Download Using the ventrogluteal site for intramuscular

Using the ventrogluteal site for intramuscular injection Nursing
Standard Harrow-on-the-Hill Mar 3-Mar 9, 2004
------------------------------------------------------------------------------Authors:
Kathleen Greenway
Volume:
18
Issue:
25
Pagination:
39-42
ISSN:
00296570
Copyright RCN Publishing Company Ltd. Mar 3-Mar 9, 2004
Full Text:
Summary
The administration of intramuscular injections is a common nursing
intervention in clinical practice. This article aims to raise awareness
of the use of the ventrogluteal site for administering intramuscular
injections. It describes the main reasons for using this site and
outlines the complications associated with the dorsogluteal site. It is
hoped that this review of the literature will shift everyday practice
in favour of the ventrogluteal site.
Key words
* Injections
* Intramuscular injection sites
* Nursing practice
These key words are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
THE EXTENT to which the ventrogluteal site is used in the UK for
administering intramuscular (IM) injections is unknown (Rodger and King
2000). It is important that practitioners constantly re-evaluate and
update the care they give and embrace the latest research findings, by
applying evidence-based practice. Hamerand Collinson (1999) view this
as: 'Finding, appraising and applying scientific evidence to the
treatment and management of healthcare. Its ultimate goal is to support
practitioners in their decision-making to eliminate the use of
ineffective, inappropriate, too expensive and potentially dangerous
practices.'
The dorsogluteal versus ventrogluteal injection sites
Nurses in the UK tend to use the dorsogluteal site as the site of
choice for IM injections, despite the fact that this choice of site is
ineffective, inappropriate and potentially dangerous (Table 1 ). A
study by Parley et al (1986) identified that only 12 per cent of the
nursing staff in a teaching hospital in the United States used the
ventrogluteal site. Whether it is better to use the ventrogluteal or
the dorsogluteal site has not yet been debated in the UK.
The administration of injections is one of the skills that nurses use
regularly in clinical practice. The objective of an IM injection is to
deliver the drug into the muscle layer beneath the subcutaneous tissue.
This route of administration provides rapid systemic action and
absorption of the drug in relatively large doses (up to 5ml in most
sites) (Campbell 1995). As muscle tissue has relatively few sensory
nerves, IM injections allow less painful administration of concentrated
or irritating drugs, and also avoid such drugs damaging the
subcutaneous tissue (Campbell 1995).
Dorsogluteal injection site
The dorsogluteal site or the 'upper outer quadrant' as it is known
colloquially, is traditionally the IM injection site of choice. However,
when this injection site is used there is a significant risk that the
drug will not reach the muscle, but will be injected into the
subcutaneous tissue layer, as this area is covered with subcutaneous
tissue in many people. A study by Cockshott et al (1982) identified
that of 213 adults who were injected in the dorsogluteal site by nurses,
less than 5 per cent of women and 15 per cent of men would have
received an IM injection into the glutei. These results support earlier
work by Lachman (1963), who reported that subcutaneous fat in adults in
the dorsogluteal area varies from 1cm to 9cm. This means that the
absorption rate of the drug will be adversely affected, or the tissue
may become irritated when the drug does not reach the intended target
muscle.
This is not the only problem associated with using the dorsogluteal
site. Rodger and King (2000) state that the system of visually
bisecting the buttocks horizontally and vertically has been used for
many years. Yet the threat of injury remains significant as the sciatic
nerve and the superior gluteal artery lie only a few centimetres distal
to the dorsogluteal injection site. Injecting into the sciatic nerve
(Figure 1) could cause pain and temporary or permanent paralysis
(Covington and Trattler 1997).
Ventrogluteal injection site
The ventrogluteal site is relatively free of major nerves and blood
vessels, the muscle is large and well defined, and the landmarks for
administration are easy to locate (Wong 2002). The ventrogluteal site
consists of the gluteus medius muscle, which is located on top of the
gluteus minimus muscle. Colloquially, it is also called the 'hip site'
(Figure 2). Zelman (1961) reported that this location provides the
greatest thickness of gluteal muscle - the gluteus medius and gluteus
minimus. The site is sealed off by bone and there is a narrower layer
of fat of consistent thinness than is present in the posterior buttock.
Michaels and Poole (1970) concluded that the ventrogluteal site
provides the most consistent layer of adipose tissue, eliminating the
need to determine the depth of subcutaneous fat. They studied cadavers
and deduced that the subcutaneous fat in the ventrogluteal area is less
than 3.75cm. This means that a ventrogluteal injection can be
administered with confidence that the drug will reach the target muscle
and not the subcutaneous tissue in each patient (Figure 3). In effect,
it removes the subjectivity of assessment as the nurse can be sure that
a standard 21 gauge (green) or a 23 gauge (blue) needle will penetrate
the muscle.
[IMAGE TABLE] Captioned as: Table 1. Comparing dorsogluteal and
ventrogluteal IM injection sites Captioned as: Figure 1. Location of
the dorsogluteal site
Beyea and Nicoll (1996) suggest that the ventrogluteal site should be
the primary site for anyone more than seven months of age and state
that the only contraindications are muscle contraction, damage in the
area and the administration of the hepatitis B vaccine. The typical
volume of drug administered is 1-4ml (Workman 1999).
Use of the ventrogluteal site is not new - Hochsetter (1954) was the
first person to suggest it as an appropriate site. Zelman (1961 )
suggested the two basic sites for an IM injection: the traditional
upper outer quadrant that is the posterior gluteal muscle; and the
anterior gluteal muscle, which he called the anterior lateral site, and
is now termed the 'ventrogluteal site'. It is no surprise that the
terminology became confused and that, despite the evidence, nursing
texts perpetuated the use of the dorsogluteal site throughout the 1960s.
Beyea and Nicoll (1995) directly attribute this to the confusion
surrounding site names, location, landmarks and target muscles.
Many authors have described the ventrogluteal technique with varying
diagrams and large lengths of text, which give the impression that it
is a complex procedure. This is not the case. The most succinct
description of the technique of administering a ventrogluteal injection
is given by Beyea and Nicoll
(1996) who state that: To identify the ventrogluteal site, position the
palm of your right hand on the left greater trochanter so your index
finger points towards the anterior superior iliac spine (use your left
hand on the right greater trochanter). Now spread your middle finger to
form a V. The injection site is in the middle of the V.'
During this technique, it is advisable to position the patient on his
or her side (left or right as appropriate) with the knee bent, as
bringing up the knee helps to relax the buttock muscles (Box 1). Giving
the injection with the patient in a seated position is also possible.
The key to this technique is to map out and then visualise the site.
Remember to remove your fingers before inserting the needle to avoid
needlestick injury. If you have small hands, Covington and Trattler
(1997) suggest that you slide your palm above the trochanter until you
can reach the anterior superior iliac spine with your index finger
(Figure 2). A comparison between the ventrogluteal and dorsogluteal
injection sites is outlined in Table 1.
Health and safety
Needlestick injuries continue to be a source of concern for every nurse
giving an injection. This concern is justified as the Exposure
Prevention Information Network (1999) surveillance system demonstrated
that nurses are the healthcare personnel most likely to sustain a
sharps injury, which is directly related to the amount of direct
patient care they provide. However, all healthcare workers and patients
are at risk of sustaining a sharps injury.
The hepatitis B virus carries the highest risk of transmission,
although most staff are not at risk as they will have been immunised
and therefore possess antibodies to the virus. If they are not
protected, it is possible to give hepatitis B immune globulin postexposure. This is not the case for hepatitis C, for which there is no
vaccine and exposure can only be treated by irrigating the injury site.
Promoting bleeding at the site is also recommended, although the
efficacy of this intervention is unknown (Fahey et al 1993).
May and Brewer (2001) state that the risk of acquiring HIV infection
following occupational exposure to HIV-infected blood is relatively low.
Post-exposure viral medication such as zidovudine appears to be
effective in halting seroconversion, showing results of up to 80 per
cent reduction in the risk of infection (Cardo et al 1997). Similar
guidance is given by the Department of Health (2004), despite the fact
that Ricketts and Deschamps (1992) reported at least four instances
where the administration of zidovudine failed to prevent HIV infection
following exposure. The risk of seroconversion to HIV may be higher in
injuries sustained following sub-categories of sharps procedures, such
as venepuncture or IM injection (Heptonstall et al 1993).
Barriers to changing practice
The reluctance of nurses to change from a familiar procedure is
understandable, considering all the concerns about needlestick injury
and landmarking the injection site. Another issue is that nurses are
giving fewer IM injections, with the advent of alternative methods for
giving medication, such as patient-controlled analgesia pumps and
epidural infusions. This may also have the effect of decreasing the
nurse's confidence in trying a different technigue.
Reluctance to use the ventrogluteal site may also stem from that fact
that, unless they are taught how to use this technique, nurses will
lack the confidence to carry out the procedure unaided - it is
difficult to put the information learned from a diagram into practice
or even to graduate from practising on a mannequin to injecting a
patient without support and guidance. This difficulty is fully
acknowledged and is an issue for nurses and nursing lecturers with an
interest in clinical practice development to debate.
[IMAGE ILLUSTRATION] Captioned as: Figure 2. Location of the
ventrogluteal site for intramuscular injection
Nurses may also express concern about what site should be used if the
ventrogluteal site is inflamed, has an abscess or local tissue damage.
The deltoid muscle should be used for 1 ml or less of injection fluid
and the vastus lateralis (outer thigh) is the site of choice for more
than 1ml of fluid (Covington and Trattler 1997). Covington and Trattler
(1997) state that the dorsogluteal site should be the last option for
administering IM injections.
Conclusion
The evidence for using the ventrogluteal site has been presented, and
yet it seems that the UK is falling behind other countries in the
uptake of this technique. In the interest of patient safety, the
evidence that the dorsogluteal site has several risks associated with
it, such as damage to the sciatic nerve, entering the superior gluteal
artery and irritation to subcutaneous tissue, cannot be ignored. In
addition, the depth of fat in the buttock is so variable that the
result is usually an 'intra fat' (subcutaneous tissue) injection as
opposed to an IM injection, which may adversely affect the uptake of
medication.
[IMAGE TABLE] Captioned as: Box 1. Giving a ventrogluteal injection
[IMAGE ILLUSTRATION] Captioned as: Figure 3. The skin
A potential way forward to promote change in practice would be to teach
students the ventrogluteal IM technique alongside instruction of the
dorsogluteal site. Feedback from students currently being taught the
ventrogluteal IM technique at Oxford Brookes University suggests that
their mentors cannot support them in using this site as they are not
familiar with this route of administration. Therefore, micro-teaching
sessions in a skills laboratory need to be directed at qualified staff
as well as students for this change in practice to be achieved.
The potential difficulties of this approach relate to resources,
particularly in relation to the time involved in releasing ward staff
and the usual problems that nurses experience when faced with change of
a long-established practice such as the change from task-allocated care
to named nursing or primary nursing
Greenway K (2004) Using the ventrogluteal site for intramuscular
injection. Nursing Standard. 18, 25, 39-42. Date of acceptance:
September 8 2003.
Online archive
For related articles and author guidelines visit our online archive at:
www.nursing-standard.co.uk and search using the key words below.
REFERENCES
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Beyea S, Nicoll L (1995) Administration of medications via the
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Campbell J (1995) Injections. Professional Nurse. 10, 7, 455-458.
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Kathleen Greenway MEd, BSc(Hons), RN, Cert HE, is senior lecturer,
School of Health and Social Care, Oxford Brookes University, John
Radcliffe Hospital, Oxford. Email: [email protected]
Reproduced with permission of the copyright owner.
Further reproduction or distribution is prohibited without permission.