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Jim Kinsman
Aspirating for blood before injecting a subcutaneous medication.

Hello Nursing Colleagues! I was given your website by Michelle Followell CRNI with Midwest Vascular Access, LLC to see if anyone can help me with a project. I am searching for any literature to substantiate it is not necessary to aspirated for blood return when giving a subcutaneous injection. I was taught some 24 years ago in school it is not necessary and is a safe practice based on there are no large vessels in subcutaneous tissue to worry about giving a drug IV. When I taught in an LPN program we taught both schools of thought. I am now working on this for the company I work for. I work as  program specialist in a call center that deals only with patient's who inject the drug Enbrel. We are trying to change our scripting to alleviate removing the air bubble from the pre-filled syringe and aspirating for blood but the manufacturer is reluctant for legal reasons. They want something that says it is a safe practice which I understand from their standpoint. Interestingly enough, with our SureClick autoinjector the same amount of air is in it as the pre-filled syringe and we have scripting that states it is ok to inject a small amount of air into the subcutaneous tissue and obviously one can not aspirated for blood with any autoinjector. Please feel free to contact me. Any and all suggestions will be helpful. Have a wonderful holiday weekend. I look forward to your responses. Thank you in advance.

Jim Kinsman RN
Program Specialist
Accredo-Clinical Business Solutions
12900 Foster, Suite 300
Overland Park, KS 66213
913.339.7176 / 800.321.6622 x7176
[email protected]

lynncrni
I write the anatomy and

I write the anatomy and physiology chapter of the INS textbook and I would question the idea that there are no large blood vessels in the subcutaneous tissue. Quite the contrary!! The veins that we use for starting all short peripheral catheters and drawing blood samples are located in the subcutaneous tissue. So it is quite possible for a SC injection to enter a blood vessel, either a vein or small artery. All layers of skin are supplied by blood, which means arteries and veins, however the size decreases as you move toward the skin surface. The layers include epidermis, dermis and the subcutaneous tissue. So no matter the size of the vessel, there will always be the possibility that you will enter a vessel. With that being said, we would have to ask what is the likelihood that these SC injections would have the needle tip residing in the lumen of a vessel so that IV injection will happen. I don't know the answer to this based on evidence, but I hope someone would. BD Medical has a resource booklet on all injection processes with references. That may have an answer, but I am not in my office to check it. When SC injection is given for injection of local anesthetics prior to venipuncture, aspiration for a lack of blood return is an important step.  

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Jim Kinsman
Thank you for responding

Thank you for responding Lynn. I guess I should have been more specific. The three injection sites we teach are the front of the middle thighs (anterior surface), the abdomen except for the two inch area around the naval, and the outer aspect of the upper arm. All of our needles are 27 g 1/2 inch. The SureClick autoinjector injects at 90 degrees and penetrates into the subcutaneous tissue only 6 mm. Our prefilled syringes we teach to inject at a 45 degree angle. Hope that clarifies. To the best of my knowledge there should be no vessels large enough in these areas to enter unless the patient is extremely emaciated. By the way your name was given to as well as an outstanding resource to contact. I spent many of my nursing years in home infusion nursing. Thanks again.

Jim Kinsman RN 

lynncrni
thanks for the information

thanks for the information about the size and length of needle. I was wondering that after I wrote my message. I have been injecting Byetta for 2 years now with a 31 g, 3/8 inch needle and have had many bruises and a few occasions of bleeding. I would have to refresh my memory on the depth of the skin layers, but I think it is commonly about 4 mm and it becomes thinner with age. I do think it is possible to inject into a subcutaneous vein with a 1/2 inch needle. But the autoinjector pens have no mechanism for aspirating. So this is a dilemma about how to apply this technology. These pens have so many benefits, otherwise. While it is possible to hit a blood vessel, it may be unlikely that the drug would be injected into the vessel because the needle has passed through both walls of the vessel.  

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Jim Kinsman
Good morning Lynn. Would you

Good morning Lynn. Would you be willing to write a statement substantiating it is not necessary to aspirate for blood during a subcutaneous injecton? Amgen needs a satement from an expert so we can rewrite our scripting instructions. I appreciate all of your help.

Jim

lynncrni
Please contact me at

Please contact me at 770-358-7861 to discuss your needs and the available evidence. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Jim Kinsman
Good morning Lynn. Would you

Good morning Lynn. Would you be willing to write a statement substantiating it is not necessary to aspirate for blood during a subcutaneous injecton? Amgen needs a satement from an expert so we can rewrite our scripting instructions. I appreciate all of your help.

Jim

Donna Fritz
It's interesting that in the
It's interesting that in the Lippincott reference, two subcutaneously injected medications are excepted from the "pull back" technique.  Wonder if G-CSFs might also be included in that list--also subcutaneous.  Why is it not necessary for insulin?  Because it's a subq injection? 
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