PARENTERA1ADMINISTRATION

The following are trademarks of Abbott Laboratories:

Abbocillin, Abboject, Abbo-Liter, Abbo-Vial, Bejectal, Butterfly-16, Butlerfly-19,Butlerfly-21, Butlerfly-23, Butlerfly-25, Cly-Q-Pak, Erythrocin, Hyazyme,lon-o-trate, Metaphen, Microdrip, Panheprin, Pentothal, Soluset,Twin-Site, Venopak, Venotube

Color-Break, registered trademark, Kimble Glass Co.Fiberglas, registered trademark, E. I. du Pont de Nemours & Co. (Inc.)Gold-Band, registered trademark, Wheaton Glass Co.Teflon, registered trademark, Owens-Corning Fiberglas Corp.Zephiran, registered trademark, Winthrop Laboratories

ENTERING THE VEIN .

Selecting and Preparing the Site for Injection .Making the Venipuncture .The Bevel .The Needle .Basic Venipuncture .Other Techniques .

ABOUT THE INFUSION .

Selecting and Preparing the Equipment for Venoclysis .Temperature of Solution at Time of Administration .Assembling the Apparatus .Rate of Infusion .Mechanical Difficulties .Adding Supplemental Medication .Terminating the Infusion .

ABBOTT EQUIPMENT FOR INFUSIONS .

The Abbo-Liter .The Venopak .The Surgical Venopak .The Venopak Microdrip .The Secondary Venopak .The Y-Type Venopak .Soluset .Venocath .The Butterfly Infusion Set .Venovalve 30 with "T" Connector ."T" Connector Set .Venotube 20, Venovalve 30, and Venotube 20 Sterile Pack .The Venotube Twin-Site .The Cly-Q-Pak for Hypodermoclysis .

FROM THE SYRINGE .

Transfer from the Ampoule and from the Multi-dose Vial. .From the Ampoule .From the Vial .From the Two Compartment Vial. .How to Prepare Solution .Into the Vein .Into the Muscle .Into the Subcutaneous Tissues .Into the Skin (Intradermal) .

REFERENCES .

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4749 1

INTRODUCTION

Frequently in clinical practice drugs or solutions are administered byother than the oral or rectal route. Such administration is called paren-teral (meaning apart from the intestine) and usually refers to injectionof drugs. Parenteral injection is employed for a number of reasons,among which are the following:

1. The patient may be unconscious.2. The patient may be nauseated or vomiting.3. Some drugs cannot be absorbed from the gastrointestinal tract

(for instance, some antibiotics have too large a molecular size).4. Some drugs are partially or completely destroyed by the gastric

and other digestive juices.5. A drug's action may be needed instantly (as during anaphylaxis,

an asthmatic attack, or other emergency).6. A drug's action may be needed only in a prescribed area (for in-

stance, a local anesthetic).7. Aphysicianmay wish to prolong the action of a drug by injecting

a repository form or a concentrated aqueous solution.8. Severe disturbance of fluid and electrolyte balance may require

intravenous infusion (or subcutaneous infusion when a suitable vein isnot available).

Parenteral injection encompasses several routes of administration suchas injection into a joint, into the spinal canal, into an artery, into thebrain, or (in an emergency) into the heart itself. In fact, injections maybe made into almost any organ or area of the body. However, it is ouraim here to describe only those injeCtionswhich are administered moreroutinely. These are:

1. intravenous (into the vein)2. intradermal (into the skin)3. subcutaneous (under the skin)4. intramuscular (into a muscle)

Abbott intravenous equipment will be described, and a number ofdrawings will serve to illustrate the points made, the techniques de-

2 scribed, and the equipment used.

ENTERING THE VEIN

ENTERING THE VEIN (venipuncture)

SELECTING AND PREPARING THE SITE FOR INJECTION. Certain preliminarypreparations should be made, and precautions observed, to insure assafe and painless an entry as possible. Although most superficial veinsare suitable for venipuncture, veins in the antecubital fossa (medianbasilic and median cephalic) are most frequently chosen because theyare usually large and easily accessible. However, this site is not the bestfor all occasions. Other suitable alternatives are available, sometimeswith advantage. Also, one should keep in mind that the median nervelies in the antecubital fossa and that, in some patients, the brachial arterymay lie superficially (see figure 9, page 11, for possible anatomical rela-tionships).

Other available veins include the cephalic and basilic veins in thearm above the antecubital fossa, the metacarpal and the dorsal venousnetwork 011 the back of the hand. The accessory cephalic and medianantebrachial veins of the forearm are favored by many clinicians for longinfusions. Whereas venipuncture in the antecubital fossa precludes armmovement, especially flexion at the elbow, venipuncture in a forearmvein and securing of the needle and tubing allow the patient some move-ment without the risk of puncturing the posterior wall of the vein. Here,again, one should be aware that aberrant arteries sometimes lie near thesurface.

The legs present the great saphenous and femoral veins in the thigh,and the great saphenous at the ankle. On the foot are the venous plexusof the dorsum, the dorsal venous arch, the medial marginal vein, and thelateral marginal vein.

Ordinarily at least one or two of these veins will be suitable for in-jection. Also, with careful attention to the application of heat and place-ment of the tourniquet, even veins that are small and poorly filled maybe utilized.

To avoid the difficulties described later on page 10 (figure 8), theoperator generally is urged to "use as small a needle as possible, and toinsert it into the largest convenient vein just distal to a venous junc-tion, securing it by some means which does not occlude the vein distal

4 to the point of insertion. Thus, he should try to enter large veins at the

. Anterior

V. basilica

V. basilica

V. mediana antibrachii

V. ext. sup. femoralis,

V. saphena magna

V. saphena magna

Rete venosum dorsale pedis

V. marginalis medialis

Posterior

Vv. metacarpeaedorsales

V. saphena parva

V. saphena magna

Figure 1. The superficial veins used in blood transfusion or intravenous injection.(From Proceedings Staff meetings. Mayo Clinic, 12:122-125, 1937.)

proximal end of a limb, and avoid the small veins at the distal end."1When using veins of the lower extremities, the operator should ascer-

tain that marked degrees of varicosity do not exist at or above the pro-posed point of injection. The partial stagnation of flow in such areas canresult il~ a collection of infused or injected solution there. When thisaccumulated fluid reaches the general circulation, untoward reactionsmay occur. Also, when an immediate effect is desired (as is usual whenthe intravenous route is chosen) varicose veins may considerably delaythe onset. However, if varicosities cannot be avoided, the point of in-jection should be elevated and the veins massaged centrally to increasethe blood flow.

When the site for injection has been determined, utmost care shouldbe given to the proper distention of the vein. As a simple preliminarymeasure, let the extremity in which the vein is located hang dependentfor a time. This action alone may serve to make the veins more apparent.

If the veins stand out well, manual compression above the site, aswith a tourniquet, will be sufficient to fill them. The tourniquet canvary from a twisted bandage to complicated mechanisms. A blood pres-sure cuff is probably the most efficient means of applying constrictionand of providing a quick smooth release. A soft rubber tube held by ahemostat or tied in a slip knot (figure 2) is most frequently used forthis purpose.

If a vein in the antecubital fossa is chosen, tighten the tourniquetsufficiently to obstruct venous return without stopping arterial flow.This will fill the veins to capacity and will maintain arterial flow. At

6 the same time, the patient should continually open and close his hand,

Figure 3. Shaded portions represent congestion from correct and incorrect applica-tion of heat. (From Proceedings Staff Meetings, Mayo Clinic, 12:122-126, 1937.)

finally keeping it closed until the needle is in the vein.When the veins are small or deep, constriction alone may not produce

adequate dilatation. In this event, lightly slapping the veins at the wristmay cause additional dilatation of the vein. Application of heat to theextremity is a valuable aid prior to applying the tourniquet and may benecessary should the other means mentioned be unsuccessful. Properlyadministered, this heat can mean the difference between a routine in-jection and an involved administration by a venous cut-down.

As illustrated in figures 3 and 4, heat must be applied not only to thearea around, but also distal to, the site of venipuncture. For example,if a vein of the upper extremity is to be used, the hand, wrist, forearmand arm (to a point above the elbow) should be enveloped in a warm,

Figure 4. Method of applying moist heat to dilate poorly filled veins. The arm iswrapped with a Turkish towel wrung out of hot water, over which is placed a'rubbersheet enclosed in turn by a dry Turkish towel. This is left in place 10 to 20 minutes. 7

Figure 5. Small or deeply set veins in the antecubital space are outlined after appli-cation of heat and before application of the tourniquet.

moist Turkish towel with an outer water-resistant wrapping. Hot waterbottles laid against the covering will sustain the heat.

Alternatively, hospitals are employing a thermostatically controlledelectric blanket as a convenient means of promoting vasodilatation. 1Whena vein in the ankle is to be employed, the entire foot, ankle and leg shouldbe similarly wrapped. In 10 to 20 minutes, the entire area will be con-gested with blood, so that the veins may be outlined and the tourniquetapplied (figure 5, above; figure 6, page 9). Lundy2 has suggested the useof a common hair dryer (figure 5, above) as a quick convenient methodto produce vasodilatation at almost any site. The only precaution is thatthe dryer not be employed when explosive hazards are present.

When a vein of the upper extremity has been selected, an arm boardmay facilitate the puncture by restraining the patient from jerking hisarm. The wrist can be secured to the board (not rigidly enough to stopfree circulation) by a broad strip of adhesive tape or gauze. An arm boardis particularly useful when administering parenteral fluids to children.

Lundy3 points out the necessity of warming the sponge and antisepticsolution, at least to body temperature, before cleansing the site of thepuncture. Because the arm is warm, it is more than usually sensitive tocold, so that the reflex resulting from sudden contact with a cold solu-tion causes the blood vessels to contract almost immediately.

For infants and other persons with very small veins, or for unusuallysensitive patients, venipuncture can be made painless by the simpleexpediency of raising a wheal in the skin overlying the vein. This is doneby injecting 0.5 ml. of Procaine Hydrochloride, 1.0 per cent solution. Theneedle used for making the wheal should be advanced close to the wall of

8 the vein so that the vein and the skin covering it will be anesthetized.

Figure 6. Tourniquet has been tightened and patient has been instructed to make a fist.

For an excitable or nervous patient a small dose of sedative at leastthirty minutes before infusion may calm the patient and minimizemovement of his extremities.

MAKING THE VENIPUNCTURE. All the previous preparations and pre-cautions lead directly to getting the needle safely and as painlessly aspossible into the vein and keeping it there until the injection or infusionis completed.

The Bevel: Whenever the lumen of the vein to be entered is sufficientlylarge in relation to the size of the needle (as in most cases) venipunctureshould be made with the bevel of the needle facing upward (figure 7).This attitude of the needle to the vein will facilitate entry and will causethe least injury to the skin being pierced and the vein being entered.

However, when the vein is small and the lumen is estimated to ap-proach the size of the needle, entry should be made with the bevel facingdownward (figure 8, drawing e).

The angle at which the bevel is cut (long, intermediate, or short)affects the function of the needle. A long bevel presents somewhat lessresistance to venipuncture than a short bevel, but is more susceptibleto inadvertent penetration of the opposing vein wall. Improved methodsof sharpening have made short bevel needles popular, especially in thefiner gauges.

Figure 7. A Relatively Small Needle Entering a Relatively Large Vein. This illustratesa satisfactory relationship of the lumen of the vein to the size of the needle. 9

ll!ll!!!IIlIIlI!" tlIO'!!, •••.%""ij~'''''''',~a

Tourniquet

b

Tourniquet

::

-c

Tourniquet removed

d

Tourniquet removed

e

Tourniquet removed

Figure 8. A Relatively Large Needle Entering a Relatively Small Vein. (a) A hematomamay form if the bevel faces upward. (b) In other cases, with the vein properly dilated,satisfactory entry may be made with the bevel facing upward. (c) However, when thetourniquet is released the vein tends to collapse and occlude the lumen of the needle.(d) Readjusting the needle without a tourniquet may lead to perforation of the posteriorwall of the vein and a subsequent hematoma. (e) With the patient carefully prepareda relativeiy large needle may be introduced into a relatively small vein if the bevel faces

10 downward. (From Surgery, 2:590, 1937).

.VEIN

1. basilic

2. median basiIic

3. cephalic

4. median cephalic

5. median cubital

iii NERVE

-- ARTERY

Figure 9. Two common arrangements of the veins of the cubital fossa of the left arm,showing relationship to arteries and nerves. (Adapted from Adriani, J., Techniquesand Procedures of Anesthesia, Charles C Thomas, Springfield, Illinois, 1956, p. 263.)

Figure 10. (below) Diagram of a needle

hub lumen (inside diameter)--h--41 -~===.~~be.vel__r~:::::~J_",The Needle: Although not all physicians use the same size of needle

for intravenous infusions, generally they prefer an 18-, 19-, or 20-gaugeneedlewhich is 1or 1~ inches long. However, in certain instances, whenfluids must be given at the most rapid rate possible, a 15-gauge needlemay be employed.

A "thinwall" needle.has a lumen (inside diameter) one size larger thanits gauge. Thus a 19-9auge thinwall needle has the same lumen as an18-gaugestandard walled needle.

Regardless of size, the needle should be sharp. A broken tip or the slight-est hook on the end of the needle (figure 11) can result in mechanicaldifficulty for the operator and injury or unnecessary discomfort to thepatient.

Figure 11. A simple test, such as passing the needle back and forth through sterilegauze orexamining the tip under a magnifying glass, will quickly demonstrate whetheror not the needle is suitable for use. 11

Figure 12.

Basic Venipuncture (closed technique for intravenous infusion): Afterthe site has been prepared (with heat if necessary) the tourniquet isapplied and tightened as directed on pages 6 and 7, and venipunctureproceeds with these basic steps as illustrated in figures 12, 13, 14, 15:

1. Apply antiseptic solution to the area involving the injection(figure 12).2. Clear the infusion tubing of air and fasten the pinch clamp.3. Hold the limb with the left hand, using the thumb to place theskin on stretch and to anchor the vein.4. Point the needle in the direction of the course of the vein at theproposed site of entry. The angle of the needle to the surface of theskin should be about 45 degrees.5. Place the tip of the needle slightly to one side of the vein (figure 13)and about one-half inch below the point where the needle will enterthe vein itself. (Most operators do not attempt to pierce the skinand vein in the same thrust.)6. Firmly pierce the skin and underlying tissues to the depth of thevem.7. Depress the needle (decrease its angle) so that the needle is almost

12 Figure 13.

Figure 14.

flush with the skin. Move the tip of the needle directly above thevein (figure 14).

8. Slowly send the needle into the vein. A backflow of blood into theclear plastic tubing will indicate satisfactory entry. (In some casesbottle holding fluid to be administered will have to be lowered.)9. When the blood appears, cautiously advance the needle until itlies well within the lumen of the vein. This should be done by liftingthe vein on the needle with a slight upward pressure to prevent theneedle's passing through the posterior wall of the vein.10. Release the tourniquet and relax the tension of the skin.11. Adjust pinch clamp and start infusion.12. Be sure fluid is flowing freely in the vein. (Signs of swelling mayindicate extravasation. In this event, the infusion should be discon-tinued immediately and a new site selected.)13. To protect the skin under the needle, place sterile gauze underand over the needle.14. Tape the needle firmly in place with adhesive.15. To minimize movement of the needle in the vein, tape a loopedportion of the tubing to the forearm (figure 15).

Figure 15. 13

OTHER TECHNIQUES: The "closed" technique is outlined above becauseof the growing use of previously assembled disposable equipment forintravenous infusions. However, infusions may be started by severalother techniques, although the basic venipuncture is the same.

One method employs a needle attached to a 2-ml. dry syringe ("sepa-rate syringe" technique). Again, the infusion tubing is filled with fluidand cleared of air, and venipuncture proceeds by the method outlinedunder Basic Venipuncture. The syringe (if it has no lock) should beheld so that the little finger prevents movement of the plunger duringpiercing of the skin. After the skin is pierced the little finger should exerta slight backward pull on the plunger. The negative pressure thus in-duced will allow blood from the vein to enter the syringe. After bloodappears freely in the syringe the needle is advanced into the vein as instep #9. The tourniquet is then eased, the syringe detached, and thetubing attached. Steps #11 through #14 are then performed.

In a variation of the "separate syringe" technique a larger syringecontaining 3 or 4 ml. of isotonic saline solution may be used for thevenipuncture. This minimizes the danger of clotting which may occurwith a dry syringe, especially if there is difficulty in entering the vein.In infants and other subjects with exceedingly small veins only a small

14 amount of blood may be aspirated before the vein collapses. It is then

Figure 16. Venipuncture at antecubital fossa. Arm has been prepared with antisepticsolution, draped and tourniquet tightened. Needle is aimed parallel to long axis of vein.

necessary to remove the tourniquet and inject saline solution to be surethe vein has been entered properly. Venipuncture proceeds as outlined,the syringe being held as shown in figures 16, 17, 18. For piercing theskin, the syringe should be held by both the plunger and the barrel(figure 16). After the skin is pierced the syringe should be held by theplunger with the thumb against the barrel to create negative pressure(figure 17). Thus, when the vein is entered blood will be aspirated intothe syringe. After blood appears freely in the syringe, the needle is ad-vanced into the vein as in step #9. The tourniquet is then eased, andthe contents of the syringe are injected into the vein (figure 18). Finally,the syringe is detached, the tubing is attached, and steps #11 through#14 are performed.

One other method of beginning an infusion is called the "connectedsyringe" technique. Here the syringe is assembled with a sidearm outletfrom the barrel, and the tubing (cleared of air) is attached to this outletbefore venipuncture. Venipuncture proceeds as with the basic "separatesyringe" method. After blood appears freely in the syringe the needle is 15

Figure 17. Thumb of left hand tenses skin back of needle. Position of right hand andthumb against the barrel of syringe permits slight aspiration duirng venipuncture.

advanced into the vein. The plunger is withdrawn past the opening ofthe sidearm and the tourniquet is eased, thus starting the infusion. Steps#11 through #14 are then performed.

This technique eases the task of the operator but may be a burdento the patient, since the syringe remains attached throughout the infu-sion. Even though a pad of sterile cotton is placed under the syringe,the extra weight may lead to severe discomfort during an infusion last-ing several hours. For this reason the technique is not used often.

16 Figure 18. Method of holding syringe with needle inserted into median cephalic vein.

ABOUT THE INFUSION

ABOUT THE INFUSION

SELECTION AND PREPARATION OF EQUIPMENT FOR VENOCLYSIS: Althoughthere are mechanical differences between the equipment manufacturedby different firms, a basic unit usually consists of the following:

1. A bottle or other reservoir containing the solution to beadministered,2. A dispensing cap,3. A drip chamber,4. A length of tubing,5. A pinch clamp,6. An air filter,7. A needle adapter,8. A needle.

A small syringe is sometimes employed ("separate syringe" and "con-nected syringe" techniques, pages 14 and 15) to determine that theneedle is in the vein (by aspiration of blood).

Despite a similarity of component parts, there are two distinctly dif-ferent types of equipment available: disposable and permanent. Selectionof one type or other determines the amount of preparatory work to be done.

A disposable unit (such as the Venopak, shown on page 23) is de-livered to the hospital sterile and ready for immediate use. After a singleinfusion the complete unit is then discarded. According to Lundy4:"Most pyrogenic reactions following blood and fluid infusions seem toarise from improperly cleansed and unsterile equipment. This is particu-larly true with reference to rubber tubing. Tubing should be used onlyonce for blood transfusions. Disposable tubing is to be preferred. Itmight be well if there were a member of the hospital staff designated asa 'snatcher' whose function it would be to snatch up and dispose of alltubing once used for transfusion or infusion purposes. The 'snatcher'would save us many needless reactions."

The need for strictly aseptic techniques throughout the preparationand infusion is well established. When the same equipment is reused (asis permanent equipment) it should be carefully cleansed, thoroughlyrinsed with triple-distilled water, packed in sterile gauze, and sterilizedby autoclaving.

TEMPERATURE OF SOLUTION AT TIME OF ADMINISTRATION: Generally,solutions are administered without regard to the temperature. Practi-cally all commercial intravenous solutions are stable at room tempera-

18 ture and are not stored under refrigeration. A rather wide temperature

range is tolerable to the patient, because the small volume infused witheach drop is quickly diluted and brought to the temperature of the cir-culating blood.

ASSEMBLING THE APPARATUS: Attach the tubing to the bottle (or otherreservoir) according to the.manufacturer's directions. Suspend the bottleon a stand two to three feet above the level of the bed. Adjusting theheight of the bottle is one means of controlling the rate of infusion.

RATE OF INFUSION: This is one of the most important factors in thesuccessful administration of fluids. Usually (except in emergency pro-cedures) the rate should be slow. Specific rate of flow must be deter-mined by the clinician who orders the medication. As indications mayvary with the kind and concentration of solution being administered,condition of patient and other factors, no attempt is made to discussthem here.

Before venipuncture, the operator determines the maximum rate offlow by his choice of needle-size. For most infusions, an 18-, 19-, or20-gauge needle (lor 172 inches long) is used.

Occasionally, when parenteral solutions are given too rapidly "speedshock" may occur. Usually, the patient is flushed, uncomfortable andcomplains of a pounding headache or constriction of the chest. Theremay be pulse irregularity and, in extreme instances, there is a cessationof respiration or disappearance of the radial pulse. The best preventiveof speed shock is slow infusion. More commonly, too rapid administra-tion of fluids may cause subcutaneous edema.

MECHANICAL DIFFICULTIES: Relatively few things will inhibit the flowof an infusion properly assembled and started. However, flowis alteredoccasionally, usually from one of four causes- a kink in the tubing, aplugged air filter, displacement of the needle or an obstruction in theneedle.

A simple preventive or remedy is to flush the needle every half houror so. This reduces considerably the possibility of clogging the needle.

If the needle is not clogged, the tubing should be checked to be surethat there are no obstructions. Should difficulties still be encounteredafter the needle and tubing have been checked, the infusion should beterminated (page 20) before any major adjustment .ismade.

ADDING SUPPLEMENTAL MEDICATION: With the versatility of parenteralequipment currently available, the physician may administer severalmedications through the same infusion needle simultaneously or sepa- 19

20

rately. Several mechanical devices may facilitate this process. For in-stance, a three-way stopcock attached to the needle provides the oper-ator with two inlets to the blood stream. This is especially desirablewhen one or more supplemental medicaments must be given during thecourse of an infusion.

The usual venoclysis apparatus itself allows ample range for routinechanges in therapy. When a drug for immediate effect is desired theoperator may pierce a gum-rubber insert with needle (and attachedsyringe) and make the injection. With the commercial sets and specialtubing with multiple injection sites now available, additional fluids maybe introduced into the bottle or injected into the tubirig,'Finally, theinfusion of a separate solution may be facilitated with a series hook-upor a tandem hook-up.

Regardless of the means employed for supplemental medication orthe point at which it enters the primary infusion system, one should bealert for signs of leakage or for air bubbles in the tubing. Any openingintroduced into the tubing may permit air to be pulled into the movingfluid, and air embolism may result. Stopcocks may also be a point of

entry for air.TERMINATING THE INFUSION: To terminate an infusion (before or at

the end of the procedure) :1. Stop" the flow of fluid by means of the clamp nearest the needle.2. With the needle held firmly in place, gently remove the adhesivetape by which the needle and adapter were secured.3. With one hand, place and hold a small wad of sterile cotton over

the site of injection.4. With the other hand keep the hub of the needle flush with theskin and slowly withdraw the needle, taking care not to drag the tipagainst the posterior wall of the vein.5. Secure the wad of cotton over the injection site with a piece ofadhesive tape,

Since the patient's arm has been immobilized for a period of time, donot attempt to flex it for him. Let the patient do so himself when his

arm has "recovered."

ABBOTT EQUIPMENT FOR INFUSIONS

ABBOTT EQUIPMENT FOR INFUSIONS

The Abba-Liter

Abbo-Liter is the registered trademark of the special container inwhich Abbott solutions for infusion are offered. The Abbo-Liter is grad-uated and labeled for reading in the standing or hanging positions. Solu-tions are sterile and pyrogen-free and are packaged at atmos-pheric pressure.

Modern techniques of preparation, sterilization, and packaging havereplaced the need to bottle solutions under vacuum. Thus, in principlethe Abba-Liter is an enlarged ampoule. An operator need only open theAbbo-Liter, connect the appropriate apparatus, and begin venoclysisor hypodermoclysis. With aseptic techniques no contamination willoccur.Since there is no vacuum to be relieved before the solution is adminis-tered, there can be no inrush of air and possible air-borne contaminants.

Additional selected electrolytes may be added to the Abbo-Liter fromthe Abbo-Vial which contains Ion-o-trate, Abbott's line of concentratedelectrolyte solutions. Simply unscrew the plastic hood of the Abbo-Vialto break the seal; then aseptically pour the calculated amount of theselected Ion-o-trate into the standard Abbott bulk solution.

Abbott equipment for infusions has many unique features. For instance,the Secondary Venopak may be connected in series with the Venopak tochange fluid therapy during the course of an infusion. Alternatively,two Abbo-Liter containers may be connected by means of a Y-type tub-ing. Other sets are designed for extension, for administration by syringe,for micro-administration, or for administration from several sites on thesame tubing. All sets are packaged with complete operating instructions.

VENOPAK for Simple Venoclysis

The Venopak is a completely disposable set for administering intravenousfluids from the Abbo-Liter. Important to this all-plastic unit are thefollowing features: The drip chamber is flexible. One squeeze primes it(or clears it if ever flooded). It is oversize for improved performance andvisibility. The air filter is made of woven Fiberglas discs, coated withTeflon. The filter is non-wettable virtually eliminating leakage or inter-ruption of air flow. The screw clamp can be operated with one handpermitting close regulation of the flow rate.

Two lengths are available: Venopak (60 inches) and Venopak-78 (7822 inches).

NEEDLE-ADAPTER

VENOPAK-List No. 4622; (With 20-G Needle-List No. 4615); (With 19-G Thinwall[18-G I.D.] Siliconed Needle-List No. 4638)VENOPAK-78-List No. 4631; (With 20-G Needle-List No. 4644); (With 19-G Thinwall[18-G I.D.] Siliconed Needle-List No. 4621)

Assembling and operating the Venopak

1. Remove protective lid from dispensing cap, and fit capto Abbo-Liter by turning container against it.

2. Suspend bottle. Hold the coiled tubing in one hand.Half fill drip chamber by squeezing chamber.* Closeclamp.

3. Remove protective cover from needle adapter, andattach sterile vein needle.

4. Open clamp and clear tubing of air by filling with fluid.Close clamp.

5. Make venipuncture in prepared site, and adjust rateof flow.

Screw clamp iseasily adjustedwith one hand.

Injecting supplementary medication

To inject supplementary medication, sterilize the gum rubber insertby applying Metaphen (nitromersol, Abbott) Tincture or other suitableantiseptic solution and allowing to dry. Inject, using a syringe and25-gauge needle.

Compatible medication may also be added directly to the solutionby removing the air filter and attaching the syringe without needle tothe air vent. Inject, remove syringe, and replace filter. The procedure

*If drip chamber ever floods. simply close" clamp and turn Abbo-Liter back to the upright (non-inverted) position. Squeeze drip chamber to clear the excess fluid, then resuspend. 23

takes only a few seconds. Medications can be added while the infusion isin progress. Although mixing is accomplished by air bubbles rising duringthe infusion, it may be well to swirl the bottle immediately after adding

the supplementary medication.

SURGICAL VENOPAKto Provide Extra Injection Sites

SCREW CLAMP-~-76" PLASTIC TUBING

__ INJECTION SITE

fjEEDLEADAPTER

h ~. . -INJECTION SITE

GUM TUBING

SURGICAL VENOPAK-List No. 4557SURGICAL VENOPAK with 18-G Thinwall (17-G 1.0.) Siliconed Needle List No. 4666

The Surgical Venopak differs from the Venopak in having a 76-inchtubing with three injection sites. Two are Y-type sites. The third site(immediately preceding the needle adapter) is heavy gum rubber capa-ble of withstanding multiple needle punctures. Both a screw clamp and aslide clamp are provided. Flow may be temporarily interrupted with theslide clamp without disturbing the adjustment of the screw clamp.

VENOPAK MICRODRIP (List No. 4740) for Precision Drop Control

For a slower rate of administration or for more precise control of therate, the Venopak Microdrip is offered for use with Abbo-Liter solu-tions. This special disposable set consists of a dispensing cap with airfilter, the Microdrip and flexible drip chamber, clear plastic tubing withinside diameter of 0.100 inch, a screw-type pinch clamp, a metal pinchclamp, a multiple-injection site, and a needle adapter. The screw-typepinch clamp affords the control desired.

Approximately 60 drops from the Microdrip deliver one milliliter.This will vary slightly with individual sets, viscosity of the solution,

24 and the flow rate.

ADAPTER

CLAMPCLAMP

INJECTION SITE

_PLASTICTUBING

The infusion rate should be checked periodically and, if necessary,adjusted to maintain the desired rate.

SECONDARY VENOPAK (List No. 4613) for Series Hookup

DISPENSINGCAP

The Secondary Venopak provides a simple and economical means ofadding more fluid, or of changing fluids, while an infusion continues.This disposable unit is similar to the primary Venopak, but has no dripchamber. It permits attaching a secondary container in series to theprimary container. The Secondary Venopak can be attached withoutstopping flow from the primary container.

If specific gravity of the secondary fluid is greater than that of theprimary fluid, it will tend to layer under, and will mainly infuse first.Otherwise the two fluids will intermingle to varying degrees, and infusesimultaneously. The secondary container always empties first. Air fromthe secondary tubing rises to the top of the primary container.

Because some degree of mixing is always possible, we recommend thatsecondary hookup never be made into a primary bottle containing a potentdrug (e.g., intravenous anesthetics or muscle relaxants). This avoids anyhazard of an overdose of primary fluid which may mix in during thesecondary infusion. 25

Assembling and operating the Secondary Venopak

1. Remove protective lid from dispensing cap, and fit cap by turningAbbo-Liter secondary container against it. Place secondary containerupright, or hold it as shown in sketch below.2. Remove air filter from primary Venopak, uncover adapter of Sec-ondary Venopak, and plug adapter tightly into exposed vent.3. Suspend the secondary container.

Convenient way to hold secondary container and attached set. Hold adapterbetween thumb and forefinger. Then suspend secondary container by its bail fromlast two fingers of same hand. This allows both hands free movement for plugging inand avoids spillage, since adapter is higher than secondary container.

Y-TYPE VENOPAK (List No. 4656) for Alternate Administration of Fluids

NEEDLEADAPTER

This set is for alternate venoclysis from two Abbo-Liter containers26 exclusively. Completely disposable, it contains two dispensing caps with

air filters and drip chambers, two slide clamps, a screw clamp, clearplastic tubing, a gum rubber injection site, and a needle adapter.

Assembling and operating the Y -Type Venopak1. Remove protective lid from one dispensing cap, and fit cap toAbbo-Liter by turning container against it. Repeat with other con-tainer.2. Close both slide clamps and suspend containers.3. Holding coiled tubing in one hand, half fill each drip chamber bysqueezing chamber.4. Remove protective cover from needle adapter, and attach sterilevein needle.

5. Expel air as follows: Open one slide clamp, and allow fluid to filltubing to a point below the Y; close the clamp. Open other slideclamp, and fill all remaining tubing and needle; close the clamp.6. Make venipuncture in prepared site.7. Fully open slide clamp below the desired container, regulating therate of flow with the screw clamp below the Y.8. To switch to the alternate container, tightly close the slide clampbelow the first container; then fully open slide clamp below secondcontainer, regulating rate of flow with screw clamp.

WARNING: Do not allow either container to empty completely. Be sure slideclamp closure is complete (no dripping in chamber). If either bottle emptiescompletely, air may be drawn into main tubing and administered with fluid.

Precision Volume SOLUSET-100 (List No. 4578) and SOLUSET -250 (List No. 4680)

The Soluset isAbbott's solution administration set with rigid calibratedchamber. It permits the physician to administer limited amounts ofsolution in precise volumes. It is well suited to pediatric use. It iscomplete, requiring no other parts except a vein needle,

Major feature of the set is a rigid cylinder of 100-ml. or 250-ml.capacity. By filling the cylinder to an appropriate level, the operatorcan give any precise volume desired. Amounts larger than capacity maybe given simply by refilling the cylinder. Because the cylinder is rigid,it permits positive reading of the fluid level. The graduations are in5-ml. intervals, spaced equidistantly. A hinged valve abruptly seals offthe cylinder when the fluid level reaches the 0 mark.

Soluset-lOO is fitted with a Microdrip orifice, which provides approxi-mately 60 drops per ml. Soluset-250 is calibrated at 15 drops per ml.Both sets provide a screw clamp for precise control of flow rate. Con-veniently, it is not necessary to close this clamp during refilling. 27

28

Supplemental medication may be injected (1) at the top of the cylin-der, (2) at a Y-type site on the tubing, and (3) at the gum rubberpreceding the needle adapter.

The cylinder is connected to the bottle by two lengths of tubing, oneside for movement of fluids, the other side for air. A single slide clampcloses both.

5 mi. SCALE

HINGED VALVE

MICRODRIP

DRIP CHAMBER

INJECTION SITE

~-SCREW CLAMP

Note: Toshowthat the set is outof jservice between infusions, and IIyet leave it completely connected, IIthe cylinder may be looped over Iithe stand. . I II

Assembling and operating the Soluset

1. TO ASSEMBLE. Close both clamps. Fit dispensing cap by turningAbbo-Liter container against it. Invert and suspend container.2. TO PRIME TUBING. Open slide clamp, fill calibrated chamber aboutone-third, and close slide clamp again tightly. Gently squeeze dripchamber until about one third full. Without removing needle adapter

cover, open screw clamp to fill tubing with fluid, expelling all airfrom tubing. Close screw clamp.3. TO FILL. Open slide clamp and fill calibrated chamber to desiredlevel. Tightly close slide clamp.4. TO ADMINISTER. Attach vein needle. Proceed with venipuncture,taking caution to avoid air bubbles in tubing prior to venipuncture.Adjust flow rate with screw clamp; 60 drops equal one milliliter.The set will shut off automatically at pre-set volume.5. TO REFILL. It is not necessary to close screw clamp for refilling.Simply open slide clamp, fillcalibrated chamber to desired level, andtightly close slide clamp. Gently squeeze lower part of drip chamberjust enough to open rubber diaphragm. Slowlyrelease fingerpressure.

VENOCATH Sterile Peel. Pack(Intravenous catheter inside the needle)

VENOCATH-14-List No. 4614; 11)1," catheter, 15-G. bore; needle 13.G. bore.

VENOCATH-16-List No. 4816; 11X" catheter, 18-G. bore; needle 15-G. bore.

VENOCATH-18-List No. 4718; 11)1," catheter, 21-G. bore; needle 17-G. bore.

The Venocath is a flexible intravenous catheter inside a needle. Thiscatheter is radio-opaque; its position in the vein is always readily visiblein X-ray films. A removable stainless steel wire stylet prevents thecatheter from buckling while being threaded into the vein. After theneedle is withdrawn from the vein, a unique folding guard shields theentire length of the needle. The catheter may be left indwelling duringrepeated infusions, and the limb usually need not be immobilized. Useof the pliant catheter is more comfortable for the patient than adminis-tration via a rigid needle, especially if therapy is prolonged. It alsoobviates surgical cutdown and sacrifice of the vein. 29

30

Assembling and operating the Venocath

1. To open-Leave the sterile inner sheathintact until immediately before use.Then grasp base of blue needle guardand strip sheath down enough to exposeonly two-thirds of guard.

3. Enter Vein-Make venipuncture, hold-ing needle bevel up. Grasping catheterthrough its protective sheath, slowlypush catheter well into vein. (If duringthis maneuver, it becomes necessaryto withdraw catheter, always withdrawneedle simultaneously; this preventssevering of catheter by needle.)

5. Withdraw Stylet-Remove protectivecap from white adapter, and withdrawwire stylet. Immediately connect admin-istration set to adapter.

2. Expose Needle-Slide back clear plasticring on needle guard, and open guardwings. Discard inner white cover, ex-posing needle.

4. Withdraw Needle-After blood fills cath-eter, apply finger pressure over catheterin vein. Hold it thus while withdrawingneedle. Discard sheath. Snap hub ofneedle guard into white adapter at cath-eter end.

6. Close Needle Guard-Close wings ofguard in place over needle, and slidering back to distal end of wings, to lockthem in place. Tape catheter, needleguard, and end of administration set forproper immobilization.

BUTTERFLY INFUSION SETS (Formerly called "Scalp Vein Infusion Set")

Butterfly sets serve as extensions for infusion of blood or solutions fromthe Venopak or any standard syringe. They have flexible plastic wingsthat can be folded upward to provide a fingergrip for more accurateneedle manipulation. This allows the needle to be held flat against theskin and inserted into the vein with a sliding motion. The same featurefacilitates venipuncture in difficult patients-for example, elderly per-sons with fragile, rolling veins. When released, the wings fold flat againstthe skin, where two short strips of tape suffice for stable anchorage. Toeliminate any possibility of separation, tubing and needle are perma-nently joined at the time of manufacture.

The short needle, compact anchorage, and flexible tubing contributeto greater patient comfort-with reduced chance of phlebitis, or ofpressure necrosis beneath a bulky taped hub connection. The sets aresterile inside and out, come in sterile peel-pack envelopes, completewith stainless needle.

BUTTERFLY-16-List No. 4716with 16-G. thinwall needle (15-G. bore)

Designed primarily as a surgical infusion set, the Butterfly-16 is suppliedwith a 16-gauge thin wall needle (15-G. bore) for rapid infusion andpressure administration. The .100" r.D. tubing is 3D-inches long, whichallows connection to the administration set at a clearly visible locationoutside the surgical drapes.

BUTTERFLY-19-List No. 4590with 19-G. thinwall needle (18-G. bore) and .054" 1.0. tubingBUTTERFLY-21-List No. 4492with 21-G. thinwall needle (20-G. bore) a[ld .040" 1.0. tubingBUTTERFLY-23-List No. 4565with 23-G. needle and .040" 1.0. tubingBUTTERFLY-25-List No. 4506with 25-G. needle and .040" 1.0. tubing

These sets are supplied with small J.D. ultra flexible tubing, 12-incheslong. The 19- and 21-gauge sets are adaptable for infusions at manysites, and on patients of all ages. The 23- and 25-gauge sets are pediatricsizes, especially convenient when working with infant scalp veins.

31

VENOVALVE 30" with "T" ConnectorList No. 4730

This is a syringe administration set, 30 inches long. A check valve atthe terminal female adapter prevents backflow. An additional injectionsite (latex-covered) is provided at the T-type male needle adapter; thissite may be uncovered to expose a female adapter.

"T" CONNECTOR SET-List No. 4612

Use this connecting unit to join any two pieces of equipment or syringes.with or without needles to a common outlet. It provides a female adapter,four inches of plastic tubing, slide clamp, and attached T-type maleneedle adapter with injection site (with latex cover which may be re-moved to expose a female adapter).

VENOTUBE

VENOTUBE 20-List No. 4429VENOTUBE 30-List No. 4481VENOTUBE 30 Sterile Peel-Pack-List No. 4610

These sets consist of tubing (20 and 30 inches long respectively) withpinch clamp and male and female adapters. They are used as flexibleconnections between syringe and needle during administration ofPentothal Sodium (Sodium Thiopental for Injection), or as extensionswhere added length is needed. The inside sterility of No. 4429 and 4481is maintained by air filters and hoods at each end. No. 4610 is suppliedin a sterile peel-open envelope, and is sterile inside and out; it has a

32 smaller lumen tubing than 4481, and is without air filters and hoods.

VENOTUBE TWIN-SITE (List No. 4522) for Versatility

FEMALE ADAPTER

-TO VEIN

MALE ADAPTER

This 30-inch assembly with two injection sites is designed to be used forinfusions, tra'nsfusions, or the administration of Pentothal Sodium(Sodium Thiopental for Injection). The set consists of 30 inches of clearplastic tubing, multiple injection sites, two pinch clamps, and male andfemale adapters. This is a versatile set offering a number of combinations.I t is disposable.

ClY.Q-PAK for Hypodermoclysis (Subcutaneous Infusion)

When a suitable vein is unusually difficult to find or enter (as in infantsor obese patients) parenteral fluids may be administered by hypodermoc-lysis (subcutaneous infusion). The same rigi<;l precautions-sterility ofequipment and employment of aseptic techniques throughout-are asimportant for subcutaneous infusion as for intravenous infusion.

Needle size: For general use the Cly-Q-Pak furnishes two 22-gaugeneedles two inches long. Where another size needle is preferred, theCly-Q-Pak is also available without needles.

Other factors: Patients, especially children, should be well attendedthroughout the infusion, since a sudden movement of the patient maydislodge a needle or disconnect a tubing. Should this happen, the infusionshould be discontinued until the equipment can be properly adjustedor reassembled.

Selecting the equipment: When one needle is employed, the basic unitfor hypodermoclysis is the same as that used in venoclysis (for instance,the Venopak, page 23). However, to hasten administration, two needlesare generally utilized. This can be accomplished by use of the Cly-Q-Pak 33

;_PLASTIC

, "Y" TUBE

CLY-Q-PAK (Hypodermoclysis Unit) With two Needles, List No. 4617; Without Needles

which is basically the same as the Venopak except that an inverted plas-tic "Y" joins two separate arms of tubing to the primary tube. Each armis 14 inches long. Cly-Q-Pak (see illustration) is completely assembled,is delivered in a sterile individual carton, and is ready for immediateuse. A pinch clamp on each arm allows the operator to control the flowto each site. Cly-Q-Pak is assembled in the same manner as the Venopakand operates on the same principles. Discard the entire unit after one use.

Selecting and preparing the site: The best site for hypodermoclysis isthe outer middle surface of the thighs. The anterior surfaces of thethighs, the flanks, and the loose tissues at the sides of the chest belowthe axillae are also suitable. The injection is into the fatty tissues justbeneath the skin.

Adequate cleansing of the skin can be accomplished by applying Tinc-ture of Metaphen within a five-inch radius of the proposed site of injec-tion. A wheal is then raised by intradermal injection of 0.5 m!. ofprocaine hydrochloride, 1%. In a few moments the needle for hypo-dermoclysis can be inserted through the center of the wheal.

34 Introducing needle and infusing the fluid: As with venipuncture the

clysis tubing should be cleared of air before' insertion of the needle.To guard against inadvertent intravascular injection, the needle shouldbe introduced either unattached or attached to a syringe. The technique:• With thumb and index finger pinch a fold of the skin and hold firmly.• Through the center of the wheal plunge the needle to about three-fourths of its length at an angle of about 30 degrees to the skin.• Watch for the flow of blood or (if syringe is attached) aspirate. If noneappears, connect the clysis tubing to the needle by means of the adapter.• Place sterile gauze under and over the needle; tape the needle, adapt-er, and tube securely to the skin. Adjust the pinch clamp and start theflow of liquid.

Rate of flow: The rate at which such an infusion can be administeredwill vary from person to person and must be adjusted accordingly. Abil-ity to absorb fluids is variable, and tissues may become unduly distendedand painful if the rate is too fast. The flow should be stopped fromtime to time in order to gauge the rate of absorption. If an individual'sabsorption is found to be very slow, a new site (or sites) should beconsidered.

Hyazyme (hyaluronidase for injection, Abbott) is also available forincreasing the rate of absorption. This enzyme accelerates the diffusionand absorption of fluids and drugs injected subcutaneously. For thisreason, it is used frequently as an aid in hypodermoclysis. Absorptionmay be enhanced considerably, so usual time for this type of infusioncan be reduced to one-half or one-third.

Hyazyme is supplied as a lyophilized powder in one-milliliter vials, eachcontaining 150 U.S.P. units of hyaluronidase. The powder is reconstitutedby addition of 1.0 ml. of sterile water for injection, U.S.P., or sodiumchloride injection, U.S.P. (isotonic). This solution is then injectedthrough the wall of the gum rubber insert or is injected directly into thesite chosen for hypodermoclysis immediately preceding the infusion.

The exact solutions to be administered by subcutaneous infusion willbe determined by the attending physician according to the patient'sneeds and general condition. Those usually given by this route are iso-tonic solutions containing some electrolytes. Care should be taken dur-ing the administration of hypertonic solutions or of isotonic solutionscontaining only a sugar, since these may cause pain by drawing fluidfrom the surrounding tissues. If the patient is salt-deficient, or is in thebeginning stage of shock, or has impaired kidney function, fluid may bedrawn from the circulating volume, thus, leading to circulatory diffi-culties. The operator should be alert for signs of unusual swelling oredema in the area of clysis. 35

FROM THE SYRINGE

38

FROM THE SYRINGE

Solutions or other liquid preparations may be administered from asyringe by any of several routes, the exact volume depending on theroute chosen by the operator or dictated by other factors. Thus, medi-cations or diagnostic materials may commonly be injected intrave-nously (into the vein), intramuscularly (into a muscle or muscle-mass),subcutaneously (under the skin), or intradermally (into the superficiallayer of skin).

Transfer from the Abbott ampoule and from the multi-dose vial

Both the ampoule (for a single dose) and the vial (for multiple doses)are designed specifically for delivering a solution to the syringe. Formaximum ease of operation many Abbott sterile ampoules are offeredwith Color-Break or Gold-Band to eliminate the necessity for filing,sawing, or scoring by the operator. The neck of the ampoule breakscleanly and evenly with only slight pressure.

From the ampoule

1. Always read the label of the ampoule to be certain it contains the drugand dosage which were prescribed. Never use the contents of an un-labeled ampoule.2. Cleanse the neck of the ampoule with an antiseptic sponge orswab:

A. Abbott ampoules with paper labels may be sterilized exter-nally by immersion in alcohol (70 per cent) or in Zephiran(benzalkonium chloride). They should not be immersed in

Metaphen (nitromersol, Abbott), since the adhesive is attackedby alkaline solutions.B. Abbott ampoules labeled with a silk-screen printing processmay be immersed in water, alcohol, or other antiseptic solutions.

3. Grasp both ends of the ampoule as shown below and bend thestem until it snaps. No filing, scoring, or sawing is required.

4. Insert the needle deep into the ampoule and aspirate the solution.5. Holding the syringe vertically with the needle pointed up, expelthe air and check the dosage.6. Proceed with the injection.7. If the drug is not to be injected immediately, place the emptyampoule on the sterile tray with the full syringe to identify its con-tents. Use the neck of the ampoule as a cover for the needle.

From the vial

1. Remove the safety seal and dust-cap.2. Cleanse the top of the vial with antiseptic sponge or applicator.The cleansing solutions for Abbott vials are the same as for the am-poules (described immediately above).3. Place the plunger of the syringe at the desired volume, insert theneedle through the center of the rubber stopper, and force air fromthe syringe into the vial.4. Holding the vial upside down, withdraw the desired volume intothe syringe and withdraw the needle from the vial.5. Proceed with the injection.6. Replace the dust-proof cap on the vial and store for future use.7. If the injection is not to be given immediately, wrap the syringeand needle in sterile gauze or place in a sterile container, leaving thevial nearby for identification. 39

40

From the TWO COMPARTMENT VIAL

A unique container for parenteral products is the Two CompartmentVial, a sterile vial with one compartment containing lyophilized (dried)solids, the other containing the diluent. For instance, Bejectal (injec-table vitamin B complex, Abbott) improved with Vitamin C is offeredin the Two Compartment Vial. Solids and diluent are mixed just priorto the injection by pressing the top (exposed) rubber stopper.

The dry solids are stable indefinitely, and the Two Compartment Vialeliminates many steps usually required in reconstituting solutions. Mix-ing is accomplished internally by a closed sterile technique.

How to prepare solution:

1. Remove plastic dust-cap by pushing off with thumb. Press topof rubber stopper with firm, steady pressure to dislodge rubber plugwhich separates the two compartments.

2. Shake Two Compartment Vial until all solids have been dissolved.3. Sterilize top of stopper, invert vial. Using needle attached tosyringe, pierce stopper squarely through center ring. Withdrawdesired volume.

Into the vein

In contrast to the larger volumes administered by infusion, relativelysmall volumes of solutions or liquid suspensions are injected into thevein from a syringe. Reasons for this route include the following:

1. An immediate effect is desired,2. The drug may not be capable of absorption from the gastrointes-tinal tract or from the tissues,3. A drug may be too irritating for other parenteral routes,4. Tests of circulatory function may be desired.

SELECTING AND PREPARING THE SYRINGE AND NEEDLE: The size of thesyringe should be in proportion to the volume of solution to be adminis-tered. The availability of 2-ml., 5-ml., and 20-ml. syringes usually pro-vides adequate latitude for all routine injections. Ideally a small syringewill be calibrated in both cubic milliliters and minims, and a darkenedplunger will aid in the measurement of small doses.

The needle should be chosen for the occasion. Hence, when a drugmust be administered slowlya 24- or 26-gaugeneedle can be used advan-tageously if the vein is easily accessible. However, in most cases a largerneedle is generally preferred, such as a 20-gauge needle which is 1 or 1~inches long.

Aseptic techniques should be employed throughout the preparationand injection. The syringe and needle must be properly sterilized beforeuse. A dry syringe and needle are preferred, since some preparations areaffected by water or are incompatible with it.

PREPARING THE SITE AND PERFORMING THE INJECTION: The generalcomments on pages 4 to 11 apply here as does the "separate syringe"technique (page 14). To complete the injection, proceed with the follow-ing steps:

1. With the needle satisfactorily located in the vein and the tourni-quet released, slowly depress the plunger of the syringe.2. When the contents have been injected, aspirate a small amount ofblood to be sure the needle is still in the vein.3. With one hand, place and hold a small wad of sterile cotton overthe site of injection.4. With the other hand, keep the syringe flush with the skin andslowly withdraw the needle.5. Instruct the subject to hold the cotton in place by manualpressure for two minutes. 41

Inadvertent intra-arterial inJectwn. When aspirating in order to deter-mine whether the needle has entered the vein (described page 15), theoperator should also be alert for signs of inadvertent arterial puncture.The presence of bright red blood within the syringe and evidence of pul-sation are strong indications that an artery has been entered. If arterialentry is not detected during aspiration, then partial or complete injectionof the contents of the syringe may cause arterial spasm and pain down thelength of the arm (in the direction of arterial flow). In either event theprocedure should be terminated and appropriate measures instituted.

Thrombophlebitis. Excessive trauma to the vein (as from multiple punc-tures), injection of very irritating agents, or injection of relatively highconcentrations of certain drugs may cause complications in the vein at orabove the site of the injection. A hardening of the vein and pain up thelength of the arm (in the direction of venous flow)are signsof this compli-cation. The procedure should be terminated and proper treatment begun.

Pain. Certain agents are known to cause pain on injection. Occasion-ally this pain may be accompanied by venous spasm which will greatlyinhibit the injection. If any difficulty is encountered during administra-tion of such material, the procedure should be discontinued.

Swelling. Occasionally, despite care, the posterior wall of the vein maybe pierced and the contents of the syringe injected into the subcutane-ous tissues. Thus, throughout the injection the operator should watchclosely for signs of swellingor of tissue irritation. Should these occur, theinjection should be stopped at once and suitable measures taken.

Into the muscle

Whenever practicable, the intramuscular route is utilized, since it is moreconvenient to both the patient and the operator than is the intravenousroute. Also, when prolonged action is preferred to immediate, a drugmay be injected into the muscle and gradually absorbed by the bloodstream. For example, prolonged blood levels of penicillin may be ob-tained by intramuscular injection of penicillin G procaine. Similarly, theaction of heparin may be prolonged considerably by intramuscular injec-tion of a very concentrated aqueous solution.

For the operator, intramuscular injections are much easier to adminis-ter-no tourniquet, less equipment, a minimum of mechanical maneu-vers. The technique is straightforward and remains constant, withinlimits, from person to person.

42. Nevertheless, precautions are necessary to insure that a blood vessel

has not been entered. The equipment, must be sterile, the medicationmust be sterile and pyrogen-free, and aseptic techniques should be em-ployed throughout.

SELECTING THE SYRINGE AND NEEDLE: Large quantities of a drug areseldom injected into the muscles, and a 5-ml. syringe is the largest whichwill be required. Generally a 2-m1. syringe will suffice. The needle shouldbe small, sharp, and strong with a gauge of 20 to 23 and a length not lessthan 172 inches, preferably about 272 inches.

In addition to the standard syringes available, Abbott offers the Abbo-ject syringe, a completely disposable unit containing accepted doses ofcertain medications. Preparing it for use requires only the attachmentof a standard Luer hub needle. This type of equipment has gained con-siderable popularity because it is delivered sterile and is used but once,thus eliminating the possibility of cross infection, serum reactions, orimproper sterilization.

Currently offered in this unit are:

Abbocillin-DC (penicillin G procaine), 600,000 Units, in Abboject Dis-posable Syringe with Needle, List No. 6310.Erythrocin-I.M. (erythromycin, Abbott), 100 mg., in Abboject Dis-posable Syringe, List No. 6350.Penicillin G Procaine in Aqueous Suspension, 300,000 Units, in Abbo-ject Disposable Syringe with Needle, List No. 6332.

SELECTING AND PREPARING THE SITE FOR INJECTION: As with intra-venous injections, a variety of sites is available for intramuscular in-jection. The gluteal muscles, triceps, deltoid, pectoral, and vastuslateralis of the quadriceps femoris are all suitable. However, the glutealmuscles are usually considered to be the site of choice, especially whenthe medication is irritating or when relatively large volumes are to beadministered. The overlying skin in the area is thin and easily pierced.Also, this site offers the operator a definite psychological advantagewhen the patient is apprehensive. Lying prone, the patient does notsee the approach of the needle.

Nevertheless, one should remember that under the gluteal muscles liethe sciatic nerve and the superior gluteal artery.

Although the hazards of introducing a drug into the gluteal musclesare real, they can be considerably minimized, if not eliminated, if the 43

Figure 19. The gluteal muscle-site ofchoice for intramuscular injections. Up-per outer quadrant lies well away fromgreat sciatic nerve and superior glutealartery.

Figure 20. Patient should lie relaxed-face down, feeUoeing in, arms hangingover sides of table.

operator is cognizant of this fact: the inner angle of the upper outer quad-rant (see figure 19, above) is the safest point for injection. This area lieswell away from the sciatic nerve and has a good thickness of muscle.PREPARING THE PATIENT:

Instruct the patient to lie face down on the table.Cleanse the upper outer quadrant with a suitable antiseptic and allow

it to dry. If injection is made while the skin is still wet, the antiseptic maybe carried into the tissues with the injection, thus leading to irritation.

PERFORMING THE INJECTION:

1. With the left hand, tense the skin by pulling down on the buttock.2. With the right hand, hold the syringe by the index finger andthumb, steadying it by the second finger of the right hand.3. By one quick thrust introduce the needle almost perpendicularlyto the skin. The depth of insertion varies and depends on the indi-vidual's size.For example,an obesepatient may require a penetrationas deep as 2 or 27i inches, while a child's muscle may be reached ata depth of 72 to 1 inch. In any event, the needle should be advancedonly about three-fourths of its length. Thus, should the needle break(usually at the hub), the cannula may be removed without dissec-tion or probing. An experienced operator can usually tell when theneedle is in the muscle by "feel," since the muscle will offer more

44 resistance to passage of the needle.

4. Grasp the syringe with the left hand and, using the thumb andindex finger of the right hand, draw back on the plunger. If no bloodor exudate appears, return the left hand to its former position tensingthe skin. (If blood appears in the syringe, the needle is in a vein orartery and should be withdrawn immediately.)5. Inject slowly. The solution should flow freely without force.6. Pinch the area of injection with the free hand and withdraw theneedle.7. When rapid absorption is desirable, massage the site vigorouslyfor about two minutes. This will distribute the drug in the muscleand prevent an accumulation at one point. When slow absorption isindicated, do not massage. Simply sponge the area with an antiseptic.

MULTIPLE INJECTIONS. If several injections are to be given at relativelyclose intervals, different sites should be selected for each puncture-preferably in the gluteal, deltoid, or triceps groups. Whatever site ischosen, the technique of injection remains almost the same.ALTERNATIVES TO THE GLUTEAL MUSCLES. As an alternative to glutealinjections, the lateral aspect of the thigh has been suggested as a safeand convenient site.5,6 The muscle mass involved is the vastus lateralisof the quadriceps femoris group. The attitude of the syringe and needleshould be perpendicular to the skin and on a horizontal plane. Theprocedure is the same as for other intramuscular injections includingaspiration. In adults, a needle 17;2 inches long is usually suitable, whilea shorter needle should be employed for infants. Gilles7 recommendsthat infants receive the injection in the distal third of the thigh.

The ventrogluteal site has also been recommended as an alternativeto dorso-intragluteal injection.s,9,lo For one methods,9 of locating theproper site the patient stands. The anterior iliac spine is taken as areference point and the trochanter is palpated. In the other method 12

of locating the site the patient is recumbent. The site is defined withindex and middle fingers, usually of the left hand which rests on thepatient's hip. The ventral index finger rests on the iliac, and the middlefinger (stretching dorsally) palpates the crest of the ilium. Then thetop of this finger presses exactly below the iliac crest. The trianglebetween the index finger, middle finger and the iliac crest confines theinjection site (figure 21). Curtis and Tuckerll believe that this approachwill work well for infants.

Combes12 recommends the mid anterior thigh (vastus medialis) (figure 45

Figure 21 Figure 22

22) as the preferable site for intramuscular injections III infants andyoung children.

Into the subcutaneous tissues

When a drug is to be administered parenterally in small amounts, thesubcutaneous route may be utilized. When drugs are given other thanintravenously, the rate of absorption is an important determinant of theintensity and duration of their activity. The speed of absorption, in turn,is dependent on the physiochemical properties of the drug and the localblood supply of the injected area. Water-soluble drugs are absorbedrapidly; fat-soluble and insoluble drugs, slowly.

Unfortunately, however, irritating drugs or drugs in heavy vehiclesor suspensions so administered may produce induration, sloughing, orabscess formation-and are extremely painful to the patient. As a result,not all medications are suitable for subcutaneous injection.

In common with all substances administered parenterally, drugs in-jected subcutaneously must be sterile. The same exacting aseptic tech-nique previously outlined should be employed. Variations from otherparenteral procedures can be found in the following three basic steps:

1) Selecting the syringe and needle.2) Selecting and preparing the site for injection.3) Performing the injection.

SELECTING THE SYRINGE AND NEEDLE. The volume of a subcutaneousinjection is seldom greater than 2.0 ml. Thus, a 2-ml. syringe, calibratedin minims or fractional milliliters, should usually be employed. Thelength of the needle should be ~ or ~ inch and the gauge should be 26,

46 although any needle ranging in size from 22- to 26-gauge may be used.

SELECTING AND PREPARING THE SITE FOR INJECTION. The injection of adrug beneath the surface of the skin is usually made in the loose inter-stitial tissues of the arm, forearm, thigh, interscapular region, or thebuttocks. Edematous tissues, where absorption is poor, should beavoided. The site of entry should be changed when injections are to bemade frequently. To prepare the site, simply cleanse skin with an an-tiseptic solution and allow to dry.PERFORMING THE INJECTION. With the thumb and index finger, pinch upa fold of the skin and hold firmly. Plunge the needle boldly into fold at45-degree angle to the long axis of the extremity or part. As explainedon page 44, the needle should be inserted only about three-fourths of itslength. Aspirate. If blood appears in the syringe, select a new site. Ifthere is no show of blood, inject the contents of the syringe. Then with-draw the needle and massage site gently with an antiseptic sponge.DEEP SUBCUTANEOUS INJECTION. The usual sites for subcutaneousinjection mentioned above often do not provide the deep administrationwhich is sometimes desirable. For instance, concentrated aqueous solu-tions ofheparin*willproduce a prolonged therapeutic effectwith the leastlikelihood of local irritation if they are injected into deep subcutaneoustissues. A prolonged effect for as long as twelve hours may be obtainedby injection deep into the subcutaneous tissues. Best sites are immedi-ately above and below the iliac crest, in the lower abdominal wall, and,in some patients, in the thigh. Absorption and effect are prompt. Thereis little or no pain, and local reactions are rare and minor. The patienthimself may be taught to make these injections.

Into the skin (Intradermal)

For diagnostic purposes, desensitization, or immunization, a numberof substances may be injected into the corium, the more vascular layerof skin just beneath the epidermis. By intradermal administration ofcertain antigens, the body's response or lack of response to specificallergens can be evaluated and the need for prophylactic therapy indi-cated. A tuberculin syringe with 26-gauge needle % inch long is usuallyemployed. The usual site of intradermal injection is the anterior (volar)surface of the forearm.TECHNIQUE OF ADMINISTRATION. Holding the forearm with one hand,use the thumb to place the skin on stretch. Holding the syringe between'Sodium heparin, U.S.P., supplied by Abbott Laboratories as Panheprin; professional literatureavailabie on request from Abbott Laboratories, North Chicago, illinois. 47

48

the thumb and forefinger of the other hand, seat the plunger againstthe heel of the palm. First, expel the air from the needle by slightlycontracting the thumb and forefinger. Then, at an angle to the longaxis of the forearm, place the syringe and needle horizontally flat againstthe skin with the bevel of the needle facing upward. Depress the syringeand needle until there is no more give and advance the syringe and needleuntil the bevel just disappears into the corium. Contract the handslowly so that the thenar eminence advances the plunger and the desiredamount (usually about 0.1 ml.) of fluid is injected to raise a wheal.Remove the needle and wipe the site.

Figure 23

REFERENCES

1. Thrombophlebitis after Infusions, Lancet, 2:541, September 10, 1955.2. Lundy, J. S., An Excellent Method for Obtaining Speedy Vasodilation for Veni-

puncture, Proc. Staff Meet. Mayo Clin., 34:550, November 11, 1959.3. Lundy, J. S., Suggestions to Facilitate Venipuncture in Blood Transfusion, In-

travenous Therapy and Intravenous Anesthesia, Proc. Staff Meet. Mayo Clinic,12:122, February 24, 1937.

4. Lundy, J. S., Remarks at 93rd Annual Session of Minnesota Medical Association,St. Paul, Minnesota, May 1946.

5. Levi, W. M., Jr., and Ferrari, B. E., The Preferred Site of Intramuscular Injec-tion, J. South Carolina M. A., 54:44, February 1958.

6. Augustine, R. W., Landmesser, W. E., Jr., Parker, M. V., and Vaden, O. L.,Site for Intramuscular Injection, U.S. Armed Forces M. J., 3:1787, December1952.

7. Gilles, F. H. and French, J. H., Postinjection Sciatic Nerve Palsies in Infantsand Children, J. Pediat., 58:195, February 1961.

8. von Hochstetter, A., tiber Probleme und Technik der Intraglutaalen Injecktion,Teil I, Schweiz. med. Wchnschr., 85:1138, November 19, 1955.

9. von Hochstetter, A., tiber Probleme und Technik der Intraglutaalen Injecktion,Teil II, Schweiz. med. Wchnschr., 86:69, January 21, 1956.

10. Schmidt, R., Beitrag zur Intramuscularen Inj ecktion :Anatomische Untersuchungund Klinische Prufung der Neuen Intraglutaalen Injecktionstechnik nach vonHochstetter, Helvetica med. Acta, 24:561, Fasc. 5, November 1957.

11. Curtiss, P. H., Jr., and Tucker, H. J., Sciatic Palsy in Premature Infants,J.A.M.A., 174:1586, November 19,1960.

12. Combes, M. A., Clark, W. K., Gregory, C. F., and James, J. A., Sciatic NerveInjury in Infants: Recognition and Prevention of Impairment Resulting fromIntragluteal Injections, J.A.M.A., 173:1336, July 23, 1960.

49

ABBOTT

LABORATORIES

North Chicago, Illinois

This Little Booklet on the parenteral administration of medicines probably has very little useful information in it for anyone in the United States; it is more of a History of Medicine Document for two reasons. First, it was a “detail” pamphlet provided by a manufacture of medical supplies of the old type that had some educational information in it. It demonstrated how to use the item while pushing there sale. Booklets such as this were fairly common in the 1960’s and early 70’s, were readily provided to students, interns, nurses, doctor’s in the hope that the use of this particular product would catch on. They were really kind of ambitious and expensive, which really doomed them. They did provide useful information. Second, here in the United States we no longer use hung bottles, bags having replaced them as being easier to use, easier to dispose of. Nor do we usually use Drip Chambers to control the rate of infusion, but usually use electronic metering devices. Yes I am sure there are still hospitals even here in the U.S. that cannot afford such. If one should find oneself in a third world country or if the world should degenerate to such a point, It might be good to know this material, either as a practitioner or to know if the job is being done correctly. Such materials are still used in a good part of the world at large.

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