Trial of Botulinum Toxin for Isolated or Essential Head Tremor.

BACKGROUND: Local injections of botulinum toxin type A have been used to treat essential head tremor but have not been extensively studied in randomized trials. METHODS: In a multicenter, double-blind, randomized trial, we assigned, in a 1:1 ratio, adult patients with essential or isolated head tremor to receive botulinum toxin type A or placebo. Botulinum toxin or placebo was injected under electromyographic guidance into each splenius capitis muscle on the day of randomization (day 0) and during week 12. The primary outcome was improvement by at least 2 points on the Clinical Global Impression of Change (CGI) scale at week 6 after the second injection (week 18 after randomization). The CGI scale was used to record the patient's assessment of the degree of improvement or worsening of head tremor since baseline; scores range from 3 (very much improved) to -3 (very much worse). Secondary outcomes included changes in tremor characteristics from baseline to weeks 6, 12, and 24. RESULTS: A total of 120 patients were enrolled; 3 patients were excluded during screening, and 117 patients were randomly assigned to receive botulinum toxin (62 patients) or placebo (55 patients) and were included in the intention-to-treat analysis. Twelve patients in the botulinum toxin group and 2 patients in the placebo group did not receive injections during week 12. The primary outcome - improvement by at least 2 points on the CGI scale at week 18 - was met by 31% of the patients in the botulinum toxin group as compared with 9% of those in the placebo group (relative risk, 3.37; 95% confidence interval, 1.35 to 8.42; P = 0.009). Analyses of secondary outcomes at 6 and 12 weeks but not at 24 weeks were generally supportive of the primary-outcome analysis. Adverse events occurred in approximately half the patients in the botulinum toxin group and included head and neck pain, posterior cervical weakness, and dysphagia. CONCLUSIONS: Injection of botulinum toxin into each splenius capitis muscle on day 0 and during week 12 was more effective than placebo in reducing the severity of isolated or essential head tremor at 18 weeks but not at 24 weeks, when the effects of injection might be expected to wane, and was associated with adverse events. (Funded by the French Ministry of Health; Btx-HT ClinicalTrials.gov number, NCT02555982.).

Intramuscular injection: exploring the evidence on effective administration.

Administering medicines by intramuscular (IM) injection is a familiar, though not necessarily common, nursing procedure. To ensure effective administration of IM injections it is important that nurses are up to date with the evidence on factors such as selection of injection site, use of appropriate equipment and injection technique. This article explores the evidence on effective administration of IM injections with the aim of enhancing nurses' decision-making and technique when undertaking this procedure.

A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity.

Accurate targeting of overactive muscles is fundamental for successful botulinum neurotoxin (BoNT) injections in the treatment of spasticity. The necessity of instrumented guidance and the superiority of one or more guidance techniques are ambiguous. Here, we sought to investigate if guided BoNT injections lead to a better clinical outcome in adults with limb spasticity compared to non-guided injections. We also aimed to elucidate the hierarchy of common guidance techniques including electromyography, electrostimulation, manual needle placement and ultrasound. To this end, we conducted a Bayesian network meta-analysis and systematic review with 245 patients using the MetaInsight software, R and the Cochrane Review Manager. Our study provided, for the first time, quantitative evidence supporting the superiority of guided BoNT injections over the non-guided ones. The hierarchy comprised ultrasound on the first level, electrostimulation on the second, electromyography on the third and manual needle placement on the last level. The difference between ultrasound and electrostimulation was minor and, thus, appropriate contextualization is essential for decision making. Taken together, guided BoNT injections based on ultrasound and electrostimulation performed by experienced practitioners lead to a better clinical outcome within the first month post-injection in adults with limb spasticity. In the present study, ultrasound performed slightly better, but large-scale trials should shed more light on which modality is superior.

Análise das gestações ectópicas íntegras tratadas com o protocolo de dose única de metotrexato / Analysis of unruptured ectopic pregnancies treated with single-dose methotrexate protocol

Objetivo: Avaliar o índice de sucesso do tratamento da gravidez ectópica com o protocolo de dose única do metotrexato e verificar sua correlação com variáveis clínicas e dados dos exames complementares. Métodos: É um estudo epidemiológico observacional, analítico, retrospectivo, de delineamento transversal. Foi realizado de janeiro de 2014 a agosto de 2020 em um hospital público, de ensino, em nível terciário, do Sul do Brasil. Em 73 casos com diagnóstico de gestação ectópica íntegra, foi utilizado o protocolo de dose única de metotrexato intramuscular, com a dose de 50 mg/m2 de superfície corporal. As variáveis do estudo foram relacionadas ao sucesso do tratamento e abordaram as características clínicas na admissão, dos exames complementares e do tratamento realizado. As variáveis foram comparadas por análise de regressão de Poisson. O nível de significância estabelecido foi de p < 0,05. Resultados: O índice de sucesso foi de 83,6%, e em nove casos foi necessária uma segunda dose da medicação. Nível de ß-hCG inicial superior a 5.000 mUI/mL foi relacionado a menor chance de sucesso (odds ratio ajustado de 0,20 [0,05-0,95]). Tamanho da imagem anexial, presença de líquido livre na cavidade abdominal e demais variáveis estudadas não afetaram a chance de sucesso do tratamento. Conclusão: O protocolo de dose única de metotrexato mostrou-se uma opção válida para o tratamento da gestação ectópica íntegra, notadamente quando o nível de ß-hCG inicial é inferior 5.000 mUI/mL.

Objective: The purpose of the present study is to evaluate the success rate of treatment of ectopic pregnancy with the single-dose methotrexate protocol and to verify its correlation with clinical variables and complementary exam data. Methods: This is a retrospective epidemiological observational analytical cross-sectional study. It was carried out from January 2014 to August 2020 in a tertiary level teaching hospital in southern Brazil. In 73 cases with a diagnosis of intact ectopic pregnancy, the intramuscular methotrexate single-dose protocol was applied with a dose of 50 mg/m2 of body surface. The study variables were related to the success of the treatment and addressed the clinical characteristics on admission, the complementary exams and the treatment performed. The variables were compared by Poisson regression analysis. The level of significance was set at p < 0.05. Results: The success rate was 83.6%, and in nine cases a second dose of the medication was necessary. An initial ß-hCG level greater than 5,000 mIU/mL was related to a lower chance of success (adjusted odds ratio of 0.20 [0.05- 0.95]). The size of the adnexal image, the presence of free fluid in the abdominal cavity and other variables studied did not affect the chance of a successful treatment. Conclusion: The methotrexate single-dose protocol proved to be a valid option for the treatment of intact ectopic pregnancy, notably when the initial ß-hCG level is below 5,000 mIU/mL.

What variables should inform needle length choice for deltoid intramuscular injection? A systematic review.

OBJECTIVES: (1) Assess the distribution of skin-to-deltoid-muscle distance (SDMD) at the deltoid intramuscular (IM) injection site; (2) its relationship with demographic and anthropometric variables and (3) Consider the findings in relation to clinical guidance on IM injection, such as COVID-19 vaccines. DESIGN: Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL and SCOPUS between June and July 2021 with no publication date limit. ELIGIBILITY CRITERIA: Studies reporting measurements of the SDMD in living adults aged 16 years and older, at the deltoid IM injection site, published in English were considered. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers performed each stage of screening, data extraction and quality assessments using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross sectional studies. RESULTS: 16 105 papers were identified, of which 11 studies were suitable for review, representing 1414 participants. Heterogeneity in the definition of the deltoid IM injection site, locations measured and methods of measurement precluded meta-analysis. Evidence from ultrasound SDMD measurements demonstrated some patients in all but 'underweight' body mass index (BMI) categories, may require needles longer than 25 mm for successful IM injection. Calliper measurements overestimated SDMD compared with ultrasound. Female sex, higher BMI categories and greater weight in women were associated with greater SDMD. CONCLUSIONS: The reviewed evidence was insufficient to inform definitive needle length 'cut points' for IM injection based on demographic or anthropomorphic variables. Contemporary clinical guidance currently based on this evidence, including the site of injection and choice of needle length, may result in subcutaneous administration in a small proportion of recipients, particularly if obese or of female sex. PROSPERO REGISTRATION NUMBER: CRD42021264625.

Comparison of pain levels developed during intramuscular injections to laterofemoral and ventrogluteal regions in children: a randomized controlled study.

OBJECTIVE: The aim of this study was to compare the levels of pain developed during intramuscular injections to the laterofemoral and ventrogluteal regions in children. METHODS: The study population consisted of all children aged between 7 and 12 years who presented to the pediatric emergency clinic of a hospital. The sample consisted of 62 children who met the inclusion criteria and agreed to participate in the study, and the children were randomly assigned to each group (laterofemoral n=31, ventrogluteal n=31). "Buzzy" and "deep breathing" were applied to children in both groups to relieve pain during the procedure. The data were obtained using an Information Form, a visual analog scale, and the Facial Pain Scale-Revised. RESULTS: It was determined that the children in the ventrogluteal group during the intramuscular injections had lower visual analog scale and faces pain scale-revised scores immediately after the procedure compared with the vastus lateralis group, that is, they experienced less pain, and the difference between the two groups was significant (p<0.001). CONCLUSION: In children, it is recommended to choose the less painful ventrogluteal region for intramuscular injection and to inform health professionals about it.

Investigation of the Necessity of Aspiration During the Intramuscular Injection Administered in the Ventrogluteal Site and Its Effect on Pain: A Randomized Controlled Trial.

This experimental study, which was conducted to examine the necessity of aspiration procedure and its effect on pain in intramuscular (IM) injections made into the ventrogluteal site (VGS), is randomized controlled and double-blind. The patients in the study group (n = 834) were assigned to the IM group with the aspiration period of 5 to 10 seconds (Implementation Group A-IGA), the aspiration period of 1 to 2 seconds (Control Group-CG), and no aspiration (Implementation Group B-IGB) according to stratified block randomization list. Patients' pain levels were evaluated with the Visual Analog Scale (VAS). No bleeding was observed when aspiration periods of 1 to 2 and 5 to 10 seconds were followed during the injections administered to the VGS. The difference between the pain medians of patients in IGB and the CG were not significant (p = .521). It can be said that there is no need to apply aspiration in IM applied into the VGS if the correct site is determined.

Pharmacokinetic and pharmacodynamic comparison of epinephrine, administered intranasally and intramuscularly: An integrated analysis.

BACKGROUND: Manual intramuscular epinephrine injection is the standard of care for treating severe allergic reactions and anaphylaxis. Epinephrine autoinjectors were approved on the basis of the assumption that their pharmacokinetic and pharmacodynamic profiles are equivalent to manual intramuscular injection; however, although there is emerging evidence for product-related differences in pharmacokinetic profiles, very little is known about the comparative pharmacodynamic profiles. OBJECTIVE: To compare pharmacokinetic and pharmacodynamic profiles of epinephrine delivered through manual intramuscular injection, autoinjectors, and intranasal spray. METHODS: This integrated analysis was based on data from 4 randomized cross-over phase 1 trials that compared the pharmacokinetics and pharmacodynamics of epinephrine using manual intramuscular epinephrine 0.3 mg injection, epinephrine 0.3 mg autoinjectors (Symjepi and EpiPen), and epinephrine 1 mg intranasal spray (neffy). RESULTS: Data from 175 participants showed that although neffy (1.0 mg intranasal spray) resulted in a maximum concentration (258 pg/mL) that was lower than or comparable with manual epinephrine intramuscular injection (254 pg/mL), Symjepi (438 pg/mL) and EpiPen (503 pg/mL), it led to comparable increases in systolic blood pressure (maximum effect [Emax], 16.9, 10.9, 14.9, and 18.1 mm Hg, respectively). The effect of neffy on diastolic blood pressure was also markedly more pronounced than that of other products (Emax, 9.32, 5.51, 5.78, and 5.93 mm Hg, respectively). CONCLUSION: Intranasal delivery of epinephrine using neffy increases systolic blood pressure more efficiently than do manual intramuscular injection and epinephrine autoinjectors, despite lower maximum plasma concentrations.

Intramuscular Neural Distribution of the Serratus Anterior Muscle: Regarding Botulinum Neurotoxin Injection for Treating Myofascial Pain Syndrome.

The serratus anterior muscle is commonly involved in myofascial pain syndrome and is treated with many different injective methods. Currently, there is no definite injection point for the muscle. This study provides a suggestion for injection points for the serratus anterior muscle considering the intramuscular neural distribution using the whole-mount staining method. A modified Sihler method was applied to the serratus anterior muscles (15 specimens). The intramuscular arborization areas were identified in terms of the anterior (100%), middle (50%), and posterior axillary line (0%), and from the first to the ninth ribs. The intramuscular neural distribution for the serratus anterior muscle had the largest arborization patterns in the fifth to the ninth rib portion of between 50% and 70%, and the first to the fourth rib portion had between 20% and 40%. These intramuscular neural distribution-based injection sites are in relation to the external anatomical line for the frequently injected muscles to facilitate the efficiency of botulinum neurotoxin injections. Lastly, the intramuscular neural distribution of serratus anterior muscle should be considered in order to practice more accurately without the harmful side effects of trigger-point injections and botulinum neurotoxin injections.

A Novel Piriformis Injection Technique Utilizing Combined Fluoroscopy and Ultrasound - A Pilot Study.

BACKGROUND: Piriformis syndrome is a constellation of symptoms associated with low back, gluteal, and sciatic pain. One treatment for piriformis syndrome is the injection of local anesthetic, steroid, or botulinum toxin into the piriformis muscle. Various approaches for needle navigation into the piriformis muscle have been described using fluoroscopy or ultrasound. This study introduces a new method of image guidance combining fluoroscopy and ultrasound. OBJECTIVES: The primary aim of this study was examining whether the imaging modality used for needle guidance was associated with significant differences in pre- and post-piriformis injection pain scores. Secondary objectives were assessing differences in adverse events and procedure time. STUDY DESIGN: This study is a retrospective cohort study. SETTINGS: This study was conducted at Oregon Health and Science University's Comprehensive Pain Center, Portland, OR, USA. METHODS: Institutional chart review was performed from 09/21/2014 to 01/21/2020 to identify patients that underwent piriformis steroid injections which generated a list of 95 patients and totaled 154 procedures. Inclusion criteria were met for 78 patients and 109 procedures. Pain scores were modeled longitudinally using robust variance estimates. The nonparametric Kruskal-Wallis test was used for procedure duration, while adverse events were too rare to evaluate statistically. RESULTS: Piriformis steroid injections using the combined ultrasound and fluoroscopy technique had the lowest mean post-procedure pain score of 1.3 (SD 1.7) and the largest change in pain with a score difference of -3.9 (SD 2.1). Procedure durations were 8 (quartiles 5 to 10), 10 (quartiles 7 to 13), and 11 minutes (quartiles 9 to 13) for fluoroscopy alone, ultrasound alone, and combined techniques, respectively. All 3 modalities had duration ranges of minimum time of 3-5 minutes and a maximum time of 25-28 minutes. Adverse events across all imaging strategies were noted in 5 patients at the time of procedure and in 7 patients during follow-up appointments, the most common symptom being transient leg weakness or numbness. LIMITATIONS: The major limitation is the retrospective collection of data. Another limitation is that 6 different providers performed the injections, which may influence procedural consistency. Additionally, the inclusion of subjects with low pre-procedure pain scores could create a floor effect that minimized the occurrence of clinically significant shifts in pain scores. Adverse events were too few across all groups to assess. CONCLUSION: Piriformis injections using combined fluoroscopic and ultrasound guidance provides comparable efficiency to standard techniques and may result in improved accuracy into the target and thus improved efficacy. Larger prospective trials are required to comprehensively examine the efficacy of this novel technique.

Botulinum Toxin Type A Injection in the Treatment of Postparetic Facial Synkinesis: An Integrative Review.

ABSTRACT: This study aimed to review the recent literature about botulinum toxin type A treatment patterns, including muscle targets, doses, duration of effect, adverse effects, and clinical outcomes in patients with postparetic synkinesis. A bibliographic research of studies published in the last 10 yrs was carried out on PubMed database, using the medical subject heading terms: botulinum toxin and synkinesis. English-language cohort studies or randomized controlled trials about botulinum toxin type A treatment on patients with postparetic synkinesis were eligible for inclusion. Ten studies met the inclusion criteria, seven prospective studies, two retrospective studies, and one randomized controlled trial, involving 23-99 patients. The target facial muscles included frontalis, corrugator supercilli, orbicularis oculi, levator labii superioris, zygomaticus major, orbicularis oris, risorius, buccinator, depressor anguli oris, depressor labii inferioris, mentalis, and platysma. The dose of onabotulinumtoxinA administered per injection site ranged between 0.5 and 10 U. Adverse effects were rare and temporary. The mean duration of onabotulinumtoxinA effect ranges from 66 days to 4 mos. There was a statistically significant improvement in posttreatment evaluation, both in objective and subjective assessments. There is scientific evidence of the benefit of botulinum toxin type A treatment for postparetic synkinesis, but there is lack of standardized treatment protocols.

Pharmacokinetics of tranexamic acid after intravenous, intramuscular, and oral routes: a prospective, randomised, crossover trial in healthy volunteers.

BACKGROUND: In response to the World Health Organization call for research on alternative routes for tranexamic acid (TXA) administration in women with postpartum haemorrhage, we examined the pharmacokinetics of TXA after i.v., i.m., or oral administration. METHODS: We conducted a randomised, open-label, crossover trial in 15 healthy volunteers who received i.v. TXA 1 g, i.m. TXA 1 g, or oral TXA solution 2 g. Blood samples were drawn up to 24 h after administration. Tranexamic acid concentration was measured with liquid chromatography-mass spectrometry, and the parameters of the pharmacokinetic models were estimated using population pharmacokinetics. RESULTS: The median time to reach a concentration of 10 mg L-1 was 3.5 min for the i.m. route and 66 min for the oral route, although with the oral route the target concentration was reached in only 11 patients. Median peak concentrations were 57.5, 34.4, and 12.8 mg L-1 for i.v., i.m., and oral routes, respectively. A two-compartment open model with body weight as the main covariate best fitted the data. For a 70 kg volunteer, the population estimates were 10.1 L h-1 for elimination clearance, 15.6 L h-1 for intercompartmental clearance, 7.7 L for the volume of central compartment, and 10.8 L for the volume of the peripheral compartment. Intramuscular and oral bioavailabilities were 1.0 and 0.47, respectively, showing that i.m. absorption is fast and complete. Adverse events were mild and transient, mainly local reactions and low-intensity pain. CONCLUSIONS: The i.m. (but not oral) route appears to be an efficient alternative to i.v. tranexamic acid. Studies in pregnant women are needed to examine the impact of pregnancy on the pharmacokinetics. CLINICAL TRIAL REGISTRATION: EudraCT 2019-000285-38; NCT03777488.

Statistical estimation of deltoid subcutaneous fat pad thickness: implications for needle length for vaccination.

Current US Centers for Disease Control and Prevention intramuscular injection needle length guidelines for injection fo the deltoid muscle are based on weight and gender. The aims of this study are (1) to evaluate whether other biometric data (age, gender, height, weight and body mass index (BMI)) are better predictors of the thickness of the deltoid subcutaneous fat pad (DSFP) than weight and gender and (2) to evaluate the performance of the CDC weight-based needle length guidelines. This was a retrospective single center cohort study of 386 patients who underwent surveillance PET/CT between 01/01/2020 and 04/01/2021. Patient age, gender, height, weight, BMI and CT measurements of the DSFP were evaluated. DSFP was positively correlated with weight and BMI in men (r = 0.67, P < 0.001; r = 0.74, P < 0.001) and women (r = 0.69, P < 0.001; r = 0.75, P < 0.001) respectively. DSFP was negatively correlated with age in women (r = - 0.19, P = 0.013). Age and BMI were better predictors of DSFP than weight. The best model to predict the DSFP is: [Formula: see text] A 1-inch needle is expected to reach the deltoid in 85.3% of women less than 200 pounds, and 98.6% of men less than 260 pounds. This rate differed between genders (P < 0.001, odds ratio (OR) 0.08, 95% CI (0.02, 0.29)). A 1.5-inch needle is expected to reach the deltoid in 76.7% of women greater than 200 pounds, and 75.0% of men greater than 260 pounds. Current CDC deltoid intramuscular injection needle length guidelines result in women and obese individuals being more likely to receive subcutaneous injections. Age and BMI based guidelines for needle length selection are more accurate.

The botulinum neurotoxin for pain control after breast reconstruction: neural distribution of the pectoralis major muscle.

INTRODUCTION: The use of the botulinum neurotoxin injection is a growing area of research and clinical activity, with a focus on its role in facilitating postoperative pain management after reconstructive breast surgery. The study aimed to find out the standard injection points for botulinum neurotoxin injection by revealing the intramuscular nerve arborization of the pectoralis major. METHODS: Sihler's technique was conducted on the pectoralis major muscles (16 cadaveric specimens). The intramuscular nerve arborization was documented relative to the inferior border of the clavicle bone and lateral border of the sternum. RESULTS: After the staining, the pectoralis major was divided into fifths transversely from the inferior border of the clavicle and vertically into fifths from the lateral border of the sternum. Intramuscular nerve arborization of the pectoralis major muscle was the largest in the middle sections of the muscle belly. DISCUSSION: The results indicate that botulinum neurotoxin should be applied to the pectoralis major in certain regions. The regions of major arborization are optimal as the most effective and most reliable points for injecting botulinum neurotoxin.

Utilização da Técnica em Z na administração de medicamentos por via intramuscular: revisão integrativa / Use of the Z-Technique in intramuscular drug administration: integrative review / Uso de la Técnica Z en la administración intramuscular de fármacos: revisión integradora

Objetivo: analisar as evidências disponíveis na literatura sobre a utilização da Técnica em Z na administração de medicamentos por via intramuscular. Método: revisão integrativa realizada entre os meses de julho e dezembro de 2021 por meio da busca de publicações em periódicos indexados no Pubmed, Cinahl, Lilacs, Web of Science, Scielo e Cochrane, seguindo as etapas das diretrizes PRISMA. Os critérios de elegibilidade foram: artigos publicados em periódicos que abordassem o uso da Técnica em Z na administração de medicamentos por via intramuscular; encontrados nos idiomas português, inglês e espanhol; sem apresentação de delimitação de tempo de publicação. Resultados: foram incluídos 11 artigos (10 das bases de dados e um extraído das referências dos estudos selecionados), analisados em duas categorias: dor/reações locais da injeção e realização da Técnica em Z na prática profissional. A utilização da Técnica em Z mostrou redução da dor e das reações locais quando comparada ao procedimento sem o emprego da Técnica. A maioria dos profissionais de enfermagem relatou não conhecer ou nunca ter empregado a Técnica em Z. Conclusão: Os resultados podem alertar para a necessidade de ampliar a investigação deste tema, visando incentivar o conhecimento e a prática assistencial na administração de medicamentos por via intramuscular.(AU)

Objective: to analyze the evidence available in the literature on the use of the Z-Technique in intramuscular drug administration. Method: integrative review conducted between July and December 2021 by searching for publications in journals indexed in Pubmed, Cinahl, Lilacs, Web of Science, Scielo and Cochrane, following the steps of the PRISMA guidelines. The eligibility criteria were: articles published in journals that addressed the use of Z-Technique in intramuscular drug administration; found in Portuguese, English, and Spanish; without presenting publication time delimitation. Results: 11 articles were included (10 from the databases and one extracted from the references of the selected studies), analyzed in two categories: pain/local reactions to the injection and performance of the Z-Technique in professional practice. The use of the Z-Technique showed reduction of pain and local reactions when compared to the procedure without the use of the technique. Most nursing professionals reported not knowing or never having used the ZTechnique. Conclusion: The results may point to the need to expand the investigation of this topic, aiming to encourage knowledge and care practice in intramuscular medication administration.(AU)

Objetivo: analizar la evidencia disponible en la literatura sobre el uso de la Técnica Z en la administración intramuscular de medicamentos. Método: revisión integradora realizada entre julio y diciembre de 2021 mediante la búsqueda de publicaciones en revistas indexadas en Pubmed, Cinahl, Lilacs, Web of Science, Scielo y Cochrane, siguiendo los pasos de las directrices PRISMA. Los criterios de elegibilidad fueron: artículos publicados en revistas que abordaran el uso de la Técnica Z en la administración intramuscular de fármacos; encontrados en los idiomas portugués, inglés y español; sin delimitación del tiempo de publicación. Resultados: Se incluyeron 11 artículos (10 de las bases de datos y uno extraído de las referencias de los estudios seleccionados), analizados en dos categorías: dolor/reacciones locales a la inyección y realización de la Técnica Z en la práctica profesional. El uso de la técnica Z mostró una reducción del dolor y de las reacciones locales en comparación con el procedimiento sin el uso de la técnica. La mayoría de los profesionales de la enfermería afirmaron no conocer o no haber utilizado nunca la Técnica Z. Conclusión: Los resultados pueden alertar sobre la necesidad de ampliar la investigación de este tema, con el objetivo de fomentar el conocimiento y la práctica asistencial en la administración de la medicación intramuscular.(AU)

Dorsogluteal intramuscular injection depth needed to reach muscle tissue according to body mass index and gender: A systematic review.

AIMS AND OBJECTIVE(S): The objective of this systematic review was to determine the needle length required to reach the dorsogluteal muscle based on body mass index and sex. Our aim was to provide evidence-based recommendations to current intramuscular injection guidelines from the result(s) of this review. BACKGROUND: Studies worldwide are documenting reduced medication effectiveness due to improperly placed dorsogluteal intramuscular injections because of incorrect needle length, wrong site selection and/or obesity. Current intramuscular injection guidelines lack specific instructions according to weight or sex. While there are similar concerns with other injectable sites, this review focuses solely on adult dorsogluteal intramuscular injections. DESIGN: A systematic review of relevant literature of dorsogluteal intramuscular injections based on body mass index and sex. METHODS: This systematic review was reported using the PRISMA checklist 2020. The review protocol was registered with Center for Open Science (OSF). We analysed 1,412 articles from nine databases. We compared twelve studies that utilised computerised tomography or ultrasonography using The Johns Hopkins Evidence-Based Practice Model and Guidelines. RESULTS: A significant number of dorsogluteal intramuscular injections are administered into subcutaneous tissue rather than muscle because needles are too short for populations with body mass indexes over 25, especially women. Poor landmarking often results in improperly placed injections. CONCLUSIONS: To prevent administering a dorsogluteal intramuscular injection into subcutaneous tissue, women with a BMI of 25 and over require needles longer than 38 mm (1.5 inches). Men have less subcutaneous tissue in the dorsogluteal area and only require longer needles if BMI is 35 and over. If skin-to-muscle depth is questionable in either sex, an ultrasound-guided intramuscular injection is warranted for accurate dorsogluteal placement. Landmarking and needle length are key to appropriately placed IM injections. RELEVANCE TO CLINICAL PRACTICE: Dorsogluteal injections are often injected into subcutaneous tissue rather than muscle because needles are not long enough to reach muscle, especially in women. Critical elements that determine placement of intramuscular injections into muscle versus subcutaneous tissue are sex, BMI, needle length and landmarking. Medications delivered into subcutaneous tissue may have reduced bioavailability.

The Effect of ShotBlocker Application on Intramuscular Injection Pain in Adults: A Meta-Analysis.

This meta-analysis study was conducted to determine the effects of ShotBlocker application during administration of intramuscular injections to adult patients for providing an evidence-based practice. The PubMed, Scopus, Science Direct, Ovid and Google Scholar databases were used for the literature review. The literature review was conducted by two researchers using the key phrases intramuscular injection AND ShotBlocker AND pain AND adults. According to the result of the meta-analysis, the pain levels in the experiment group in which ShotBlocker was used during IM injection to adult patients was found to be significantly different in comparison to the control group (SMD = -0.769, 95% CI = -1.449 to -0.090, p = .027). As a result of the meta-analysis, it was found that ShotBlocker application in IM injection in adult patients reduced patients' pain intensity. High-quality studies conducted with appropriate research methods are required for achieving a more comprehensive and effective result.

Capacity for Hand-as-a-Holder Function of the Spastic Combination Hand: A Proof-of-Concept Study.

ABSTRACT: We call a hemiparetic hand with paralyzed finger extensors and volitional but spastic flexors a "spastic combination hand." Anecdotally, patients report hand-as-a-holder function with objects like pill bottles, motivating us to formally study spastic combination hand holding capacity using cylinders with different diameters. Nine participants with spastic hemiparesis and spastic combination hand more than 24 mos performed a standardized motor task with 10 cylinder diameters ranging between 1.3 and 9.5 cm and weighing 0.8 and 8.4 oz. Using the unaffected hand, participants attempted to insert a given cylinder into their spastic combination hand, holding it independently for 5 secs. Successful holds were counted during two sessions before and one session after botulinum toxin intervention of Ashworth 3 hand muscles. Findings revealed that a median capacity of six different cylinder diameters was successfully inserted into spastic combination hand at least once before block and a median capacity of 10 cylinders was inserted after block. A mixed-effect statistical model using fixed effects of cylinder diameter and session revealed that total number of successful holds was 43% higher after botulinum. We conclude that this proof-of-concept study does support the idea that spastic combination hand has holding capacity for cylindrical objects of specified diameter and weight and that botulinum neurotoxin offers potential for enlarging spastic combination hand capacity.

A Novel Injection Technique to the Lateral Pterygoid Muscle for Temporomandibular Disorders: A Cadaveric Study.

BACKGROUND: Lateral pterygoid muscle activity is associated with the pathological mechanisms of some temporomandibular disorders. The authors aimed to define and demonstrate a novel, practical, and safe technique for botulinum toxin type A injection to the lateral pterygoid muscle based on their findings. Their secondary aims were to standardize the injection pattern according to the variations of the lateral pterygoid muscle and its surrounding anatomical structures, and to establish its advantages over intraoral injection. METHODS: Twenty cadaver heads were dissected. The lateral pterygoid muscle and its surrounding structures were investigated for anatomical variations. Based on these findings, a standardized extraoral injection protocol was defined and compared with the intraoral technique for accuracy and safety. RESULTS: The average depth of the lateral pterygoid plate from the skin surface was 49.9 ± 2.2 mm, and the mean width of the lateral pterygoid plate was 10.5 ± 3.9 mm. The extraoral injection approach based on the location of the maxillary tuberosity, tragus, and lateral pterygoid plate was consistent in all dissections for the accuracy of the intramuscular injection. In the intraoral approach, standardization of the entry point of the needle through the oral mucosa is difficult, which makes adjustment of the depth of the injection challenging while increasing the risk of neurovascular injury. CONCLUSIONS: The clinical significance of the lateral pterygoid muscle makes it worthwhile to implement minimally invasive treatments before considering more invasive options. The authors define a safe, accurate, and reliable approach with ease of administration in patients with temporomandibular disorders.