1. Injection Administration Techniques
Rachel Nowak, PharmD
Clinical Instructor, UWSOP
Bartell Drugs Clinical Coordinator
January 29, 2010

2. Objectives
Describe proper techniques for administering injectable drugs
Describe precautions to take when administering injectable products
Appreciate pharmacist role in administering injectable medications

3. Vaccines 101

4. Immunity Passive Immunity Active Immunity
Antibody produced by one human or other animal is transferred to another
Temporary protection
Example: Immunity an infant receives from its mother
Active Immunity
Immune system is stimulated to produce cellular and humoral immunity
Lasting protection
Example: Survive infection from the disease causing organism

5. Basic MOA of Vaccines Vaccinations produce active immunity.
Immune response and immunologic memory produced is similar to that caused by natural infection.
Comes without the risks of the actual disease and associated complications.

6. Classifications of Vaccines
Live attenuated
Attenuated or weakened form of disease-causing bacterium or virus
Must replicate to be effective
Uncontrolled replication of the vaccine virus can cause severe reactions - only occurs in patients with immunodeficiency
Immune response is cellular & humoral
Circulating antibodies interfere
Usually produce immunity after one dose

7. Classifications of Vaccines
Inactivated
Inactivated form of bacterium or virus
Can’t replicate
Can’t cause disease, even in immunodeficient patients
Immune response primarily humoral
Less affected by circulating antibody than live vaccines
Always requires more than one dose
Antibody titer decline over time

8. Immunization Procedures

9. Screening Standard Questions Do you have any drug/food allergies?
Do you have any chronic diseases?
What medications do you take?

10. Basic Vaccine Screening Questions
Are you sick today?
Are you allergic to latex?
Do you have any allergies to any vaccine or vaccine components?
Ex: Eggs, gelatin
Have you ever had a serious reaction after receiving a vaccine?
Have you had Guillian-Barre Syndrome in the past?
Is it possible that you could be pregnant? Breastfeeding?

11. Additional Vaccine Screening Questions
Do you have cancer, leukemia, AIDs, or any other immune system problem?
Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you had radiation treatments?
In the past year, have you received a transfusion of blood or blood products or been given immune globulin or an antiviral medication?
Have you received any vaccinations in the past 4 weeks?

12. Consent Answer any questions patient may have
Patient needs to understand benefits and risks of getting immunized and consent to vaccine administration.
If it is a child under 18, then parent or guardian consent should be obtained

13. Vaccine Information Statements (VIS)
Patient education sheets developed by the CDC
Helps to explain the risks and benefits of receiving a particular vaccine
Federal law requires that VISs be used for most vaccines when vaccinating patients
Should be given before vaccine administered

14. Parts of a Syringe

15. Preparing Syringe Choose correct SYRINGE size Maximum volumes
If <0.5ml need low-dose syringe (1mL, 3mL)
Finely graduated syringe will ensure accurate amount
Fluzone (influenza) is 0.5mL dose
Pneumovax (pneumonia) is 0.5mL dose
Maximum volumes
Deltoid – No more than 0.5-1mL
Large muscle (gluteus medius)
Adult – no more than 4mL
Child – no more than 1-2mL

16. Needle Lengths and Gauges

17. Preparing Needle Choose correct needle LENGTH and GAUGE
Minimize tissue injury and SQ leakage
Allow easy passage (23 vs. 25 gauge)
Needle length depends on injection site
Adults 5/8” vs. 1” vs. 1.5”
Children 5/8” vs. 1”
If less SQ fat, use smaller needle

18. Get Organized Get all supplies ready in advance Double Check Record
ex: Band-Aid, alcohol pad, cotton ball, VIS
Double Check
Correct vaccine, dose, & expiration date
Go over screening/consent form with patient
Record
Vaccine name, manufacturer, lot number, expiration date
Location of administration (L/R deltoid)
Provider administering the vaccine
Vaccine Information Sheet publication date

19. Administer the Vaccine
Cleanse area with alcohol swab
Allow alcohol to dry
Target
C technique and shoot (IM)
Bunch skin (SQ)
Inject – DO NOT Aspirate
Dart-like motion with steady pressure
Inject at:
90° angle for IM
45° angle for SQ

20. Final Steps Do not recap needle Dispose of needle properly
Apply pressure to injection site with cotton ball (if necessary)
Apply adhesive bandage
Provide patient with immunization record & Vaccine Information Statement (VIS)
Record all necessary information
Have patient remain under surveillance for ~15 minutes

21. Routes of Administration

22. Intramuscular (IM) Injections

24. Subcutaneous (SQ) Injections

26. Self-Injection Teaching: Insulin
Advise patients to wash hands
Have patient confirm type of insulin on bottle label
Roll vial or pen in palms, if appropriate
Show patients in counseling where to read dose on syringe and appropriate amount to draw
Ensure using best syringe for dose
Inject at 90° angle for SQ insulin
Injecting into the subcutaneous fat of the belly most common
Site should be approximately 2 inches from belly button
Rotate sites
avoid formation of fatty deposits or scarring

27. Insulin Injection Sites
Alternate sites include the back of the arms, thighs, and buttocks
Slower onset with alternate sites

28. Self-Injection Teaching: Insulin
Go over insulin storage
Generally insulin not in use should not be stored in fridge
Extreme temperatures and excess agitation should be avoided
Discard dates
Important to go over how long insulin can be stored at room temperature
Insulin inspection
Mixing of Insulins
Proper disposal of sharps

29. Self-Injection Teaching
Pen devices/ insulin cartridges:
Deliver insulin subcutaneously through a needle.
All a little different and might require extra teaching time
In specific patient populations these devices have been demonstrated to improve:
accuracy of administration
adherence
Requires needle to be left embedded in skin for at least 5 seconds after plunger depressed

30. Managing Adverse Reactions

31. Vasovagal Syncope (Fainting)
Be aware of patient behavior
Have patient sit before administration
Lay patient down if necessary
Check airway, breathing and vital signs

32. Anaphylaxis Rare but potentially fatal Occurs within 15 minutes
Call 911
Lay patient down, check airway, breathing, vital signs
Be prepared and ready to administer epinephrine (Epipen)

33. Delayed Adverse Reactions
Child – fever, fussy, crying, injection site
Adult – injection site discomfort
Symptomatic relief
Fluids
Pain medications
No aspirin for children
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)

34. Reporting Adverse Reactions
Vaccine Adverse Event Reporting System (VAERS)
Required for:
- Rare, serious or unexpected events

35. Emergency Plan and Training
Access to Emergency Medical Services (EMS) – phone on hand
Be prepared for adverse reactions
CPR trained staff
Necessary medications on hand
Have patient remain under surveillance after administration

36. Universal Precautions
Controlling Infection Transmission

37. Practice good technique
Be Prepared
Control infection transmission
Use universal precautions
Proper cleaning and disposal of waste
Anticipate adverse effects
Assure patient safety
Know your equipment
Establish quality procedures
Practice good technique

38. Protect Yourself: Use Universal Precautions
Infection control guidelines designed to protect workers from exposure to diseases spread by blood and certain body fluids
Assume all patients to be infectious for blood-borne diseases

39. Universal Precautions Apply To:
cerebrospinal fluid
pleural fluid
peritoneal fluid
pericardial fluid
amniotic fluid
Blood
semen
vaginal secretions
synovial fluid
Universal precautions should be applied to all body fluids when it is difficult to identify the specific body fluid or when body fluids are visibly contaminated with blood.

40. Universal Precautions DO NOT necessarily apply to:
feces
nasal secretions
sputum
sweat
tears
urine
vomit
saliva (except in the dental setting)
But, you must still be mindful of transmitting infectious material.
They may not carry blood-borne illness, but they do carry viruses and bacteria.

41. Universal Precautions
Wear gloves if likely to touch body substances or mucous membranes
Latex or non-latex
Monitor for allergies
Wear eye protection if likely to be splashed
Wear lab coat or gown if likely to be soiled

42. Universal Precautions
Place needles in special containers (Sharps Container)
Place soiled articles in plastic bag for disposal
Place soiled linen in laundry bag

43. Pharmacists Role

44. Pharmacist Role Dispensing versus administration Makes sense for:
Vaccinations
Teaching patients to self-inject
Insulin and glucagon
Increasing availability of self-injection products
Allergic reactions, migraine, MS, infertility
Proper training required

45. Why are immunizations so important?
Profession:
Establishes the role of the pharmacist
Patients:
Pharmacists are easily accessible
Population:
Preventing disease

46. For More Information
APhA: Pharmacy-Based Immunization Delivery Certificate Program
Center for Disease Control – Vaccines
Vaccine Adverse Event Reporting System