Body Mass Index: A Reliable Predictor of Subcutaneous Fat Thickness and Needle Length for Ventral Gluteal Intramuscular Injections

Considering skin-to-muscle depth for successful intramuscular injections in an increasingly obese population

BACKGROUND

Intramuscular (IM) injection practice is an essential nursing skill. Current practice relies on clinical judgement to determine needle length (unless specified in the medicine's product licence). Obesity is increasing in the global population, but guidelines have largely ignored how to select needle length to meet individual patient need.

AIM

The aim of this review was to systematically review the skin-to-muscle depth required to achieve injection into muscle in adults. The objectives were to identify any implications of obesity status when selecting an appropriate needle length and site in clinical practice. Search and review methodology: Studies of subjects above the age of 18 years using observational or experimental designs where the distance from the skin to muscle had been measured at any IM injection site, and obesity status was reported, were included in the search strategy. The primary outcome of interest was the distance from skin surface to muscle penetration.

FINDINGS

14 studies were identified that investigated the dorsogluteal, ventrogluteal, deltoid and vastus lateralis sites, all used cross-sectional observational designs. Ten used ultrasound, three used computed tomography (CT) and one used magnetic resonance imaging. Obesity status was reported as BMI or hip-to-waist ratio. In all studies there was a correlation between obesity status and the distance from skin surface to muscle. In females this exceeded 37 mm at both gluteal sites, independent of obesity status.

CONCLUSIONS

There should be an assessment of obesity status before selecting needle length for IM injections in both genders. Needles longer than the standard 37 mm are recommended for all females, whatever their obesity status, for any gluteal site. Injections into gluteal sites should be avoided in females who are obese. Deltoid injections are more likely to achieve muscle penetration in both genders, and in patients who are overweight or obese. Further research is required.

Clinical implementation of long-acting antiretroviral treatment in high-income countries: challenges and advantages

PURPOSE OF REVIEW

Long-acting antiretroviral therapy (LA-ART) brings a paradigm shift to HIV care with injectable cabotegravir/rilpivirine (IM-CAB/RPV) in current or imminent use in several countries. This brings the usual opportunities and challenges of a new therapy, plus requirements to adapt services to reliably deliver injections and ensure patients understand advantages and limitations. We summarise key considerations for implementation in high-income countries.

RECENT FINDINGS

Monthly IM-CAB/RPV is noninferior to oral ART and monthly IM-CAB/RPV to 1-monthly in carefully selected virally suppressed people. The numerically higher virological failure rate on two-monthly IM-CAB/RPV warrants close attention and careful monitoring. Implementation projects report positive experiences for patients and staff, but also barriers. Data is needed in younger people, pregnancy/breastfeeding, and in those with detectable viraemia secondary to suboptimal adherence.

SUMMARY

We highlight a paucity of real-world data and key unanswered questions. Existing data on injection techniques may have implications for training; monitoring of outcomes is crucial to ensure clinical trial results are replicated in real-life. Better understanding of treatment failure, and individualised therapy, is crucial, and it is important to repeat patient preference surveys as new data emerges to ensure decisions are based on the most recent evidence of benefit vs risk.

Evaluating the effectiveness of gluteal intramuscular injection sites: a cadaveric study

The gluteal region is a frequent target for injecting high volumes. However, the safe intramuscular injection sites have been controversy in this region. This study was aimed to compare the subcutaneous fat and muscle thicknesses at the two gluteal injection sites and to determine the influence of sex and body mass index (BMI) on fat and muscle thicknesses. The ultimate purpose of this study is to suggest the most suitable intramuscular injection site among the ventrogluteal and dorsogluteal regions. Eleven fresh cadavers were injected with colored gelatin using syringes at the two gluteal injection sites. Seven variables were measured at both gluteal injection sites and analyzed relative to sex and the BMI. No variables showed statistically significant differences between the two gluteal injection sites according to sex. In a one-way analysis of variance, total length and muscle thickness had significant difference according to the BMI category. In obese cadavers, the injected gelatin core was located in the subcutaneous layer (average 109.0 percentile), and in the muscle layer (average 78.9 percentile) in the dorsogluteal region. These were found that the success rate of injection in the dorsogluteal region was higher than in the ventrogluteal region, especially when classed as obese. Also, it is suggested that nurses should use the traditional intramuscular injection method. It will also be necessary to consider expanding these findings to other ethnic groups in the Asia–Pacific region and then also education in universities and health providers on selecting the intramuscular gluteal injection site.

Evaluation of the effect of selecting gluteal injection site on the pain injection based on anthropometric indices and body shape pattern: A randomised controlled trial study

AIMS AND OBJECTIVES

This study was aimed at comparing the effect of injection site selection based on anthropometric indices and body shape pattern on pain injection.

BACKGROUND

Pain is one of the common complications of intramuscular injection. Selecting the right place for gluteal injection is one of the challenges of nursing which can increase the safety and success of the injection and thereby reduce the pain severity caused by it.

DESIGN

Open-label randomized controlled trial study.

METHODS

In this study, 162 eligible subjects referred to the emergency unit of Vasei Hospital of Sabzevar, Iran were randomly assigned to three groups of control, anthropometric indices and body shape pattern. Subjects in the control group received dorsogluteal injection (traditional way). In the anthropometric group, body mass index (BMI), waist circumference (WC) and anterior superior iliac spine to iliac tubercle (ASIS-IT), and in body shape pattern group, observed body shape indices (OBS), BMI and sex were used to select the gluteal injection site. Pain injection was assessed using the Visual Analogue Scale (VAS). The CONSORT checklist was used.

RESULTS

The mean age of the participant was 39.43 ± 13.16 and 43.21% (n = 70) were male. Based on multiple linear regression analysis, the mean pain injection was substantially lower in body shape pattern as compared to the control group (r² : .26; bxy = -0.41; 95% CI: -0.81, -0.01; p = .043). The mean pain injection was significantly greater in the left leg injection than right one (r² : .26; bxy = 0.44; 95% CI: 0.06, 0.81; p = .021).

CONCLUSIONS

Findings of this study suggest that the selection of a gluteal injection site based on body shape pattern in comparison with traditional dorsogluteal injection method has a significant effect on pain injection relief.

RELEVANCE TO CLINICAL PRACTICE

Nurses can choose the appropriate gluteal injection site based on the body shape pattern to reduce the pain of the intramuscular (IM) gluteal injections.

A narrative review of the success of intramuscular gluteal injections and its impact in psychiatry

There are 12 billion injections given worldwide every year. For many injections, the intramuscular route is favoured over the subcutaneous route due to the increased vascularity of muscle tissue and the corresponding increase in the bioavailability of drugs when administered intramuscularly. This paper is a review of the variables that affect the success of intramuscular injections and the implications that these success rates have in psychiatry and general medicine. Studies have shown that the success rates of intended intramuscular injections vary between 32 and 52%, with the rest potentially resulting in inadvertent subcutaneous drug deposition. These rates are found to be even lower for certain at-risk populations, such as obese patients and those on antipsychotic medications. The variables associated with an increased risk of injection failure include female sex, obesity, site of injection, and subcutaneous fat depth. New guidelines and methods are needed in order to address this challenge and ensure that patients receive optimum care. Looking forward, the best way to improve the delivery of intramuscular injections worldwide is to develop uniform algorithms or innovative medical devices to confirm or guarantee successful delivery at the bedside.

Associations Between Sleep Deprivation and Salivary Testosterone Levels in Male University Students: A Prospective Cohort Study

Sleep deprivation is a common health problem that is growing rapidly worldwide and it is associated with short- and long-term impacts on health. The aim of this study was to detect potential predictors of salivary testosterone (sT) association with sleep deprivation in Arab male university students. In this prospective cohort study, 77 university male students in the age range of 18 to 26 years were divided into two groups, sleep-deprived (SD) participants and non-sleep-deprived (NSD) participants. Sleep deprivation was defined as sleeping less than 5 hr per night. Blood samples and sT were collected from fasting participants to measure serum levels of glucose, lipid profile, leptin, serotonin, sT, and body mass index (BMI) values. The multiple linear correlation model of high-density lipoprotein cholesterol (HDL-C), BMI, and serotonin was positively correlated with sT (r = .977, p < .05) in the SD group. No correlations were identified with sT in the NSD group. In the SD study group, the multiple linear regression model of HDL-C, BMI, and serotonin was significantly influenced by sT (R² = .955, p < .05). These predictors together explained approximately 96% of the variance in sT levels in the SD study group. No predictive variables for sT were reported in the NSD group. Results indirectly confirmed the presence of a positive association between sT and sleep deprivation in young men. This association is mediated by three factors, HDL-C, BMI, and serum serotonin, which are collectively considered as part of a significant physiological adaptation to sleep deprivation in young men.

Patient Satisfaction and Its Influencing Factors of Microtia Reconstruction Using Autologous Cartilage

BACKGROUND

This study aimed to investigate patient perceptions of and satisfaction with surgical outcomes of microtia reconstruction using autologous cartilage. It also analyzes associations between patient background characteristics and their evaluation.

METHODS

Lobule-type microtia patients who had received first-stage surgery were interviewed using a questionnaire, which included assessment of nine auricle substructures, superior and inferior parts and overall impression. Answers were recorded on a five-point Likert-style scale. Satisfaction rate and average scores were used to compare satisfaction with different substructures. Chi-square tests and logistic regression were used to analyze the impact of background characteristics such as gender, age, side and body mass index (BMI) on satisfaction, measured as the total scores for different parts.

RESULTS

The highest level of satisfaction was seen for the helix and the lowest for the tragus. The average score for the helix was significantly higher than for the concha (p < 0.05), tragus (p < 0.05), anti-tragus (p < 0.05), incisura (p < 0.05) and lobe (p < 0.05). The overall satisfaction was significantly correlated with work on the inferior part (ρ = 0.63, p < 0.05). Satisfaction from children under 12 years old was significantly higher than from children above 12 years old for superior structures and overall evaluation (p < 0.05). Left-sided microtia patients showed significantly higher satisfaction for inferior structures and overall evaluation than right-sided patients (p < 0.05). Overweight and obese patients were less satisfied with the tragus-incisura-anti-tragus complex compared with the rest (p < 0.05).

CONCLUSION

Microtia patients were most satisfied with the helix and least satisfied with the tragus. Overall patient satisfaction was more dependent on inferior structures; the characteristics of younger age (<12 years), proper BMI (under overweight or obese) and left-sided microtia were linked with higher ratings.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .