Several organizations do not recommend aspiration when administering vaccines because no data exist to justify the need for this practice. They argue that: 1) Aspiration is more painful for the patient, 2) IM injections are not given in areas where large vessels are present, so the inadvertent intravascular injection is improbable and 3) There is no reports of a vaccine being administered intravenously and causing harm in the absence of aspiration.
However, 1) there seems not to be more pain in the adult in relation with aspiration (Taddio et al. Procedural and Physical interventions for vaccines injections: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin J pain, 2015), 2) the inadvertent intravascular injection is relatively frequent with 40% of the nurses claiming blood aspiration, and this is not exclusive of dorso gluteal site –dorso gluteal (15%) vs deltoid (12%)— (Cristine M Thomas. Blood Aspiration During IM Injection. Clinical Nursing Research 2015) and 3) such reports justifying security do not involve many patients, not consider secondary effects in the long run and not consider a potential decrease in efficacy of the vaccines -- intravenous administration seems to produce a rapid antigen depletion-- (Sissons H. Aspirating during the intramuscular injection procedure: a systematic literature review. Journal of Clinical Nursing 2015).
Are we doing it right?
I have seen recommendations for no aspiration unless you are using the dorsogluteal- but like the argument for not using the dorsogluteal area at all, I haven't seen especially strong evidence to support those recommendations. For example in the studies you cite, Christine and Thomas identify a high enough rate of blood aspiration to warrant continuing a practice that Taddio et al say doesnt cause additional pain. So why not use it?
The ventrogluteal is preferred over the dorsogluteal due to less complications for larger volume injections. According to Perry & Potter (2018) "research shows that injuries such as fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain are associated with all the common IM sites EXCEPT the ventrogluteal site (page 601)."
Aspiration was a practice nurses were taught many years ago, but is no longer current. I read differing evidence on the Z-track method for IM injections in large muscles. Some literature suggests that Z-track reduces pain and seals the medication for some medications (i.e. IM dextran) but is not a universal practice, yet Z-track is still encoded in many policies & procedures. What does the group think about Z-track for IM injections?
The current nursing practice is evidence based. There is no documented evidence that a nurse aspirated blood during intramuscular injection. There no aspiration during intramuscular injection is correct.
As for me, I can not be fine if, I didn't aspirant before administrating medication in IM or IV because there is some medication for IV that can not be authorized to be administrated in IM.
Regarding this issue and the potential link of severe secondary effects seen in AstraZeneca vaccine for COVID (Vaxzevria), I made a question to European Medicines Agency, who sent me to the document: “Signal assessment report on embolic and thrombotic events (SMQ) with COVID-19 Vaccine (ChAdOx1-S [recombinant]) – COVID-19 Vaccine AstraZeneca (Other viral vaccines)”.
In it, it can literally be read:
...”Replication in-competent adenovirus vectors based on different serotypes of human adenoviruses are known to be able to cause thrombosis, secondary (consumptive) thrombocytopenia and disseminated intravascular coagulation, potentially leading to multiorgan failure and death, especially after intravenous injection of virus particles. This has been consistently described in preclinical models eg nonhuman primates and rabbits, and one fatality has also been reported in a phase 1 clinical trial [44-49]…
…This hypothesis is mechanistically plausible but not supported by the fact that IV administration might be needed to observe the abnormalities. However the latter should be nuanced due to known challenges in the implementation of the “syringe-not-in-vessel” test in the context of massive vaccination…
…As mentioned by other experts, a thrombocytopenia following the administration of adenoviral gene transfer vectors has been described, involving von Willebrand factor and P-selectin. It is true that the “syringe-not-in-vessel” test is hardly ever realized by vaccinators and that the risk of intravenous injection may possibly increase the risk of activation of this thrombocytopenic mechanism. However, it is considered unlikely that the thrombotic complications possibly associated with the vaccine would be imputed to adenovirus and would have no pathophysiological link with the thrombotic complications observed with COVID19 infections.”
In conclusion, it is proved that inadvertent intravenous injection of vaccines (at least adenoviral) has a role in severe secondary effects. My believe is that non-aspiration during vaccines may be causing more harm than benefit (at least in adults). Perhaps, since aspiration before intramuscular injections has a sound theoretical reason, the burden of probe should still rely on the “non-aspiration technique”.
No aspiration need because no blood vassals in that area and it is painful
ACIP Vaccine Administration Guidelines for Immunization | CDC
https://www.cdc.gov › hcp › acip-recs › general-recs › ad..
This is from the Electronic medicines compendium database for Depixol, a depot antipsychotic administered via the z track technique because of the viscosity of the liquid. In mental health care this is the most common form of IM injection given and even the manufacturers recommend aspiration- A quote from from this website below
"Note: As with all oil-based injections it is important to ensure, by aspiration before injection, that inadvertent intravascular entry does not occur"
A mouse model has confirmed VITT after intravenous injection of AstraVeneca COVD-19 vaccine.
Preprint Thrombocytopenia and splenic platelet directed immune respon...
Dear Geoff,
Yes, there is some evidence that intravascular injections of vaccines containing adenoviral vectors are associated in preclinical models with several secondary effects: thrombosis, secondary (consumptive) thrombocytopenia and disseminated intravascular coagulation, potentially leading to multiorgan failure and death (1). Thus, the European Medicines Agency (EMA) has alerted about a potential link between inadvertent IV injection and the report of thrombotic events with thrombocytopenia associated with COVID-19 vaccine involving adenovirus, though EMA admitted this link has not been formally assessed (2).
1. Wolins N, Lozier J, Eggerman TL, Jones E, Aguilar-Córdova E, Vostal JG. Intravenous administration of replication-incompetent adenovirus to rhesus monkeys induces thrombocytopenia by increasing in vivo platelet clearance. Br J Haematol. 2003 Dec;123(5):903-5.
2. Signal assessment report on embolic and thrombotic events (SMQ) with COVID-19 Vaccine (ChAdOx1-S [recombinant]) – COVID-19 Vaccine AstraZeneca (Other viral vaccines) EMA/PRAC/157045/2021.
Please, find attached a 50-day-free link to a Letter to the editor that we have writen regarding this issue.
https://authors.elsevier.com/a/1e8JD418DR0oLH
Comparison of Intravenous versus Intramuscular Pfizer clearly shows damage by the former.
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab707/6353927
Dear G. Pain,
Thanks a lot for sharing this paper. It reinforces the concerns regarding IV injections of vaccines.
This is the link to a "Letter to the Editor" regarding this issue.
https://authors.elsevier.com/a/1eSwZ8hzbTK6Z2
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