SAFE INJECTION TECHNIQUES
Dr. Sachidananda Kamath*
Department of Pediatrics.*
Injections are one of the most often used health care interventions in clinical practice, and are used for preventive, curative and diagnostic interventions. They can be defined as "a skin-piercing event performed by a syringe and needle with the purpose of introducing a curative substance or vaccine into a patient by the IM/IV/SC/ID route".

WHO defines safe injection as one, which (a) does no harm to the recipient (b) does not expose the health worker to any risk, and (c) does not result in waste that is dangerous for the community

To achieve this, first, the injection should be prepared on a clean workspace that is free from any blood contamination. Second, the provider should wash his hands in an appropriate and technically correct manner. Third, a sterile syringe and needle should be used. Fourth, medication and diluents should be drawn from a sterile vial. Fifth, the skin should be cleaned before injection. Sixth, the used syringe and needle should be collected in a puncture and liquid-proof container. Finally, sharp waste should be managed appropriately. Failure to respect any of these steps exposes the recipient, the provider, or other people to unacceptable risks.

The most common danger of unsafe injections are infections, particularly infections with blood-borne pathogens, among which hepatitis B virus (HBV), Hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Infections represent the largest burden of death and chronic disease. Besides HBV, HCV and HIV, selected outbreaks of viral hemorrhagic fevers have been associated with unsafe injection practices. Other injection-associated infections are of bacterial etiology and include abscesses and septicemia.

Injection therapy over the years has become widespread and popular in India. Of all the injections given, majority are for curative purposes and only 15-20% are for immunization. Both the qualified and unqualified healthcare providers give these injections. Various studies done in India have over a period of time have found unsafe injections to be major risk factor in transmission of blood-borne pathogens. Government of India with World Bank funding has instituted an assessment of injection practices in India, which was conducted by the INCLEN; the study found out that:

  • Overall on an average, 2.9 Injections per person per year are administered in the country based on a 3 month recall.
  • At the country level, almost half (48.1%) of all clients coming out of health facilities had received injections during their visit.
  • 51.1% of the curative injections at the all India level were prescribed for symptoms of fever/cough/diarrhea.
  • 62.9% injections i.e., nearly 2/3rd Injections are unsafe and 31% of these carried a potential risk of transmitting blood-borne viruses, and 53% were unsafe due to use of faulty techniques.

Other studies published over the years have put the number of injections given at 4 injections/person/year and proportion of unsafe injections at 50% of all injections given; these unsafe injections were also seen as a major risk factor in the spread of blood-borne pathogens like Hepatitis B, C and HIV.

Many of the 12 billion injections that are administered annually worldwide are administered under unsafe conditions. In a review of published and unpublished studies, Adam Kane and his collaborators in the bulletin of WHO estimated that in the developing world, the proportion of injections that are administered with a syringe and/or needle administered without sterilization ranges from 15% in former socialist economies of Eastern Europe and in the Middle East crescent to 50% in sub-Saharan Africa, China, India, and the Rest of Asia.

When injections are overused and when breaks in infection control occur, blood-borne pathogen may be transmitted. Across the various regions of the world, the number of new persons infected with blood-borne pathogens due to unsafe injections ranges from 96,000 for HIV, 2 million for Hepatitis C virus (HCV), and 21.7 million for Hepatitis B virus (HBV).

The transmission potential of HBV, HCV, and HIV is known from the studies for which healthcare workers have been followed for occurrence of infection with blood-borne pathogens after accidental needle-stick injuries. After an accidental needle-stick from an HBV-infected source patient, the probability of infection for susceptible recipients averages 30%. After an accidental needle-stick from an HCV infected source patient, the probability of infection for susceptible recipients is 10 times smaller and averages 3%. For HIV, the probability of infection for susceptible recipients after an accidental needle-stick is 100 times smaller than HBV and averages 0.3%. Thus, while the transmission of HIV through unsafe injections is of particular concern because of its severity, it is less common than HBV and HCV transmission. Hepatitis B is the most likely pathogen transmitted through unsafe injections.

To achieve prevention, a multidisciplinary approach is needed to achieve safe and appropriate use of injections. First, behaviour of healthcare providers and patients must be changed to decrease injection overuse and achieve injection safety. Second, there should be provision of sufficient quantities of appropriate injection equipment and infection control supplies. Third, a sharp waste management system should be set up to ensure that disposable equipment is destroyed and not re-used.
Safe Injection Practices
To make sure that the entire process of administering an injection is safe, the equipments used, techniques applied and processes involved should be handled in a most safe and hygienic manner. It is also known that skin and the environment contain micro-organisms which may be commensals but on the first opportunity become pathogenic. Unsafe injections can spread pathogens more easily than inhalation, swallowing or sex as they introduce them directly into the blood stream. As health care professionals, it is our responsibility to ensure that all healthcare interventions are safe for our clients, the community at large and ourselves.

Hands are the principal route by which cross-infection occurs and hand-washing is one of the most important standard precautions for preventing the spread of diseases. Hand decontamination is a simple and effective way in which Health Care Workers or Professionals (HCW/HCP) can prevent the transmission of infection. Effective hand washing technique involves three stages; Preparation, Washing and Rinsing and Drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The hand wash solution must come in contact with all the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10-15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly prior to drying with presterilized and clean towels or allowed to air dry. Apply an emollient hand cream regularly to protect skin from the drying effects of regular hand decontamination.

Cleaning the injection site before giving injection is a good clinical practice. It decreases number of microorganisms present in the skin and may reduce the risk of abscess. If swabs are used to clean the skin they should be used in an inside out semicircular movement or, top to bottom without returning to the site. In most cases though the recipient may be asked to wash the site prior to injecting. If Alcohol is used for cleaning, it should be allowed to dry before injection is given.

Preventing contamination of injection equipment is as important as having a clean site. Any part of the syringe that comes in contact with the injectable drug and human anatomy should NOT be touched. If accidentally any of these parts are touched, the syringe and needle are NOT sterile and needs to be discarded immediately in the appropriate container and new sterile syringe and a sterile needle should be used.
Site Selection
It varies according to the age of the recipient and the vaccine/drug effect may be enhanced or diminished. All complications of nerve injury, muscle contracture of injection are also site dependent. The preferred site for injections in pediatric patients is anterolateral aspect of thigh and the deltoid region. Vaccines should never be given in the gluteal region, as gluteal fat retards absorption, thus affecting antibody titers.

Anterolateral thigh is the preferred site for IM injection in children, the target muscle is Vastus Lateralis. Here injection is given on the anterolateral aspect of thigh, middle third portion between greater trochanter and lateral femoral condyle.

The Rectus Femoris muscle (which is anterior on the thigh) should not be used.

Deltoid muscle is the alternate site for children above 3 years. The injection is given 3-5 cm below the acromion process or midway between acromion process and deltoid insertion. The muscle space is adequate for low volume injections. If not positioned properly, there is a potential for injury to axillary and radial nerves and posterior circumflex humeral vessels.

Triceps muscle should never be used since radial, brachial and ulnar nerves and profunda brachii artery are under the muscle.

Positioning is important to ensure that the pain is less and also there is no injury to the provider and the patient.

Thigh: Child may be laid supine or be held on adult's (mother's) lap.

Deltoid: Child may be held on adult's lap or may sit. The part should be completely exposed and the child positioned such that the target muscle is fully relaxed.

Needle Size: Needle length depends upon the site, age of child and muscle mass.

Intradermal for BCG: 26/27G x 16 mm.

Intramuscular Injection:

  • 23G x 25 mm needle for most children
  • For preterm/small babies (<2 m) - 26/27G x 16 mm.
  • Very obese children - 23G x 38 mm.

Subcutaneous injection: (Measles, MMR vaccines): 23G x 25 mm needle.
Injection Technique
  • Intra-muscular: Stretch the skin flat and push the needle down at 90°.
  • Subcutaneous: Pinch up the skin between thumb and forefinger so as to lift the adipose tissue and then push the needle in the pinched up tissue at a 45°.
  • Intradermal: Needle inserted at an angle parallel to long axis (at approx. 15°) for about 2 mm, so that entire needle bevel penetrates the skin and the injected solution raises a small bleb.

    There is no need to aspirate before injecting in immunization. The vaccine should be injected at a moderate rate of around 1 ml/10 sec.
  • Multiple Injections: Use separate syringe and needle for each injection, if more than one preparation is administered or if vaccine and an immunoglobulin preparation are administered simultaneously, it is preferable to administer each at a different anatomic site. It is also preferable to avoid administering two intramuscular injections in the same limb, especially if DPT is one of the products administered. However, if more than one injection must be administered in a single limb, the anterolateral aspect of thigh is usually the preferred site because of the greater muscle mass; the injections should be sufficiently separated (i.e., 1-2 inches apart) so that any local reactions are unlikely to overlap.


Post Injection

The child should be observed for 15 minutes. The recipient should be explained to look out for complication, both immediately and 2-4 hours later if possible. Instruct parents regarding self management of minor reactions and to report if any major problem arises.

Emergency and resuscitation equipment should always be kept in readiness.

Injections are the most common invasive interventions carried out in the OPD, and so has the most potential to transmit blood-borne pathogens. Strictly following the safe injection practices and techniques would help in minimizing the risk of spread of disease and make injections a safe and effective technique for our patients.
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