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North Carolina Injectables Workshop

By Joann Freeman,2014-05-10 01:30
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North Carolina Injectables Workshop

    INJECTABLE MEDICATIONS IN PRIMARY CARE OPTOMETRY

    Tammy Than, MS, OD, FAAO

    UAB School of Optometry

    tthan@uab.edu

I. BASICS

     A. Indications

     B. Needles

     Hypodermic

     Intravenous

     C. Syringes

     D. Needle Safety

     E. Instrumentation

     F. Medications

     G. Type of Injections

     Intradermal

     - least used

     - TB skin test, allergy tests

     - 30-45 minutes

     Subcutaneous

     - insulin, epinephrine, narcotics

     - 30 minutes

     Intramuscular

     - for larger volumes

     - quicker absorption (10-15 minutes)

     - less irritation

     Intravenous

     - largest volume

     - quickest route

II. LOCAL INFILTRATIVE INJECTION (SUBCUTANEOUS EYELID INJECTION)

     A. Purpose: to deliver local anesthesia prior to various procedures

     cyst removal or drainage

     incision and curettage of chalazion

     sutures

     papilloma removal

     punctoplasty (laser or thermal cautery)

     argon laser treatment of trichiasis

     B. Medication

     lidocaine 1 or 2% (; 1:100,000 epinephrine)

     C. Contraindications

     known hypersensitivity to amide anesthetics

     sites with active infection, bony prominences, large nerves

     D. Equipment

     27-30 gauge needle with 1 cc syringe, ?”

     E. Technique

     obtain written, informed consent

     wash hands and don gloves

     clean area first with alcohol or betadine swab allowing skin to dry

     if utilizing a Jaeger plate, instill one drop of 0.5% proparacaine then

     insert plate

     position bevel up

     pull skin taut and insert needle using a gentle stabbing motion with the

     angle at about 15 degrees relative to skin surface

     pull out stopper of syringe to ensure no intravascular penetration

     inject approximately 0.2 0.3 cc

    - simultaneously depress plunger and begin slowly withdrawing

     needle while moving it side to side (infiltrative)

     if injection follows a line instead of diffuse filling stop!

     - may have hit a small vessel

     - can cause cardiac arrhythmia

    - watch patient for 5-10 minutes checking heart rate, if ok, restick,

     and inject

     two to three sites may be needed to provide adequate anesthesia

     apply moderate pressure with gauze to allow diffusion of the local

     anesthesia

     place the used needle and syringe in a puncture-resistance container

     (do NOT recap)

     after waiting for 5 minutes, use tissue forceps to gently determine area

    of anesthesia

III. INTRALESIONAL INJECTIONS

     A. Indications

     Chalazion management

     Strawberry nevus (capillary hemangioma)

     B. Contraindications

     Known hypersensitivity

     Caution with darkly pigmented patients

     Rule out sebaceous cell carcinoma

     C. Potential Complications

     skin depigmentation

     bruising

     ptosis

     subcutaneous abscess

     CRAO

     D. Evaluating Chalazion

     How big?

     How long has it been present?

     Anterior or posterior to the tarsal plate?

     E. Equipment

     2

     25-27 gauge needle with 1 cc syringe, ?”

     chalazion clamp or Jaeger plate

     gauze

     F. Medication

     triamcinolone acetonide suspension 10 or 40 mg/mL (Kenalog-10 or

     Kenalog-40)

     dexamethasone

     G. Technique and Comments

     Obtain written informed consent

     Wash hands and don gloves

     25-27 gauge, ?” needle with 1 cc syringe

     Instill topical 0.5% proparacaine OU

     Clean area with alcohol

     Recommend chalazion clamp for support, isolation, protection and

     comfort

     - Alternatively, a Jaeger plate may be used

     Place clamp on securely

     Position bevel up

     If using clamp, insert needle straight ahead at apex of lesion

     If not using clamp, insert at approximately at 45 degree angle

     Push hard you will feel it give as you enter the lesion

     Push in until you have gone full thickness

     Aspirate to ensure no intravascular penetration

     Inject as much as possible (usually 0.1 0.3 cc)

    - back needle out a little and inject some more

    - repeat this process until completely out of lesion

     May repeat process at a different angle

     May also place steroid around lesion, but this may cause blanching of

     pigment. If this occurs, skin usually returns to normal in a few months.

     Apply firm pressure to the lid area with a gauze pad for a few minutes.

     Recommend patient continue digital massage at home

     Procedure works well on small to medium size chalazion (< 6mm in

     size)

     Follow up in 3-4 weeks - may need to repeat injection

IV. SUBCONJUNCTIVAL INJECTIONS

     A. Indications

     Post Trabeculectomy

     Failing Trabeculectomy

     Refractory Uveitis

     Corneal Ulcers

     Bacterial endophthalmitis

     B. Medications

     5-Fluorouracil

     3

     Mitomycin C

     Steroids

     Antibiotics

     C. Contraindications

     Known hypersensitivity

     Corneal epithelial defects (for 5-FU or MMC)

     Infectious etiology (for steroids)

     D. Complications

     subconjunctival hemorrhage

     increased IOP (steroid injection)

     globe penetration

     discomfort

     E. Equipment

     27-30 gauge needle with 1 cc syringe; ?”

     tissue forceps

     cotton swabs

     lid speculum (optional)

     F. Techniques and Comments

     obtain informed written consent

     wash hands and don gloves

     instill 2 drops of topical anesthetic

     +/- one drop of prophylactic antibiotic

     swab area to be injected with pledget of anesthetic

     direct the patient’s gaze away from the injection site

     - 4 or 8 o’clock

     - superotemporal between the SR and LR muscles

     the conjunctiva may be lifted (i.e. “tented”) with a pair of tissue forceps

     retract the upper lid with your non-dominant hand (use speculum if

     patient is uncooperative)

     hold the syringe by the flange of the barrel between your index and

     middle fingers

     position the needle and syringe tangential to the globe so that the

     needle bevel is facing toward the globe

     direct the needle posteriorly, at the equator or beyond

     use a gentle stabbing motion to introduce the needle into the

     subconjunctival space

     aspirate ensuring no intravascular penetration

     inject the desired amount of solution (0.5 1.0 cc) until a bleb is formed

     withdraw the needle and ask the patient to close the eyes

     apply pressure with a gauze pad for a few minutes this will help the

     medication diffuse through the subconjunctival space

     a subconjunctival hemorrhage may occur

     4

V. SUB-TENON’S INJECTION

     A. Indications

     Cystoid macular edema (CME)

     Pars planitis

     Severe Uveitis

     Administration of medication in certain cases

     In most cases, sub-Tenon’s injections do not offer a significant

     advantage over subconjunctival injections

     B. Contraindications

     hypersensitivity

     steroid responder

     lesions of unknown etiology

     C. Complications

     inadvertent globe penetration

     D. Equipment

     27-30 gauge needle with 1 cc syringe; ?”

     cotton swabs

     E. Medication

     triamcinolone acetonide suspension 10 or 40 mg/mL (Kenalog-10 or

     Kenalog-40)

     F. Site Selection

     Anterior sub-Tenon’s

     Posterior sub-Tenon’s

     Skin

     - inferior orbital rim

     - superior orbital rim

     G. Technique

     obtain informed written consent

     wash hands and don gloves

     instill 2 drops of topical anesthetic

     instill one drop of prophylactic antibiotic

     apply pledget of anesthetic to injection site (inferior-temporal)

     direct the patient’s gaze away from the injection site (up and in)

     with the bevel toward the globe, stick needle into conjunctiva next to

     globe avoiding vessels (at 7-8 o’clock)

     continue to insert the needle by rotating the syringe downward and

     following the curvature of the globe (continue until needle all the way in)

     always move the needle tip back and forth to ensure that you are not

     penetrating the sclera (if you feel resistance stop pull out and try

     again)

     aspirate to ensure no intravascular penetration

     inject at moderate rate

     remove needle and with patient’s eyes closed apply moderate pressure

     to area

     patient will feel fullness behind the eye for a day or two

     5

VI. INTRAMUSCULAR (I.M.)

     A. Indications

     Used for irritating medications

     - few sensory nerves within muscle tissue (less painful)

     Larger volume (up to 5 mL for single injection)

     Faster absorption (compared to subcutaneous)

     Ophthalmic indications

     - pre- or post-fluorescein angiography

     - acute angle closure glaucoma

     - management of allergic reactions (Type I and IV)

     B. Equipment

     2-5 cc syringe

     20-23 gauge 1”, 1”, 2”

     C. Site Selection (avoid injury to tissue, nerves, and vessels)

     deltoid

     - not good for pediatrics

     - 2-3 finger-widths below acromion process

     dorsogluteal

     - antibiotics

     - slowest and deepest IM

     ventrogluteal

     rectus femoris (anterior thigh)

     - emergency situations

     vastus lateralis (slightly to the anterior outer portion of thigh)

     - children

     D. Techniques

     Obtain informed written consent

     Wash hands and don gloves

     Cleanse site and allow to dry

     Compress skin between fingers to lift the muscle

     Pierce tissue quickly at 45 to 90 degree angle

     Release the tissue

     Aspirate for blood (if blood is present, remove needle).

     Inject medication slowly

     Remove needle and apply pressure at the site of injection

     Apply self-adhesive bandage over the injection site

     6

Diagrams from Nursing PhotoBooks, Giving Medications, Springhouse, 1996.

     E. Miscellaneous

     Air Lock Technique

     - ensures all of the dose is administered

     - 0.2 cc of air is left in the syringe

     - syringe is inverted, forcing the air to move up

    - the injection is given with the entire contents of the syringe

     deposited in the tissue

     Z-track

    - prevents medication from being released into the subcutaneous

     7

     tissue

     - useful for irritating drugs

     - can be used in elderly patients with decreased muscle mass

     - technique:

     drag the skin to one side

     insert needle at 90 degrees

     after injection is given remove needle and release the skin

     do not apply pressure over the site of injection

VII. INTRAVENOUS (I.V.)

     A. Indications

     to deliver large volumes

     medications that can only be given I.V.

     medical emergencies

     Ophthalmic Applications

     - intravenous fluorescein angiography

     - acute angle closure glaucoma - mannitol

     - anaphylaxis - epinephrine (1:10,000)

     - tensilon test (to rule out Myasthenia gravis)

     B. Contraindications

     hypersensitivity

     mastectomy (on that side; for FA)

     renal disease (FA)

     C. Complications

     phlebitis

     infection at injection site

     FA: discolored urine, discolored skin, allergic reactions

     D. Equipment

     25-27 gauge butterfly needle

     5-10 cc syringe, ?” – 1”

     5 cc 10% sodium fluorescein (or 2 cc of 25%)

     gauze

     band-aid

    E. Site Selection

     dorsum of the hands, forearm, inner aspect of the elbow

     large veins

     start with most distal site if difficulty expected

     ask patient for the best site then explore!

     to enhance venous dilation:

     - open and close fist

     - tap skin overlying vein

     - stroke the arm below the selected site

     F. Technique

     Obtain informed written consent

     8

     Select site

     Wash hands and don gloves

     Scrub site in a circular motion and allow to dry

     Apply tourniquet 2 to 6 inches above site selected

    - if locating a vein has taken more than a brief moment, release the

     tourniquet and reapply after cleaning area

    - have patient clench and unclench fist

     Remove cover from needle maintaining sterility

     Grasp arm distal to site with nondominant hand and place thumb about

     1 inch below site

     Pull skin to stabilize vein

     Hold need at 15-45 degree angle and insert with bevel facing up

     When vein is entered and return blood is observed, decrease the needle

     angle and advance needle to stabilize it in the vein

     Remove tourniquet

     Tape butterfly in place

     Give the injection slowly, apply pressure, and remove the needle (watch

     that extravasation does not occur)

     Apply adhesive bandage over the injection site

     Observe patient for 30-45 minutes following fluorescein angiography

VIII. PHLEBOTOMY

     A. Vacutainer system

     9

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