Intramuscular injection: An integrative research review and guideline for evidence-based practice

doi:10.1053/apnr.2002.34142

Applied Nursing Research

Volume 15, Issue 3, August 2002, Pages 149-162

https://doi.org/10.1053/apnr.2002.34142 Get rights and content

Abstract

Intramuscular injections (IM) are a common yet complex technique used to deliver medication deep into the large muscles of the body. More than 12 billion IM injections are administered annually throughout the world. However, it is not a benign procedure, and unsafe injection practices are estimated to have significant impacts on patient morbidity and mortality and result in millions of dollars in direct medical costs on an annual basis. Although there is significant research, spanning 8 decades, on the procedure and techniques of administering medications by the IM route, instruction materials and clinician practice do not always reflect research-based practice. An integrative review of the literature has resulted in the development of a guideline for evidence-based practice of IM injections. Use of this guideline can assist the clinician to maximize the therapeutic effects of administered medication while minimizing or eliminating patient injury and discomfort associated with IM injections.

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Lymph node targeting is a commonly used strategy for particulate vaccines, particularly for Pickering emulsions. However, extensive research on the internal delivery mechanisms of these emulsions, especially the complex intercellular interactions of deformable Pickering emulsions, has been surprisingly sparse. This gap in knowledge holds significant potential for enhancing vaccine efficacy. This study aims to address this by summarizing the process of lymph-node-targeting transport and introducing a dissipative particle dynamics simulation method to evaluate the dynamic processes within cell tissue. The transport of Pickering emulsions in skeletal muscle tissue is specifically investigated as a case study. Various factors impacting the transport process are explored, including local cellular tissue environmental factors and the properties of the Pickering emulsion itself. The simulation results primarily demonstrate that an increase in radial repulsive interaction between emulsion particles can decrease the transport efficiency. Additionally, larger intercellular gaps also diminish the transport efficiency of emulsion droplet particles due to the increased motion complexity within the intricate transport space compared to a single channel. This study sheds light on the nuanced interplay between engineered and biological systems influencing the transport dynamics of Pickering emulsions. Such insights hold valuable potential for optimizing transport processes in practical biomedical applications such as drug delivery. Importantly, the desired transport efficiency varies depending on the specific application. For instance, while a more rapid transport might be crucial for lymph-node-targeted drug delivery, certain applications requiring a slower release of active components could benefit from the reduced transport efficiency observed with increased particle repulsion or larger intercellular gaps.
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Biologics are unaffordable to a large majority of the global population because of prohibitively expensive fermentation systems, purification and the requirement for cold chain for storage and transportation. Limitations of current production and delivery systems of biologics were evident during the recent pandemic when <2.5% of vaccines produced were available to low-income countries and ∼19 million doses were discarded in Africa due to lack of cold-chain infrastructure. Among FDA-approved biologics since 2015, >90% are delivered using invasive methods. While oral or topical drugs are highly preferred by patients because of their affordability and convenience, only two oral drugs have been approved by FDA since 2015. A newly launched oral biologic costs only ∼3% of the average cost of injectable biologics because of the simplified regulatory approval process by elimination of prohibitively expensive fermentation, purification, cold storage/transportation. In addition, the cost of developing a new biologic injectable product (∼$2.5 billion) has been dramatically reduced through oral or topical delivery. Topical delivery has the unique advantage of targeted delivery of high concentration protein drugs, without getting diluted in circulating blood. However, only very few topical drugs have been approved by the FDA. Therefore, this review highlights recent advances in oral or topical delivery of proteins at early or advanced stages of human clinical trials using chewing gums, patches or sprays, or nucleic acid drugs directly, or in combination with, nanoparticles and offers future directions.
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Jet injection technology has become the alternative drug delivery method of conventional needle-based injection due to its obvious advantages. In order to meet the demand for larger volume injection, the pneumatic jet injection systems have efficiently administrated vaccine up to 1 mL in human. Our recent study has also demonstrated that controlling the driving pressure enabled the pneumatic jet injection system to deliver larger volumes of drugs to target sites at desired rates and times. This work continues to explore the optimal two-phase driving pressure combination with better injection efficiency for typical larger-volume (1.0 mL) jet injection with controllable pneumatic jet injection system. Under the combination of a first phase driving pressure of 1.00 MPa and a second phase driving pressure ranging from 0.25 to 0.90 MPa, dynamic characteristics, dispersion characteristics and pharmacokinetic characteristics of this controllable jet injection system were quantitatively analyzed. In all experiments, it was confirmed that the optimal driving pressure combination of 1.0 mL ejection volume was close to (1.00–0.50) MPa. That is, the injection velocities of 151.85 m/s and 102.01 m/s for the first and second phase respectively facilitated better injection performance with a controlled release of 1.0 mL ejection volume. This strategy is practical for facilitating the clinical application of large-volume controllable jet injection systems.
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Citation Excerpt :
On the other hand, the phenomenon of collapsing air pockets also generates microjets and shock waves, which can rupture red blood cells in artificial heart valves and can be detrimental to soft tissue (Garrison et al., 1994; Johansen, 2004; Rambod et al., 1999). Introducing air bubbles (0.1–0.2 ml) before drawing medication into a syringe was a common-place practice among clinicians and nurses in the United States before the widespread use of disposable syringes in the 1960s (Beyea and Nicoll, 1995; Nicoll and Hesby, 2002). These air bubbles were used to correct the medication dosage to account for the dead volume in the needle hub.
Needle-free jet injections are actuated by a pressure impulse that can be delivered by different mechanisms to generate high-speed jets ( $V_{j} ~ O (10^{2})$ m/s). During filling and transportation of disposable cartridges and ampoules, bubbles can form, which can be problematic especially for viscous fluids. Here, we report on the effect of location and size of entrapped air pockets in cartridges used in spring-powered jet injections. As air bubbles pass through the orifice, they undergo depressurization, which results in intermittent atomization and spray formation, temporarily increasing the jet dispersion. Atomization and dispersion of the jet can lead to product loss during an injection. We find that the effect of bubble location on the jet exit speed, delivery efficiency, and the projected area of the blebs formed after the injection was statistically significant ( $p < 0.05$ ). The findings of this study have implications for the development of pre-filled cartridges for jet injection applications.
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2021, Materials Science and Engineering C
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Original ArticlesIntramuscular injection: An integrative research review and guideline for evidence-based practice

Abstract

Original Articles
Intramuscular injection: An integrative research review and guideline for evidence-based practice