdrawn slowly

2. Pragmatic technique The needle is introduced at 900 with steady pressure and no aspiration is to be performed, drug is rapidly injected over 1-2 secs., and the needle to be withdrawn rapidly


Technique (cont.)

In a randomised controlled trial to compare

acute pain response during immunisation

in infants using these two techniques, it

was found that Pragmatic technique is

less painful than a standard one.


Technique (cont.)

Z track technique. Skin is pulled downwards and laterally

before injection. This displaces the skin and SC tissue leaving the muscle there only and uses the valve action to prevent leakage of medication into the SC tissue and later on irritation.

Dr. Kamlesh Lala/Dr. Mrudula lala

Z technique

21


7. During Injection

Age appropriate non pharmacological

techniques may provide distraction from

pain.

Some of the distraction techniques are age

appropriate toys, playing music, pretending

to blow away pain, watching TV,

conversation with child, deep breathing etc.


During Injection (cont.)

Tactile Stimulation

Rubbing or stroking the skin

near the injection site with

moderate intensity may

decrease the pain in older

children and adults.


During Injection (cont.)

Aspiration can be performed in non immunisation injections, but should be fast.

Ensure that the injection is deep into the muscle and fully through any subcutaneous fat. Injection into the fat may result in fat necrosis and abscess.

In case of larger volume injection, inject the drug slowly so as to reduce muscle fascia displacement (which may result in pain and scarring of muscle)

Withdraw the needle at the same angle as for penetration.


Order of Injection

For multiple injections,

especially during immunisation,

inject the most painful injection

(DTP) last


8. Post Injection

Apply a little pressure to the injection site

for 5-10 seconds.

Do not massage or rub the site.

Do not apply hot or cold compresses.

Clean cold wet wash cloth can be applied

over sore area.


Patient should leave the clinic laughing……and not crying….

Intramuscular injection pain ppt

Health & Medicine

Transcript of Intramuscular injection pain ppt