Intramuscular Injection Pain

1. Pain afterIntramuscular Injection Causes and Measures to alleviate it Dr. Kamlesh Lala MBBS, D Ped Dr. (Mrs) Mrudula Lala MD (community medicine) Ahmedabad, INDIA kamleshlala@hotmail.com Dr. Kamlesh Lala/Dr. Mrudula lala

2. Dr. Kamlesh Lala/Dr. Mrudula lala

3. Intramuscular Injection is the most widely practiced percutaneous procedure • Each child is compulsorily exposed to this in his early childhood by way of immunisation • The most common side effect is apprehension and pain Dr. Kamlesh Lala/Dr. Mrudula lala

4. Pain is a subjective phenomenon influenced by multiple factors including • Age • Anxiety level • Previous experience • Ambience • Approach of a provider • Culture Dr. Kamlesh Lala/Dr. Mrudula lala

5. It is said that “Pain is inevitable” But “Suffering is optional” But here we try to reduce this suffering Dr. Kamlesh Lala/Dr. Mrudula lala

6. Concern and anxiety about injections are common for all ages. • Several methods are found effective to relieve this apprehension and discomfort in different stages of injection procedure Dr. Kamlesh Lala/Dr. Mrudula lala

7. Despite ready availability of different modalities, only 6% of pediatric offices use pain control for shots. • Research suggests that poor pediatric pain management results in short and long term repercussions for child, parent and staff. • Untreated immunisation pain might also lead to distorted negative memories of that experience. Dr. Kamlesh Lala/Dr. Mrudula lala

8. Injection should not scare the child Dr. Kamlesh Lala/Dr. Mrudula lala

9. Different Stages of intervention in alleviation of Pain • Before Injection • Drug • Equipment • Site Selection • Pre Injection • During Injection • Post Injection Dr. Kamlesh Lala/Dr. Mrudula lala

10. 1. Before Injection • Give age appropriate dose of NSAID. Avoid aspirin in children. Administer Paracetamol in dose of 15-20 mg/kg. • Local Anaesthetic (5% Xylocaine) can be applied at the site of injection an hour before • Administer sweet tasting liquid (2ml of 20% w/v sucrose or expressed breast milk) immediately before. • Child can even be breast fed immediately before Dr. Kamlesh Lala/Dr. Mrudula lala

11. In one study, the only factor that significantly improved immunisation pain for around 6 month olds was positive parent coping statements in the 30 seconds preceding immunisation Dr. Kamlesh Lala/Dr. Mrudula lala

12. 2. Drug • Shake Test for DTwP vaccine: Shake well the vaccine vial. After shaking, the vaccine sediment within 30 minutes leaving a deposit below a column of transparent fluid. This indicates that vaccine has been frozen in a cold chain. Discard such vial. Frozen vaccine increases the chances of local reaction and sterile abscess. Dr. Kamlesh Lala/Dr. Mrudula lala

13. 2. Drug (cont.) • Benzyl Alcohol (BA) is used to increase the lipid solubility of esterified compounds and to prevent bacteria growth. It can cause destruction of cells and localised pain and inflammation. • After injection of the drug, BA is absorbed from the site causing active drug to precipitate fine crystals within the muscle. This causes pain after 4-12 hours of injection characterised by pain and induration. Dr. Kamlesh Lala/Dr. Mrudula lala

14. 2. Drug (cont.)Tissue Irritation • Tissue irritation is the most common cause of Post Injection Pain. It starts 12-24 hours after injection with warm, red, tender induration. This will fade after 72 hours. • Common with hormone injections and DTP. • More common in a brand manufactured by local drug company. (poor quality of raw material, excessive preservative, too much BA used) Dr. Kamlesh Lala/Dr. Mrudula lala

15. 2. Drug (cont.) • Addition of Benzyl Benzoate (BB) can reduce it. • Gently warm the oily injection by rubbing it in between two palms so as to improve the viscosity of the drug. • Larger than 5 ml volume is not advised for intramuscular injection. It should be divided into multiple injection at different sites. Dr. Kamlesh Lala/Dr. Mrudula lala

16. 3. Equipment • Use new syringe and needle every time. • Longer needle reduces redness and swelling, because medication is sure into the muscle. More so with Chloroquine and Diclofenac. So use 1.5” long needle for gluteal injection in adolescents and adults. • Use wide bore needle e.g.. 23g because narrow bore produces a jet under pressure causing muscle injury and pain. • For oily injection, use still wider bore needle (21g or 22g). Dr. Kamlesh Lala/Dr. Mrudula lala

17. 4. Site Selection • Use anterolateral thigh in children up to 2 years or even up to 5 years. • After that use deltoid muscle • In adults use gluteal muscle for oily injection or if volume is greater than 2 ml. • Larger volumes are better tolerated in larger muscle groups Dr. Kamlesh Lala/Dr. Mrudula lala

18. 4. Site Selection (cont.) • Do not use the same site over and over again for days for multiple injections. • It may cause irritation and muscle injury; and increases the chances of infection. • Rotate the site. Dr. Kamlesh Lala/Dr. Mrudula lala

19. 5. Pre Injection • After swabbing the site with spirit or alcohol, allow it to dry, or it may cause irritation. • Topical refrigerant (vapocoolant) spray immediately before the injection may reduce the short term pain. • Do not keep the air bubble inside the syringe. • Proper positioning of the patient allows to identify the site correctly. • Ensures patient’s comfort by muscle relaxation. Dr. Kamlesh Lala/Dr. Mrudula lala

20. 6. Techniques • 1. Standard technique The needle is introduced at 900 with steady pressure and aspiration to be performed for 5-10 seconds, drug is slowly injected over 5-10 secs., and the needle to be withdrawn slowly • 2. Pragmatic technique The needle is introduced at 900 with steady pressure and no aspiration is to be performed, drug is rapidly injected over 1-2 secs., and the needle to be withdrawn rapidly Dr. Kamlesh Lala/Dr. Mrudula lala

21. Technique (cont.) In a randomised controlled trial to compare acute pain response during immunisation in infants using these two techniques, it was found that Pragmatic technique is less painful than a standard one. Dr. Kamlesh Lala/Dr. Mrudula lala

22. Technique (cont.) Z track technique. Skin is pulled downwards and laterally before injection. This displaces the skin and SC tissue leaving the muscle there only and uses the valve action to prevent leakage of medication into the SC tissue and later on irritation. Dr. Kamlesh Lala/Dr. Mrudula lala

23. Z technique Dr. Kamlesh Lala/Dr. Mrudula lala

24. 7. During Injection • Age appropriate non pharmacological techniques may provide distraction from pain. • Some of the distraction techniques are age appropriate toys, playing music, pretending to blow away pain, watching TV, conversation with child, deep breathing etc. Dr. Kamlesh Lala/Dr. Mrudula lala

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26. During Injection (cont.) • Tactile Stimulation Rubbing or stroking the skin near the injection site with moderate intensity may decrease the pain in older children and adults. Dr. Kamlesh Lala/Dr. Mrudula lala

27. During Injection (cont.) • Aspiration can be performed in non immunisation injections, but should be fast. • Ensure that the injection is deep into the muscle and fully through any subcutaneous fat. Injection into the fat may result in fat necrosis and abscess. • In case of larger volume injection, inject the drug slowly so as to reduce muscle fascia displacement (which may result in pain and scarring of muscle) • Withdraw the needle at the same angle as for penetration. Dr. Kamlesh Lala/Dr. Mrudula lala

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29. Order of Injection For multiple injections, especially during immunisation, inject the most painful injection (DTP) last Dr. Kamlesh Lala/Dr. Mrudula lala

30. 8. Post Injection • Apply a little pressure to the injection site for 5-10 seconds. • Do not massage or rub the site. • Do not apply hot or cold compresses. Clean cold wet wash cloth can be applied over sore area. Dr. Kamlesh Lala/Dr. Mrudula lala

31. Patient should leave the clinic laughing……and not crying…. Dr. Kamlesh Lala/Dr. Mrudula lala