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Try out PMC Labs and tell us what you think. Learn More. L Samad: Primary author, contributed to literature search and overall supervision. YJ Sepah: Literature review, collation and draft of and report. A Altaf: Contributed to literature review. MS Halim: Contributed to literature review. AJ Khan: Provided overall supervision and final review of manuscript. Typos identified during the review process have been corrected and conclusion section has been updated to reflect the content of the manuscript. Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure.

While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered.

In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. An injection is defined by the World Health Organization WHO as parenteral administration of medication through a skin puncture via a syringe, while aspiration is defined as the pulling back of the plunger of a syringe for 5—10 seconds prior to injecting medicine 1 — 4. Aspiration is most commonly performed during an intramuscular IM or subcutaneous SC injection, and is meant to ensure that the needle tip is located at the desired site, and has not accidentally punctured a blood vessel.

Despite the growing wealth of medical knowledge in recent decades, the simple procedure of aspiration is still generating much controversy concerning its perceived benefits and indications 5. Advocates of aspiration contend that it is a technically easy maneuver that is rapidly performed and well tolerated by patients with no increase in costs incurred. However, due to a paucity of available data, there is no evidence that this procedure is essential or truly beneficial. This issue has been widely debated with specific regard to vaccination; there are no studies that have assessed the need for aspiration prior to IM injection of vaccines in relation to vaccine safety.

The widespread use of auto-disable AD syringes — most of which are not deed to aspirate 6 — has not been linked to adverse effects due to the elimination of the aspiration procedure prior to injection of vaccines 7. This finding has intensified the debate and raised doubts over the necessity of aspiration in non-vaccine medication administration as well. Conventional syringes are also used to aspirate materials other than blood — synovial fluid, amniotic fluid, cells via fine needle cytologypericardial fluid, peritoneal fluid and cerebrospinal fluid CSF are examples 8 — This wide spectrum of applications for conventional syringes is all the more interesting in view of the fact that although used for both aspiration and injection, the syringe is actually deed only for injection A of studies have concluded that a conventional syringe is a poorly controlled and non-ergonomic device during aspiration 21 Possible lack of precision may result in local trauma and pain, prolonged procedure time, failed or incomplete procedures, accidental puncture of blood vessels or nerve bundles, poor sample retrieval and delayed diagnosis 23 — The ingrained use of the conventional syringe for injection and aspiration is to a large extent attributable to its low cost, widespread availability and lack of an effective alternative The huge volume of injections being given worldwide — an estimated 16 billion injections per year are administered in the developing and transitional countries alone 34 — necessitates that this aspect of injection technique be given due attention.

This review aims to collate English-language literature on aspiration from all published and non-published sources in order to provide an overview on the subject. In particular, this review aims to highlight areas of debate and draw attention to key questions that remain unanswered, thus providing a starting point for controlled studies on specific areas requiring clarification. Clarification on points of debate was sought by direct communication with ISO.

Google Scholar was also used to search for relevant information. Relevant search terms for PubMed and Google Scholar literature searches are listed below. Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Product inserts for all injectable drugs on the WHO Essential Drug List EDL were collected to determine if the manufacturer had provided instructions on aspiration prior to injecting the drug.

These product inserts were collected from local pharmacies and the international manufacturers for each drug. Drug inserts from multi-nationals were acquired either directly from their websites or from other online resources including the Drug Index www. Our review was conducted between March and March Table 1 summarizes the resources searched.

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Published literature on injection technique advises aspiration before injecting a drug through different routes, i. However, it is important to note that emphasis has been placed on negative pressure being applied for 5—10 seconds for aspiration to be of benefit 134. IM injections: Aspiration prior to injection of medication through the IM route remains a part of most guidelines 43538 — Nursing curricula and guidelines 43839 clearly recommend aspiration as an essential step in IM injection technique.

Guidelines originating in the UK recommend aspiration prior to IM injection of medications 35as well as specifically as part of the Z-track technique of administering IM injections. SC injections: It is apparent that there are opposing schools of thought when it comes to aspiration prior to SC injections. There are those that insist that aspiration should continue to be part of SC injection techniques for medication administration, and those who are convinced that aspiration is not necessary and has no real advantage; in fact, several disadvantages may be attributed to this step.

Some nursing curricula do not include aspiration as part of the recommended technique 38 for SC injection.

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One nursing guideline highlights the debate existing over aspiration prior to a SC injection, concluding that while the likelihood of piercing a vessel is slim, local guidelines should be followed in determining individual practices. Others recommend routine aspiration prior to injection of medications through the SC route Both documents are primarily concerned with infection control practices in relation to injection administration, overlooking aspiration entirely.

A recent debate in relation to SC injection of immunotherapy has highlighted this controversy. Waibel recommended that aspiration before SC injection of immunotherapy be abandoned since there were no positive aspirates in 36, immunotherapy injections given at his practice While other specialists agreed that aspiration prior to immunotherapy injection in SC tissue is very rarely positive, rare anecdotes were quoted when positive aspiration has been documented 4647even in the hands of experienced specialists and nurses.

Given the potentially fatal adverse reactions of immunotherapy injected into blood vessels, it is logical to recommend that aspiration be performed as part of the standard technique. However, fatal and near fatal adverse reactions have been reported following immunotherapy injection despite precautions, including aspiration, being taken Geller 48 has reported the observation of a positive aspiration prior to epinephrine injection for asthma; if aspiration had not been performed in that instance, epinephrine would have been injected into the blood vessel with potentially hazardous consequences.

On the other hand, the preloaded auto injector commonly used for administering epinephrine in emergency situations does not allow for aspiration In this form, epinephrine is deed to be administered via IV injection, via intracardiac injection or via the endotracheal route into the bronchial tree where aspiration is superfluous. Insulin: The NMC guidelines 5051 do not mention aspiration in relation to insulin injection. Aspiration prior to insulin injection is rarely positive 36 and hence not indicated. This recommendation is supported by drawing a parallel with heparin administration, where increased hematoma formation has been associated with aspiration 4.

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Dental procedures: A study looking at dental anesthetic injections showed positive aspiration rates ranging from 3. Accuracy of needle position combined with mechanical ease at the time of dental injections are important considerations when choosing an appropriate device To this end, different self-aspirating devices have been tested in dental practice An understanding of vascular anatomy 57 is all the more important in view of the potential toxicity of anesthetic agents and the possibility of embolization to the ophthalmic artery The US CDC screening form 55 for device specifics notes whether a dental syringe is capable of aspiration.

Immunization: Vaccinations form an important subset of all injections given worldwide. At present, the WHO does not recommend aspiration prior to administering a vaccine 7 Current guidelines published by the American Academy of Pediatrics AAP 57 recommend that aspiration prior to IM vaccinations may not be necessary, while similar Canadian guidelines continue to recommend aspiration Without data indicating the need for aspiration during vaccination, ACIP is basically leaving this decision to the person giving the vaccine.

A different approach to this issue was taken by Ipp et al. The same group went on to conduct a randomized controlled trial in which they compared two injection techniques: the standard approach, which included aspiration for 5—10 seconds, and the pragmatic approach, which excluded aspiration entirely They concluded that IM vaccinations using the pragmatic approach were less painful and there were no benefits to following the standard approach.

Jablecki 60 has suggested a technique for choosing a site for administering IM injection that is relatively pain free by understanding the anatomy of cutaneous innervation at the selected site. This may mitigate the effect of increased pain in the standard approach. More recently, a study of infant vaccinations compared rapid IM injection without aspiration with slow IM injection with aspiration, and found the non-aspiration method to be associated with less pain based on behavioral pain ratings 41 Similarly, ina systematic review of 19 randomized controlled trials involving 2, infants and children found that immunization pain can be decreased by performing a rapid IM injection without aspiration In actual practice, AD syringes are recommended worldwide for vaccinations.

While this is a small proportion of all injections given worldwide, it is an important component given that the target population is healthy children, and the risks have to be minimized as much as possible. In general, AD syringes do not permit health workers to aspirate blood. This inability to aspirate with AD syringes has generated a heated debate. In theory, some devices like the BD Soloshot allow for limited aspiration 63but this does not meet the recommended criteria for the amount of negative pressure and duration of aspiration.

A summary of the rationale behind the current recommendation of not aspirating during the administration of IM or SC vaccines is given below. The WHO appreciates that there is not enough evidence to support the exclusion of aspiration 17 at present. In addition, it is suggested that in individual clinical practice using non-AD syringes, aspiration should continue to be a part of the standard technique for IM injection administration However, the published material is being distributed without warranty of any kind, either expressed or implied.

The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Special areas: The conventional syringe, primarily deed for injection, is widely used for aspiration. Sibbit et al.

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Robinson et al. Aspiration was found to be unreliable in reducing the risk of IV penetration during intraforaminal cervical and lumbosacral epidural steroid injections 36 Loss of control during t aspirations can result in serious complications 23 — 2527 — 313371 — 80as was noted during other invasive procedures like pericardiocentesis, amniocentesis and thoracocentesis Precision is important where critical organs are involved.

Improved control was seen with the FDA-approved one-handed reciprocating syringe Similarly, the US CDC guidelines for administration of vaccines 65 have clear instructions not to aspirate before injection for both IM and SC routesas no large vessels exist in the recommended injection site. None of the documents dealing with immunization including immunization in practice module 1—11 from the WHO suggest that aspiration is required before injection of a vaccine Technical details, including aspiration, are not touched upon in this document. Neither the ICN nor the Nursing and Midwifery Council 5051 Europe and British Chapters have made any kind of recommendation in their guidelines on administration of medication.

National nursing curricula in Nigeria 86 and Pakistan 87 do not mention aspiration before injection as a necessary step for IM and SC injections. Similarly, the syllabus for MSc Nursing in India did not elaborate on injection technique. None of the curricula mentioned above make any comment on the duration of aspiration. The ISO recommendations for sterile hypodermic syringes acquired via personal communication were reviewed.

Relevant sections from parts 1, 3 and 4 are reproduced below. Part 2 relates to syringes for use with power-driven pumps and is therefore beyond Im looking for only 3 scope of this review. Part 1: Sterile hypodermic syringes for single use - specifies requirements for sterile single-use hypodermic syringes made of plastic materials and intended for the aspiration of fluids or for the injection of fluids immediately after filling. Part 3: Auto-disable syringes for fixed dose immunization - specifies the properties and performance of sterile single-use hypodermic syringes, with or without needle, made of plastic materials and stainless steel and intended for the aspiration of vaccines or for the injection of vaccines immediately after filling.

Upon delivering a fixed dose of vaccine, the syringe is automatically rendered unusable.

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