Improving Anaphylaxis Care: The Impact of a Clinical Pathway.

BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Inyección ecoguiada del músculo piriforme. Un nuevo abordaje / Ultrasound-guided piriformis muscle injection. A new approach

El síndrome piriforme es una causa poco frecuente de dolor de espalda y miembros inferiores. Algunas de las opciones de tratamiento incluyen la inyección del músculo piriforme con anestésicos locales y corticoides. Se han descrito varias técnicas de inyección. Las técnicas ecoguiadas permiten la visualización directa del músculo y la inyección en tiempo real. Se presenta una serie de 5 pacientes cuya clínica es compatible con síndrome piriforme, que no han mejorado tras tratamiento farmacológico. Se optó por la inyección del músculo piriforme con anestésicos locales y corticoides mediante un nuevo abordaje ecoguiado más sencillo técnicamente, basado en la técnica estándar. En los 5 pacientes se apreció una mejoría del dolor medido por la escala verbal numérica tras la inyección. Solo en un caso se presentó como complicación una ciatalgia que mejoró espontáneamente en 10 días. En los demás pacientes no se observaron complicaciones tras la inyección. Se describe una variante de la técnica ecoguiada recomendada en la inyección del músculo piriforme, más sencilla de realizar, con un buen perfil de seguridad y con buenos resultados clínicos (AU)

Piriformis syndrome is an uncommon cause of buttock and leg pain. Some treatment options include the injection of piriformis muscle with local anesthetic and steroids. Various techniques for piriformis muscle injection have been described. Ultrasound allows direct visualization and real time injection of the piriformis muscle. We describe 5 consecutive patients, diagnosed of piriformis syndrome with no improvement after pharmacological treatment. Piriformis muscle injection with local anesthetics and steroids was performed using an ultrasound technique based on a standard technique. All 5 patients have improved their pain measured by numeric verbal scale. One patient had a sciatic after injection that improved in 10 days spontaneously. We describe an ultrasound-guided piriformis muscle injection that has the advantages of being effective, simple, and safe (AU)

Ultrasound-Guided Trigger Point Injection for Serratus Anterior Muscle Pain Syndrome: Description of Technique and Case Series.

Chronic chest pain is a challenge, and serratus anterior muscle pain syndrome (SAMPS) is often overlooked. We have developed an ultrasound-guided technique for infiltrating local anesthetics and steroids in patients with SAMPS. In 8 patients, the duration of chronic pain was approximately 19 months. Three months after treatment, all patients had experienced a significant reduction in pain. Infiltration for SAMPS confirms the diagnosis and provides adequate pain relief.

Comparison of 3 needle sizes for trigger point injection in myofascial pain syndrome of upper- and middle-trapezius muscle: a randomized controlled trial.

OBJECTIVES: To investigate (1) the relation between needle diameter and treatment efficacy of myofascial pain syndrome and (2) the relation between needle diameter and pain intensity during injection. DESIGN: Randomized controlled trial. SETTING: University-affiliated tertiary-care hospital. PARTICIPANTS: Volunteers (N=77) with myofascial pain syndrome affecting upper- and middle-trapezius muscles with at least 3 months' duration of pain. INTERVENTION: Participants were randomly assigned to receive trigger point injections on 1 side of the trapezius with a 21-, 23-, or 25-gauge needle. After a 1-time injection, participants were followed up for 14 days. Participants and the assessor were blinded for group assignment. MAIN OUTCOME MEASURES: Treatment efficacy was measured with the visual analog scale (VAS; at pretreatment, and posttreatment on days 1, 4, 7, 14) for neck and upper-back pain, the Neck Disability Index (NDI; at pretreatment, and posttreatment on days 7, 14), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36, at pretreatment and posttreatment on days 7, 14) for health-related quality of life. Pain intensity during injection was evaluated immediately after injection with VAS. RESULTS: VAS scores for posttreatment on days 4, 7, and 14 decreased significantly compared with pretreatment scores in all groups; NDI scores on days 7 and 14 decreased significantly compared with pretreatment scores in all groups; SF-36 scores on days 7 and 14 decreased significantly compared with pretreatment scores in the 21- and 23-gauge needle groups; and SF-36 score on day 14 showed significant difference between the 21- and 25-gauge needle groups. For pain intensity during injection, VAS scores indicated no significant difference between the 3 groups. CONCLUSIONS: No difference between the needle types was observed in terms of VAS or NDI, or in terms of pain intensity felt by patients during injection. In terms of SF-36 scores, injections with 21- or 23-gauge needles were found to be more effective. However, a well-controlled investigation is needed to explore the effect of needle thickness on health-related quality of life.

Does a novel prefilled injection device make postpartum oxytocin easier to administer? Results from midwives in Vietnam.

OBJECTIVE: to assess the acceptability of the Uniject prefilled injection device for delivery of oxytocin in the third stage of labour, and the effect of the device on overall willingness to perform active management of the third stage of labour (AMTSL). DESIGN: descriptive study that used baseline and post-intervention questionnaires. SETTING: three districts in northern Vietnam. The study population consisted of 52 midwives from two districts where AMTSL was already practiced, and 35 midwives from a district where AMTSL was introduced as part of the study. MEASUREMENTS AND FINDINGS: the majority of midwives reported that the Uniject device was easier to use and preferable compared with ampoules and standard syringes. They found the training materials easy to understand. KEY CONCLUSIONS: the use of a prefilled injection device overcame many of the barriers cited by midwives with regard to the use of oxytocin in ampoules, such as trying to break ampoules and fill syringes in a hurry. This device enabled midwives to deliver the correct dose of oxytocin in the third stage of labour in a safe and timely way, while attending to the other needs of the mother and her newborn baby. IMPLICATIONS FOR PRACTICE: use of a prefilled injection device for oxytocin may increase the acceptability and practice of AMTSL in primary level facilities, thus reducing maternal mortality due to postpartum haemorrhage.

Ultrasound-guided trigger point injections in the cervicothoracic musculature: a new and unreported technique.

BACKGROUND: Myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under diagnosed and under treated medical problems encountered in clinical practice. Trigger points are commonly seen in patients with myofascial pain which is responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point injection to help reduce or relieve myofascial pain. In obese patients, these injections may not reach the target tissue. In the cervicothoracic spine, a misguided or misplaced injection can result in a pneumothorax. Here, we describe an ultrasound-guided trigger point injection technique to avoid this potential pitfall. Office based ultrasound-guided injection techniques for musculoskeletal disorders have been described in the literature with regard to tendon, bursa, cystic, and joint pathologies. For the interventionalist, utilizing ultrasound yields multiple advantages technically and practically, including observation of needle placement in real-time, ability to perform dynamic studies, the possibility of diagnosing musculoskeletal pathologies, avoidance of radiation exposure, reduced overall cost, and portability of equipment within the office setting. To our knowledge, the use of ultrasound guidance in performing trigger point injection in the cervicothoracic area, particularly in obese patients, has not been previously reported. METHODS: A palpable trigger point in the cervicothoracic musculature was localized and marked by indenting the skin with the tip of a plastic needle cover. The skin was then sterile prepped. Then, using an ultrasound machine with sterile coupling gel and a sterile latex free transducer cover, the musculature in the cervicothoracic spine where the palpable trigger point was detected was visualized. Then utilizing direct live ultrasound guidance, a 25-gauge 1.5 inch needle connected to a 3 mL syringe was placed into the muscle at the exact location of the presumed trigger point. This guidance helps confirm needle placement in muscle tissue and not in an adipose tissue or any other non-musculature structure. RESULTS: The technique is simple to be performed by a pain management specialist who has ultrasound system training. CONCLUSION: Ultrasound-guided trigger point injections may help confirm proper needle placement within the cervicothoracic musculature. The use of ultrasound-guided trigger point injections in the cervicothoracic musculature may also reduce the potential for a pneumothorax by an improperly placed injection.

Electromyographically guided trigger point injections in the cervicothoracic musculature of obese patients: a new and unreported technique.

BACKGROUND: Myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under-diagnosed and under-treated medical problems encountered in clinical practice. Trigger points are commonly seen in patients with myofascial pain that can be responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point injection to help reduce or relieve myofascial pain. In the obese patients, these injections may not reach the target tissue. In the cervicothoracic spine, a misguided or misplaced injection can result in a pneumothorax. Here, we review an electromyographically guided trigger point injection technique to avoid this potential pitfall. METHODS: Using a disposable Teflon coated hypodermic injection needle attached to an electromyography (EMG) machine, a trigger point injection can be performed utilizing electromyographic guidance. This guidance by observing motor unit action potentials (MUAPs) on the EMG screen helps confirm the needle placement to be within the muscle tissue and not in an adipose tissue or any other non-musculature structure. RESULTS: The technique is simple when performed by a pain management specialist who has electromyographic training. CONCLUSION: This technique helps confirm proper needle placement within the cervicothoracic musculature in an obese patient in whom the musculature is not readily palpated. This, thus, reduces the potential for a pneumothorax by an improperly placed injection.

Preclinical evaluation of microneedle technology for intradermal delivery of influenza vaccines.

Recent clinical studies have suggested that, for certain strains of influenza virus, intradermal (i.d.) delivery may enable protective immune responses using a lower dose of vaccine than required by intramuscular (i.m.) injection. Here, we describe the first preclinical use of microneedle technology for i.d. administration of three different types of influenza vaccines: (i) a whole inactivated influenza virus, (ii) a trivalent split-virion human vaccine, and (iii) a plasmid DNA encoding the influenza virus hemagglutinin. In a rat model, i.d. delivery of the whole inactivated virus provided up to 100-fold dose sparing compared to i.m. injection. In addition, i.d. delivery of the trivalent human vaccine enabled at least 10-fold dose sparing for the H1N1 strain and elicited levels of response across the dose range similar to those of i.m. injection for the H3N2 and B strains. Furthermore, at least fivefold dose sparing from i.d. delivery was evident in animals treated with multiple doses of DNA plasmid vaccine, although such effects were not apparent after the first immunization. Altogether, the results demonstrate that microneedle-based i.d. delivery elicits antibody responses that are at least as strong as via i.m. injection and that, in many cases, dose sparing can be achieved by this new immunization method.

Drawing up and administering intramuscular injections: a review of the literature.

Drawing up and administering intramuscular injections: a review of the literature Intramuscular (IM) injections have been an integral part of drug administration in nursing practice for almost half a century. However, there are some conflicting practices which warrant investigation to determine their effectiveness in this aspect of patient care. To this end, this paper presents the results of a literature review which was carried out in order to establish current understanding of present day knowledge, procedures and guidelines for the administration of IM injections. Areas addressed within this review include injection sites used, injuries associated with IM injections, issues surrounding needle selection and volume administered through IM injections, injection techniques and nursing skills associated with IM injections. Synthesis of the research reviewed allows the development of research-based guidelines for this skill. These guidelines offer a framework for nurses who wish to provide practice in line with current research into the process of drawing up and administration of intramuscular injections.

New once-a-month injectable contraceptives, with particular reference to Cyclofem/Cyclo-Provera.

Once-a-month injectable contraceptives containing a progestogen and an estrogen have been developed that disrupt vaginal bleeding patterns less than the widely used progestogen-only preparations. Pharmacokinetic studies were undertaken of dosages and ratios of the progestogens and the respective estrogens. In Phase III clinical trials, annual pregnancy rates were below 0.4% for Mesigyna (norethisterone enanthate/estradiol valerate, Schering AG, Berlin, Germany) and below 0.2% for Cyclofem (MPA/E2C) (medroxyprogesterone acetate/estradiol cypionate, Aplicaciones Farmaceuticas, SA, Mexico and PT Tunggal, Indonesia). More than two-thirds of women had predictable, regular cycles, and discontinuation due to bleeding-related problems occurred less than half as often as with progestogen-only injectables. With MPA/E2C, return to fertility is similar to that observed with other hormonal or intrauterine methods, and both products have little effect on lipids or hemostasis. Introductory trials of MPA/E2C in 12000 women with 100000 woman-months of experience confirmed the high efficacy of the product in routine use. The use of MPA/E2C in a non-reusable injection device, Uniject (Becton Dickinson, Franklin Lakes, NJ) is discussed. Once-a-month hormonal contraceptives have been shown to provide a safe contraceptive option for all women and an alternative for women who wish to use injectable formulations that cause less disruption in vaginal bleeding and minimal side effects.

Administration of medications via the intramuscular route: an integrative review of the literature and research-based protocol for the procedure.

Administering injections is an activity inherent to nursing practice. A critical review of nursing fundamentals texts found that the "proper" procedure was often non-research based and reflected myths, traditions, and out-of-date recommendations regarding the technique. This article is an integrative review of the extensive research conducted by a variety of researchers in health-related disciplines during the last seven decades. The pertinent research is reviewed and critiqued and serves as the basis for a clinical practice protocol. This research-based procedure ensures efficient and effective nursing care related to intramuscular injections.

Use of trigger point injections in chronic pelvic pain.

In order to fully evaluate the woman with chronic pelvic pain, the clinician must consider the possibility of abdominal wall pain. A useful technique in both diagnosis and treatment may be trigger point injections.

[The metabolic and psychological assessment of 40 adolescents with type-1 diabetes during 6 months of intensified insulin therapy using the pen injector or the traditional syringe]. / Valutazione metabolica e psicologica in 40 adolescenti affetti da diabete tipo I durante 6 mesi di terapia insulinica intensificata mediante stilo-iniettore o siringa tradizionale.

Metabolic control and psychological parameters in forty insulin-dependent diabetic adolescents were evaluated during a sequential crossover study comparing two insulin regimens: a) 6 months of conventional insulin therapy (CIT) (T0-T1) using twice-daily mixture of short-acting and intermediate-acting insulins (AcHM and MoHM); b) 6 months of intensified insulin therapy (IIT) (T1-T2) using two pre-meal injections of short-acting insulin (AcHM) and one pre-dinner mixture of short-acting plus ultralente-acting insulin (AcHM + UtHM). Twenty patients received the pre-meal short-acting insulin with a pen-injector (group A) and twenty with conventional syringes (group B). All of participant received the pre-dinner insulin mixture with traditional syringes. Fasting blood glucose (BG), fructosamine, HbA1c, anxiety, depression levels and patient daily life adjustment (T1, T2) were investigated. The metabolic parameters showed similar results in both groups. There was no fasting BG variation during IIT, while post-meal (lunch and dinner) BG reduction (p less than 0.01) was observed. HbA1c levels didn't decrease but fructosamine levels significantly decreased at T2 time. Severe hypoglycemia where never observed, while the frequency of slight hypoglycaemic reactions didn't change during the study. The psychological parameters showed no differences at T0 and T1, while the differences became remarkable between the groups at T2 time. Home anxiety slightly decreased in group A and increased in group B (p less than 0.05). In group A an improvement of self-care initiative (self-injections) occurred too. In conclusion this study showed that, in a limited group of insulin-dependent diabetic adolescents, IIT with three daily injections improved fructosamine and post-meal BG levels.(ABSTRACT TRUNCATED AT 250 WORDS)