To Aspirate or Not to Aspirate, that is the Question: An Integrative Review of the Evidence

Wednesday, 15 July 2009: 11:05 AM

Cecelia L. Crawford, RN, MSN
Regional Nursing Research Program, Kaiser Permanente, Southern California, Pasadena, CA
Joyce A. Johnson, PhD, RN-BC
Education and Research, Kaiser Permanente Medical Group, Southern California, Pasadena, CA

Learning Objective 1: describe quality and quantity of the evidence supporting non-aspiration of blood for subcutaneous and intramuscular medication administration.

Learning Objective 2: discuss three methods to individualize injection techniques to decrease the risk of incorrect needle placement.

Purpose: The precautionary practice of blood aspiration during injections is a nursing tradition added and eliminated based on anecdote, assumption, and arbitrary choice. However, past literature and integrative reviews have indicated that blood aspiration prior to injection is not based on scientific evidence. This integrative review examined the aspiration technique for subcutaneous and intramuscular injections, primarily involving vaccine and immunization administration, in the ambulatory care setting.

Methods: A 2000-2008 review of the research evidence via electronic databases used the search terms of “aspiration”, “subcutaneous”, “intramuscular”, and “injections”.  A total of 306 hits yielded 14 articles.  Reference links and a web-based search resulted in 7 additional articles. 21 total articles were reviewed and 15 selected as relevant.

Results: The strength of the research evidence ranged from insufficient to fair, with a final grade of insufficient. In addition, an internationally known immunization nurse specialist assessed the integrative review. The evidence summary reveals that aspiration may not be a reliable indicator of correct needle placement. Aspiration during SC injection is not necessary. There is no evidence that aspiration with or without blood return confirms needle placement or eliminates the possibility of an IM injection into a non-SC blood vessel. Fears of adverse reactions following non-aspiration of IM injections mainly center on intra-arterial injection of penicillin and other large molecule medications. Nurses often do not follow aspiration guidelines and perform the procedure too quickly.

Conclusion: Conflicting best practice guidelines reflect the need for more research in this deceptively routine procedure. Due to patient safety issues and the large sample size required to detect this rare adverse event, a randomized control trial may not answer this question. Until a standard is determined, injection techniques must be individualized to the patient, the equipment, and the medication in order to decrease the risk of incorrect needle placement.