GENERAL PRINCIPLES INJECTION DEVICES AND ROUTE

While specific details of various procedures in pediatric practice are discussed in relevant later sections, some general guidelines are as follows:

a. Explain the purpose of procedure to child/parents in simple terms t alleviate their anxiety and ensure cooperation.

b. Obtain written consent for all major procedures. No consent is required for minor procedures, e.g. blood collection, peripheral venous cannulations or day- to-day injections, though the need for the procedure must be explained in advance.

c. Ensure availability of necessary instruments/ equipments before the procedure, including proper containers for sending laboratory samples.

d. Ensure adequate pre-procedure sedation and/or vagolytic medications before painful procedures, specially in older children. Local/general anesthesia may be necessary for select procedures.

e. Ensure adequate lighting and environmental temper­ature at the procedure site. It is preferable to conduct even minor procedures in a separate room rather than in the pediatric ward, to reduce apprehension among other children.

f. Ensure proper restraining of child during procedures, which is essential not only for the success of procedure but also to minimize the risk of injury and complications.

g. Ensure adequate aseptic precautions, including proper hand washing, use of gloves/masks, etc., local antiseptic cleaning/draping of procedure site and use of disposable/sterile equipments.

An injection may be defined as a procedure involving piercing of the skin or mucus membrane, either to introduce a substance into the body or to withdraw blood samples, body fluids or body tissues for diagnostic investigations.

Unsafe injection practices continue to be important health hazards in developing countries including poten­tial risk for transmission of infections. According to an estimate, over 30% of injections in developing countries are considered as unsafe.

An injection is considered unsafe due to: (a) faulty technique, (b) faulty drug/agent given through it, (c) faulty sterilizations of equipments, and (d) faulty waste disposal. This chapter deals with some important issues regarding injections in children, excluding IV injections, discussed elsewhere.

A. Injection devices: Two most important injection devices are syringes and needles.

Syringes may be broadly divided into three types: (a) Glass BD syringes, (b) disposable plastic syringes, and (c) auto-disabled syringes. Glass BD syringes (named after design manufacturer-Becton-Dickinson) are no longer used in routine practice.

• Disposable plastic syringes, available in pre-sterilized (gamma-radiation) pack with different sizes (2-50 ml), are most widely used syringes at present, for: (a) IM/ IV injections, (b) blood sample collections, (c) pleural/ ascetic tapping, (d) nasogastric feeding/aspiration/ lavage, (e) irrigation of abscess, etc., and (f) infusion of medications by infusion pump.

• Single-use autodisabled syringes, e.g. uni-ject or solo- shot syringes are preferred choice for immunization

Fig. 32.2: Tuberculin syringe.

purpose and available at many centers under national immunization program. In these syringes, the plunger cannot be withdrawn after single use, to prevent re-use (Fig. 32.1).

• Tuberculin or insulin syringe is a slender and long one-ml glass syringe with colored plastic or metal piston. While tuberculin syringe is graduated in ml, insulin syringe is graduated in units (Fig. 32.2). Tuberculin syringe is commonly used to administer very minute quantities of drugs for: (a) tuberculin test, (b) BCG vaccination, (c) insulin therapy, (d) test­dose of penicillin, and (e) precise dosing in newborns.

Needles may be broadly divided into two types - reusable without any plastic part and disposable with plastic shoulder. Reusable syringes are rarely used at present.

Needles are commonly used for: (a) parenteral drug injections, (b) blood samples collections, (c) withdrawal of drug from vials/ampoules, and (d) addition of drugs into IV lines, apart from, (e) miscellaneous uses, e.g. foreign body removal, etc.

B. Injection routes: Commonly used injections may be broadly divided into four categories: (a) intra­venous injections, discussed elsewhere, (b) intra­muscular injections, (c) subcutaneous injections, and (d) intradermal injections. Some important aspects of correct injection techniques for various routes of injections (Fig. 32.3) are as follows:

• Intramuscular injections are used for most vaccinations and many parenteral drug administrations. Generally, the anterolateral aspect of thigh is the safest and preferred site in infants for IM injections, due to higher risk of underlying nerve injury in gluteal or deltoid injections. Upper and outer quadrant of gluteus maximus may be used for vaccinations beyond infancy.

Fig. 32.3: Correct approach to various types of injections.

• Subcutaneous injections are used to administer selected vaccines, e.g. measles, or drugs, e.g. adrenaline. Outer aspect of upper arm is the preferred site for these injections, which should be administered by given by pinching up the skin and subcutaneous tissue with provider's fingers and piercing it at 60° angle, with a subcutaneous needle.

• Intradermal injections are usually given at shoulder or forearm, for - BCG vaccination, Mantoux testing or penicillin-sensitivity testing. It is essential to stretch the skin over injection site between nondominant thumb and fingers, before piercing it at ~15° with the bevel of needle facing upwards. Only the needle tip should be introduced beneath the skin. A successful intradermal injection is reflected by formation of a wheel at the site.

WHO has launched a Safe Injection Global Network (SIGN) program to encourage use of safe and appropriate injections practices and a WHO steering group has developed standard guidelines for evidence-based best injection practices (Table 32.1).

Important components of these practices include: (a) genuine indication, (b) pre-injection check of product information, e.g. expiry date, etc. (c) pre-injection hand washing, (d) preparation of injection site, (e) use of sterile injection equipments, (f) proper filling/dilution or injection, (g) proper method of injection, and (h) proper waste disposal (Also see Ch 9.8.2).

32.3