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PARENTERA1

ADMINISTRATION
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 . 4
Selecting and Preparing the Site for Injection . 4
Making the Venipuncture . 9
The Bevel . 9
The Needle . 11
Basic Venipuncture . 12
Other Techniques . 14
ABOUT THE INFUSION . 18

Selecting and Preparing the Equipment for Venoclysis . 18


Temperature of Solution at Time of Administration . 18
Assembling the Apparatus . 19
Rate of Infusion . 19
Mechanical Difficulties . 19
Adding Supplemental Medication . 20
Terminating the Infusion . 20
ABBOTT EQUIPMENT FOR INFUSIONS . 22

The Abbo-Liter . 22
The Venopak . 22
The Surgical Venopak . 24
The Venopak Microdrip . 25
The Secondary Venopak . 25
The Y-Type Venopak . 26
Soluset . 27
Venocath . 29
The Butterfly Infusion Set . 31
Venovalve 30 with "T" Connector . 32
"T" Connector Set . 32
Venotube 20, Venovalve 30, and Venotube 20 Sterile Pack . 32
The Venotube Twin-Site . 33
The Cly-Q-Pak for Hypodermoclysis . 33
FROM THE SYRINGE . 37

Transfer from the Ampoule and from the Multi-dose Vial. . 38


From the Ampoule . 38
From the Vial . 39
From the Two Compartment Vial. . 40
How to Prepare Solution . 40
Into the Vein . 41
Into the Muscle . 42
Into the Subcutaneous Tissues . 46
Into the Skin (Intradermal) . 47
REFERENCES . 49 1
INTRODUCTION

Frequently in clinical practice drugs or solutions are administered by


other than the oral or rectal route. Such administration is called paren-
teral (meaning apart from the intestine) and usually refers to injection
of 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. A physician may 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 is
not available).
Parenteral injection encompasses several routes of administration such
as injection into a joint, into the spinal canal, into an artery, into the
brain, or (in an emergency) into the heart itself. In fact, injections may
be made into almost any organ or area of the body. However, it is our
aim here to describe only those injeCtions which are administered more
routinely. 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 of
drawings 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 preliminary


preparations should be made, and precautions observed, to insure as
safe and painless an entry as possible. Although most superficial veins
are suitable for venipuncture, veins in the antecubital fossa (median
basilic and median cephalic) are most frequently chosen because they
are usually large and easily accessible. However, this site is not the best
for all occasions. Other suitable alternatives are available, sometimes
with advantage. Also, one should keep in mind that the median nerve
lies in the antecubital fossa and that, in some patients, the brachial artery
may lie superficially (see figure 9, page 11, for possible anatomical rela-
tionships).
Other available veins include the cephalic and basilic veins in the
arm above the antecubital fossa, the metacarpal and the dorsal venous
network 011 the back of the hand. The accessory cephalic and median
antebrachial veins of the forearm are favored by many clinicians for long
infusions. Whereas venipuncture in the antecubital fossa precludes arm
movement, especially flexion at the elbow, venipuncture in a forearm
vein 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 the
surface.
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 plexus
of the dorsum, the dorsal venous arch, the medial marginal vein, and the
lateral 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 may
be utilized.
To avoid the difficulties described later on page 10 (figure 8), the
operator generally is urged to "use as small a needle as possible, and to
insert 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 Posterior

V. basilica

V. basilica

V. mediana antibrachii

V. ext. sup. femoralis, Vv. metacarpeae


dorsales

V. saphena magna V. saphena parva

V. saphena magna

V. saphena magna

Rete venosum dorsale pedis

V. marginalis medialis

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."1
When 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 can
result il~ a collection of infused or injected solution there. When this
accumulated fluid reaches the general circulation, untoward reactions
may occur. Also, when an immediate effect is desired (as is usual when
the intravenous route is chosen) varicose veins may considerably delay
the onset. However, if varicosities cannot be avoided, the point of in-
jection should be elevated and the veins massaged centrally to increase
the blood flow.
When the site for injection has been determined, utmost care should
be given to the proper distention of the vein. As a simple preliminary
measure, let the extremity in which the vein is located hang dependent
for a time. This action alone may serve to make the veins more apparent.
If the veins stand out well, manual compression above the site, as
with a tourniquet, will be sufficient to fill them. The tourniquet can
vary from a twisted bandage to complicated mechanisms. A blood pres-
sure cuff is probably the most efficient means of applying constriction
and of providing a quick smooth release. A soft rubber tube held by a
hemostat or tied in a slip knot (figure 2) is most frequently used for
this purpose.
If a vein in the antecubital fossa is chosen, tighten the tourniquet
sufficiently 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 wrist
may cause additional dilatation of the vein. Application of heat to the
extremity is a valuable aid prior to applying the tourniquet and may be
necessary should the other means mentioned be unsuccessful. Properly
administered, 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 the
area 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, forearm
and 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 is
wrapped with a Turkish towel wrung out of hot water, over which is placed a'rubber
sheet 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 water


bottles laid against the covering will sustain the heat.
Alternatively, hospitals are employing a thermostatically controlled
electric blanket as a convenient means of promoting vasodilatation. 1 When
a vein in the ankle is to be employed, the entire foot, ankle and leg should
be 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 tourniquet
applied (figure 5, above; figure 6, page 9). Lundy2 has suggested the use
of a common hair dryer (figure 5, above) as a quick convenient method
to produce vasodilatation at almost any site. The only precaution is that
the dryer not be employed when explosive hazards are present.
When a vein of the upper extremity has been selected, an arm board
may facilitate the puncture by restraining the patient from jerking his
arm. The wrist can be secured to the board (not rigidly enough to stop
free circulation) by a broad strip of adhesive tape or gauze. An arm board
is particularly useful when administering parenteral fluids to children.
Lundy3 points out the necessity of warming the sponge and antiseptic
solution, at least to body temperature, before cleansing the site of the
puncture. Because the arm is warm, it is more than usually sensitive to
cold, 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 unusually
sensitive patients, venipuncture can be made painless by the simple
expediency of raising a wheal in the skin overlying the vein. This is done
by injecting 0.5 ml. of Procaine Hydrochloride, 1.0 per cent solution. The
needle 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 least


thirty minutes before infusion may calm the patient and minimize
movement of his extremities.
MAKING THE VENIPUNCTURE. All the previous preparations and pre-
cautions lead directly to getting the needle safely and as painlessly as
possible into the vein and keeping it there until the injection or infusion
is completed.
The Bevel: Whenever the lumen of the vein to be entered is sufficiently
large in relation to the size of the needle (as in most cases) venipuncture
should 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 cause
the 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 facing
downward (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 less
resistance to venipuncture than a short bevel, but is more susceptible
to inadvertent penetration of the opposing vein wall. Improved methods
of sharpening have made short bevel needles popular, especially in the
finer gauges.

Figure 7. A Relatively Small Needle Entering a Relatively Large Vein. This illustrates
a satisfactory relationship of the lumen of the vein to the size of the needle. 9
ll!ll!!!IIlIIlI!" %""ij~'' ' ' ',~
tlIO'!!, •••.
a

Tourniquet

::
b

Tourniquet

c -
Tourniquet removed

Tourniquet removed

Tourniquet removed

Figure 8. A Relatively Large Needle Entering a Relatively Small Vein. (a) A hematoma
may 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 the
tourniquet 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 posterior
wall of the vein and a subsequent hematoma. (e) With the patient carefully prepared
a 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., Techniques
and Procedures of Anesthesia, Charles C Thomas, Springfield, Illinois, 1956, p. 263.)

Figure 10. (below) Diagram of a needle

hub lumen (inside diameter)

--h--41
__r~:::::~J_", -~===.~~be.vel

The Needle: Although not all physicians use the same size of needle
for intravenous infusions, generally they prefer an 18-, 19-, or 20-gauge
needle which is 1 or 1~ inches long. However, in certain instances, when
fluids must be given at the most rapid rate possible, a 15-gauge needle
may be employed.
A "thinwall" needle.has a lumen (inside diameter) one size larger than
its gauge. Thus a 19-9auge thinwall needle has the same lumen as an
18-gauge standard 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 mechanical
difficulty for the operator and injury or unnecessary discomfort to the
patient.

Figure 11. A simple test, such as passing the needle back and forth through sterile
gauze orexamining the tip under a magnifying glass, will quickly demonstrate whether
or not the needle is suitable for use. 11
Figure 12.

Basic Venipuncture (closed technique for intravenous infusion): After


the site has been prepared (with heat if necessary) the tourniquet is
applied and tightened as directed on pages 6 and 7, and venipuncture
proceeds 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 the
skin on stretch and to anchor the vein.
4. Point the needle in the direction of the course of the vein at the
proposed site of entry. The angle of the needle to the surface of the
skin 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 enter
the vein itself. (Most operators do not attempt to pierce the skin
and vein in the same thrust.)
6. Firmly pierce the skin and underlying tissues to the depth of the
vem.
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 the
vein (figure 14).
8. Slowly send the needle into the vein. A backflow of blood into the
clear plastic tubing will indicate satisfactory entry. (In some cases
bottle holding fluid to be administered will have to be lowered.)
9. When the blood appears, cautiously advance the needle until it
lies well within the lumen of the vein. This should be done by lifting
the vein on the needle with a slight upward pressure to prevent the
needle'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 may
indicate 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 under
and over the needle.
14. Tape the needle firmly in place with adhesive.
15. To minimize movement of the needle in the vein, tape a looped
portion of the tubing to the forearm (figure 15).

Figure 15. 13
OTHER TECHNIQUES: The "closed" technique is outlined above because
of the growing use of previously assembled disposable equipment for
intravenous infusions. However, infusions may be started by several
other 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 fluid
and cleared of air, and venipuncture proceeds by the method outlined
under Basic Venipuncture. The syringe (if it has no lock) should be
held so that the little finger prevents movement of the plunger during
piercing of the skin. After the skin is pierced the little finger should exert
a slight backward pull on the plunger. The negative pressure thus in-
duced will allow blood from the vein to enter the syringe. After blood
appears freely in the syringe the needle is advanced into the vein as in
step #9. The tourniquet is then eased, the syringe detached, and the
tubing attached. Steps #11 through #14 are then performed.
In a variation of the "separate syringe" technique a larger syringe
containing 3 or 4 ml. of isotonic saline solution may be used for the
venipuncture. This minimizes the danger of clotting which may occur
with 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 antiseptic
solution, draped and tourniquet tightened. Needle is aimed parallel to long axis of vein.

necessary to remove the tourniquet and inject saline solution to be sure


the vein has been entered properly. Venipuncture proceeds as outlined,
the syringe being held as shown in figures 16, 17, 18. For piercing the
skin, 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 the
plunger with the thumb against the barrel to create negative pressure
(figure 17). Thus, when the vein is entered blood will be aspirated into
the 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, and
the 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 "connected
syringe" technique. Here the syringe is assembled with a sidearm outlet
from the barrel, and the tubing (cleared of air) is attached to this outlet
before venipuncture. Venipuncture proceeds as with the basic "separate
syringe" 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 and
thumb against the barrel of syringe permits slight aspiration duirng venipuncture.

advanced into the vein. The plunger is withdrawn past the opening of
the 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 burden
to 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: Although


there are mechanical differences between the equipment manufactured
by different firms, a basic unit usually consists of the following:
1. A bottle or other reservoir containing the solution to be
administered,
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 the
needle 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. Selection
of 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 single
infusion the complete unit is then discarded. According to Lundy4:
"Most pyrogenic reactions following blood and fluid infusions seem to
arise from improperly cleansed and unsterile equipment. This is particu-
larly true with reference to rubber tubing. Tubing should be used only
once for blood transfusions. Disposable tubing is to be preferred. It
might be well if there were a member of the hospital staff designated as
a 'snatcher' whose function it would be to snatch up and dispose of all
tubing once used for transfusion or infusion purposes. The 'snatcher'
would save us many needless reactions."
The need for strictly aseptic techniques throughout the preparation
and infusion is well established. When the same equipment is reused (as
is permanent equipment) it should be carefully cleansed, thoroughly
rinsed with triple-distilled water, packed in sterile gauze, and sterilized
by 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 with
each drop is quickly diluted and brought to the temperature of the cir-
culating blood.
ASSEMBLING THE APPARATUS: Attach the tubing to the bottle (or other
reservoir) according to the.manufacturer's directions. Suspend the bottle
on a stand two to three feet above the level of the bed. Adjusting the
height of the bottle is one means of controlling the rate of infusion.
RATE OF INFUSION: This is one of the most important factors in the
successful 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 may
vary with the kind and concentration of solution being administered,
condition of patient and other factors, no attempt is made to discuss
them here.
Before venipuncture, the operator determines the maximum rate of
flow by his choice of needle-size. For most infusions, an 18-, 19-, or
20-gauge needle (lor 172 inches long) is used.
Occasionally, when parenteral solutions are given too rapidly "speed
shock" may occur. Usually, the patient is flushed, uncomfortable and
complains of a pounding headache or constriction of the chest. There
may be pulse irregularity and, in extreme instances, there is a cessation
of respiration or disappearance of the radial pulse. The best preventive
of 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 flow
of an infusion properly assembled and started. However, flowis altered
occasionally, usually from one of four causes- a kink in the tubing, a
plugged air filter, displacement of the needle or an obstruction in the
needle.
A simple preventive or remedy is to flush the needle every half hour
or so. This reduces considerably the possibility of clogging the needle.
If the needle is not clogged, the tubing should be checked to be sure
that there are no obstructions. Should difficulties still be encountered
after the needle and tubing have been checked, the infusion should be
terminated (page 20) before any major adjustment .is made.
ADDING SUPPLEMENTAL MEDICATION: With the versatility of parenteral
equipment currently available, the physician may administer several
medications through the same infusion needle simultaneously or sepa- 19
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 desirable
when one or more supplemental medicaments must be given during the
course of an infusion.
The usual venoclysis apparatus itself allows ample range for routine
changes in therapy. When a drug for immediate effect is desired the
operator may pierce a gum-rubber insert with needle (and attached
syringe) and make the injection. With the commercial sets and special
tubing with multiple injection sites now available, additional fluids may
be introduced into the bottle or injected into the tubirig,'Finally, the
infusion of a separate solution may be facilitated with a series hook-up
or a tandem hook-up.
Regardless of the means employed for supplemental medication or
the point at which it enters the primary infusion system, one should be
alert for signs of leakage or for air bubbles in the tubing. Any opening
introduced into the tubing may permit air to be pulled into the moving
fluid, 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 adhesive
tape 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 the
skin and slowly withdraw the needle, taking care not to drag the tip
against the posterior wall of the vein.
5. Secure the wad of cotton over the injection site with a piece of
adhesive tape,
Since the patient's arm has been immobilized for a period of time, do
not attempt to flex it for him. Let the patient do so himself when his
arm has "recovered."

20
ABBOTT EQUIPMENT FOR INFUSIONS
ABBOTT EQUIPMENT FOR INFUSIONS

The Abba-Liter

Abbo-Liter is the registered trademark of the special container in


which 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 have
replaced the need to bottle solutions under vacuum. Thus, in principle
the Abba-Liter is an enlarged ampoule. An operator need only open the
Abbo-Liter, connect the appropriate apparatus, and begin venoclysis
or hypodermoclysis. With aseptic techniques no contamination will occur.
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 from
the Abbo-Vial which contains Ion-o-trate, Abbott's line of concentrated
electrolyte solutions. Simply unscrew the plastic hood of the Abbo-Vial
to break the seal; then aseptically pour the calculated amount of the
selected 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 to
change 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 the
same tubing. All sets are packaged with complete operating instructions.

VENOPAK for Simple Venoclysis

The Venopak is a completely disposable set for administering intravenous


fluids from the Abbo-Liter. Important to this all-plastic unit are the
following features: The drip chamber is flexible. One squeeze primes it
(or clears it if ever flooded). It is oversize for improved performance and
visibility. The air filter is made of woven Fiberglas discs, coated with
Teflon. The filter is non-wettable virtually eliminating leakage or inter-
ruption of air flow. The screw clamp can be operated with one hand
permitting close regulation of the flow rate.
Two lengths are available: Venopak (60 inches) and Venopak-78 (78
22 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 cap


to Abbo-Liter by turning container against it.
2. Suspend bottle. Hold the coiled tubing in one hand.
Half fill drip chamber by squeezing chamber.* Close
clamp.
3. Remove protective cover from needle adapter, and
attach 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 rate Screw clamp is
easily adjusted
of flow. with one hand.

Injecting supplementary medication

To inject supplementary medication, sterilize the gum rubber insert


by applying Metaphen (nitromersol, Abbott) Tincture or other suitable
antiseptic solution and allowing to dry. Inject, using a syringe and
25-gauge needle.
Compatible medication may also be added directly to the solution
by removing the air filter and attaching the syringe without needle to
the 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 is
in progress. Although mixing is accomplished by air bubbles rising during
the infusion, it may be well to swirl the bottle immediately after adding
the supplementary medication.

SURGICAL VENOPAK
to Provide Extra Injection Sites

SCREW CLAMP-~
-76" PLASTIC TUBING

__ INJECTION SITE

fj
EEDLEADAPTER

h ~. . -INJECTION SITE

GUM TUBING

SURGICAL VENOPAK-List No. 4557


SURGICAL 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-inch


tubing 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 a
slide clamp are provided. Flow may be temporarily interrupted with the
slide 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 the


rate, the Venopak Microdrip is offered for use with Abbo-Liter solu-
tions. This special disposable set consists of a dispensing cap with air
filter, the Microdrip and flexible drip chamber, clear plastic tubing with
inside diameter of 0.100 inch, a screw-type pinch clamp, a metal pinch
clamp, a multiple-injection site, and a needle adapter. The screw-type
pinch 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

CLAMP
CLAMP
INJECTION SITE

_PLASTIC
TUBING

The infusion rate should be checked periodically and, if necessary,


adjusted to maintain the desired rate.

SECONDARY VENOPAK (List No. 4613) for Series Hookup

DISPENSING
CAP

The Secondary Venopak provides a simple and economical means of


adding more fluid, or of changing fluids, while an infusion continues.
This disposable unit is similar to the primary Venopak, but has no drip
chamber. It permits attaching a secondary container in series to the
primary container. The Secondary Venopak can be attached without
stopping flow from the primary container.
If specific gravity of the secondary fluid is greater than that of the
primary fluid, it will tend to layer under, and will mainly infuse first.
Otherwise the two fluids will intermingle to varying degrees, and infuse
simultaneously. The secondary container always empties first. Air from
the secondary tubing rises to the top of the primary container.
Because some degree of mixing is always possible, we recommend that
secondary hookup never be made into a primary bottle containing a potent
drug (e.g., intravenous anesthetics or muscle relaxants). This avoids any
hazard of an overdose of primary fluid which may mix in during the
secondary infusion. 25
Assembling and operating the Secondary Venopak

1. Remove protective lid from dispensing cap, and fit cap by turning
Abbo-Liter secondary container against it. Place secondary container
upright, 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 adapter
between thumb and forefinger. Then suspend secondary container by its bail from
last two fingers of same hand. This allows both hands free movement for plugging in
and avoids spillage, since adapter is higher than secondary container.

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

NEEDLE
ADAPTER

This set is for alternate venoclysis from two Abbo-Liter containers


26 exclusively. Completely disposable, it contains two dispensing caps with
air filters and drip chambers, two slide clamps, a screw clamp, clear
plastic tubing, a gum rubber injection site, and a needle adapter.

Assembling and operating the Y - Type Venopak


1. Remove protective lid from one dispensing cap, and fit cap to
Abbo-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 by
squeezing chamber.
4. Remove protective cover from needle adapter, and attach sterile
vein needle.
5. Expel air as follows: Open one slide clamp, and allow fluid to fill
tubing to a point below the Y; close the clamp. Open other slide
clamp, 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 the
rate of flow with the screw clamp below the Y.
8. To switch to the alternate container, tightly close the slide clamp
below the first container; then fully open slide clamp below second
container, regulating rate of flow with screw clamp.
WARNING: Do not allow either container to empty completely. Be sure slide
clamp closure is complete (no dripping in chamber). If either bottle empties
completely, 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 calibrated


chamber. It permits the physician to administer limited amounts of
solution in precise volumes. It is well suited to pediatric use. It is
complete, 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 operator
can give any precise volume desired. Amounts larger than capacity may
be given simply by refilling the cylinder. Because the cylinder is rigid,
it permits positive reading of the fluid level. The graduations are in
5-ml. intervals, spaced equidistantly. A hinged valve abruptly seals off
the 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
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 rubber
preceding the needle adapter.
The cylinder is connected to the bottle by two lengths of tubing, one
side for movement of fluids, the other side for air. A single slide clamp
closes both.

5 mi. SCALE

HINGED VALVE
MICRODRIP

DRIP CHAMBER
INJECTION SITE
~-SCREW CLAMP

Note: Toshowthat the set is outof j


service between infusions, and II
yet leave it completely connected,
the cylinder may be looped over
IIIi
the stand. . I II

Assembling and operating the Soluset

1. TO ASSEMBLE. Close both clamps. Fit dispensing cap by turning


Abbo-Liter container against it. Invert and suspend container.
2. TO PRIME TUBING. Open slide clamp, fill calibrated chamber about
one-third, and close slide clamp again tightly. Gently squeeze drip
28 chamber until about one third full. Without removing needle adapter
cover, open screw clamp to fill tubing with fluid, expelling all air
from tubing. Close screw clamp.
3. TO FILL. Open slide clamp and fill calibrated chamber to desired
level. 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, fill calibrated chamber to desired level, and
tightly close slide clamp. Gently squeeze lower part of drip chamber
just enough to open rubber diaphragm. Slowlyrelease finger pressure.

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. This


catheter is radio-opaque; its position in the vein is always readily visible
in X-ray films. A removable stainless steel wire stylet prevents the
catheter from buckling while being threaded into the vein. After the
needle is withdrawn from the vein, a unique folding guard shields the
entire length of the needle. The catheter may be left indwelling during
repeated infusions, and the limb usually need not be immobilized. Use
of the pliant catheter is more comfortable for the patient than adminis-
tration via a rigid needle, especially if therapy is prolonged. It also
obviates surgical cutdown and sacrifice of the vein. 29
Assembling and operating the Venocath

1. To open-Leave the sterile inner sheath 2. Expose Needle-Slide back clear plastic
intact until immediately before use. ring on needle guard, and open guard
Then grasp base of blue needle guard wings. Discard inner white cover, ex-
and strip sheath down enough to expose posing needle.
only two-thirds of guard.

3. Enter Vein-Make venipuncture, hold- 4. Withdraw Needle-After blood fills cath-


ing needle bevel up. Grasping catheter eter, apply finger pressure over catheter
through its protective sheath, slowly in vein. Hold it thus while withdrawing
push catheter well into vein. (If during needle. Discard sheath. Snap hub of
this maneuver, it becomes necessary needle guard into white adapter at cath-
to withdraw catheter, always withdraw eter end.
needle simultaneously; this prevents
severing of catheter by needle.)

5. Withdraw Stylet-Remove protective 6. Close Needle Guard-Close wings of


cap from white adapter, and withdraw guard in place over needle, and slide
wire stylet. Immediately connect admin- ring back to distal end of wings, to lock
istration set to adapter. them in place. Tape catheter, needle
guard, and end of administration set for
30 proper immobilization.
BUTTERFLY INFUSION SETS (Formerly called "Scalp Vein Infusion Set")

Butterfly sets serve as extensions for infusion of blood or solutions from


the Venopak or any standard syringe. They have flexible plastic wings
that can be folded upward to provide a fingergrip for more accurate
needle manipulation. This allows the needle to be held flat against the
skin and inserted into the vein with a sliding motion. The same feature
facilitates venipuncture in difficult patients-for example, elderly per-
sons with fragile, rolling veins. When released, the wings fold flat against
the skin, where two short strips of tape suffice for stable anchorage. To
eliminate any possibility of separation, tubing and needle are perma-
nently joined at the time of manufacture.
The short needle, compact anchorage, and flexible tubing contribute
to greater patient comfort-with reduced chance of phlebitis, or of
pressure necrosis beneath a bulky taped hub connection. The sets are
sterile inside and out, come in sterile peel-pack envelopes, complete
with stainless needle.

BUTTERFLY-16-List No. 4716


with 16-G. thinwall needle (15-G. bore)

Designed primarily as a surgical infusion set, the Butterfly-16 is supplied


with a 16-gauge thin wall needle (15-G. bore) for rapid infusion and
pressure administration. The .100" r.D. tubing is 3D-inches long, which
allows connection to the administration set at a clearly visible location
outside the surgical drapes.
BUTTERFLY-19-List No. 4590
with 19-G. thinwall needle (18-G. bore) and .054" 1.0. tubing
BUTTERFLY-21-List No. 4492
with 21-G. thinwall needle (20-G. bore) a[ld .040" 1.0. tubing
BUTTERFLY-23-List No. 4565
with 23-G. needle and .040" 1.0. tubing
BUTTERFLY-25-List No. 4506
with 25-G. needle and .040" 1.0. tubing

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

31
VENOVALVE 30" with "T" Connector
List No. 4730

This is a syringe administration set, 30 inches long. A check valve at


the terminal female adapter prevents backflow. An additional injection
site (latex-covered) is provided at the T -type male needle adapter; this
site 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 male
needle adapter with injection site (with latex cover which may be re-
moved to expose a female adapter).

VENOTUBE

VENOTUBE 20-List No. 4429


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

These sets consist of tubing (20 and 30 inches long respectively) with
pinch clamp and male and female adapters. They are used as flexible
connections between syringe and needle during administration of
Pentothal Sodium (Sodium Thiopental for Injection), or as extensions
where added length is needed. The inside sterility of No. 4429 and 4481
is maintained by air filters and hoods at each end. No. 4610 is supplied
in 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 for
infusions, tra'nsfusions, or the administration of Pentothal Sodium
(Sodium Thiopental for Injection). The set consists of 30 inches of clear
plastic tubing, multiple injection sites, two pinch clamps, and male and
female 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 infants


or obese patients) parenteral fluids may be administered by hypodermoc-
lysis (subcutaneous infusion). The same rigi<;l precautions-sterility of
equipment and employment of aseptic techniques throughout-are as
important for subcutaneous infusion as for intravenous infusion.
Needle size: For general use the Cly-Q-Pak furnishes two 22-gauge
needles two inches long. Where another size needle is preferred, the
Cly-Q-Pak is also available without needles.
Other factors: Patients, especially children, should be well attended
throughout the infusion, since a sudden movement of the patient may
dislodge a needle or disconnect a tubing. Should this happen, the infusion
should be discontinued until the equipment can be properly adjusted
or reassembled.
Selecting the equipment: When one needle is employed, the basic unit
for hypodermoclysis is the same as that used in venoclysis (for instance,
the Venopak, page 23). However, to hasten administration, two needles
are 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 arm
is 14 inches long. Cly-Q-Pak (see illustration) is completely assembled,
is delivered in a sterile individual carton, and is ready for immediate
use. A pinch clamp on each arm allows the operator to control the flow
to each site. Cly-Q-Pak is assembled in the same manner as the Venopak
and operates on the same principles. Discard the entire unit after one use.
Selecting and preparing the site: The best site for hypodermoclysis is
the outer middle surface of the thighs. The anterior surfaces of the
thighs, the flanks, and the loose tissues at the sides of the chest below
the axillae are also suitable. The injection is into the fatty tissues just
beneath 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!. of
procaine 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 should
be 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 none
appears, 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 the
flow of liquid.
Rate of flow: The rate at which such an infusion can be administered
will vary from person to person and must be adjusted accordingly. Abil-
ity to absorb fluids is variable, and tissues may become unduly distended
and painful if the rate is too fast. The flow should be stopped from
time to time in order to gauge the rate of absorption. If an individual's
absorption is found to be very slow, a new site (or sites) should be
considered.
Hyazyme (hyaluronidase for injection, Abbott) is also available for
increasing the rate of absorption. This enzyme accelerates the diffusion
and absorption of fluids and drugs injected subcutaneously. For this
reason, it is used frequently as an aid in hypodermoclysis. Absorption
may be enhanced considerably, so usual time for this type of infusion
can be reduced to one-half or one-third.
Hyazyme is supplied as a lyophilized powder in one-milliliter vials, each
containing 150 U.S.P. units of hyaluronidase. The powder is reconstituted
by addition of 1.0 ml. of sterile water for injection, U.S.P., or sodium
chloride injection, U.S.P. (isotonic). This solution is then injected
through the wall of the gum rubber insert or is injected directly into the
site chosen for hypodermoclysis immediately preceding the infusion.
The exact solutions to be administered by subcutaneous infusion will
be determined by the attending physician according to the patient's
needs 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 solutions
containing only a sugar, since these may cause pain by drawing fluid
from the surrounding tissues. If the patient is salt-deficient, or is in the
beginning stage of shock, or has impaired kidney function, fluid may be
drawn from the circulating volume, thus, leading to circulatory diffi-
culties. The operator should be alert for signs of unusual swelling or
edema in the area of clysis. 35
FROM THE SYRINGE
FROM THE SYRINGE

Solutions or other liquid preparations may be administered from a


syringe by any of several routes, the exact volume depending on the
route 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 superficial
layer 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. For
maximum ease of operation many Abbott sterile ampoules are offered
with Color-Break or Gold-Band to eliminate the necessity for filing,
sawing, or scoring by the operator. The neck of the ampoule breaks
cleanly and evenly with only slight pressure.

From the ampoule

1. Always read the label of the ampoule to be certain it contains the drug
and dosage which were prescribed. Never use the contents of an un-
labeled ampoule.
2. Cleanse the neck of the ampoule with an antiseptic sponge or
swab:
A. Abbott ampoules with paper labels may be sterilized exter-
nally by immersion in alcohol (70 per cent) or in Zephiran
38 (benzalkonium chloride). They should not be immersed in
Metaphen (nitromersol, Abbott), since the adhesive is attacked
by alkaline solutions.
B. Abbott ampoules labeled with a silk-screen printing process
may be immersed in water, alcohol, or other antiseptic solutions.
3. Grasp both ends of the ampoule as shown below and bend the
stem 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, expel
the air and check the dosage.
6. Proceed with the injection.
7. If the drug is not to be injected immediately, place the empty
ampoule 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 the
needle through the center of the rubber stopper, and force air from
the syringe into the vial.
4. Holding the vial upside down, withdraw the desired volume into
the 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 syringe
and needle in sterile gauze or place in a sterile container, leaving the
vial nearby for identification. 39
From the TWO COMPARTMENT VIAL

A unique container for parenteral products is the Two Compartment


Vial, 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 offered
in the Two Compartment Vial. Solids and diluent are mixed just prior
to the injection by pressing the top (exposed) rubber stopper.
The dry solids are stable indefinitely, and the Two Compartment Vial
eliminates 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 top


of rubber stopper with firm, steady pressure to dislodge rubber plug
which 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 to
syringe, pierce stopper squarely through center ring. Withdraw
desired volume.

40
Into the vein

In contrast to the larger volumes administered by infusion, relatively


small volumes of solutions or liquid suspensions are injected into the
vein 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 the
syringe 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 syringe
will be calibrated in both cubic milliliters and minims, and a darkened
plunger will aid in the measurement of small doses.
The needle should be chosen for the occasion. Hence, when a drug
must be administered slowly a 24- or 26-gauge needle can be used advan-
tageously if the vein is easily accessible. However, in most cases a larger
needle is generally preferred, such as a 20-gauge needle which is 1 or 1~
inches long.
Aseptic techniques should be employed throughout the preparation
and injection. The syringe and needle must be properly sterilized before
use. A dry syringe and needle are preferred, since some preparations are
affected by water or are incompatible with it.

PREPARING THE SITE AND PERFORMING THE INJECTION: The general


comments 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 of
blood to be sure the needle is still in the vein.
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 syringe flush with the skin and
slowly withdraw the needle.
5. Instruct the subject to hold the cotton in place by manual
pressure 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), the
operator 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 arterial
entry is not detected during aspiration, then partial or complete injection
of the contents of the syringe may cause arterial spasm and pain down the
length of the arm (in the direction of arterial flow). In either event the
procedure 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 high
concentrations of certain drugs may cause complications in the vein at or
above the site of the injection. A hardening of the vein and pain up the
length of the arm (in the direction of venous flow)are signs of 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 greatly
inhibit 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 may
be pierced and the contents of the syringe injected into the subcutane-
ous tissues. Thus, throughout the injection the operator should watch
closely for signs of swelling or of tissue irritation. Should these occur, the
injection should be stopped at once and suitable measures taken.
Into the muscle

Whenever practicable, the intramuscular route is utilized, since it is more


convenient to both the patient and the operator than is the intravenous
route. Also, when prolonged action is preferred to immediate, a drug
may be injected into the muscle and gradually absorbed by the blood
stream. For example, prolonged blood levels of penicillin may be ob-
tained by intramuscular injection of penicillin G procaine. Similarly, the
action 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, within
limits, 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 medication
must be sterile and pyrogen-free, and aseptic techniques should be em-
ployed throughout.

SELECTING THE SYRINGE AND NEEDLE: Large quantities of a drug are


seldom injected into the muscles, and a 5-ml. syringe is the largest which
will be required. Generally a 2-m1. syringe will suffice. The needle should
be small, sharp, and strong with a gauge of 20 to 23 and a length not less
than 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 of
certain medications. Preparing it for use requires only the attachment
of 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, or
improper 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 vastus
lateralis of the quadriceps femoris are all suitable. However, the gluteal
muscles are usually considered to be the site of choice, especially when
the medication is irritating or when relatively large volumes are to be
administered. The overlying skin in the area is thin and easily pierced.
Also, this site offers the operator a definite psychological advantage
when the patient is apprehensive. Lying prone, the patient does not
see the approach of the needle.
Nevertheless, one should remember that under the gluteal muscles lie
the sciatic nerve and the superior gluteal artery.
Although the hazards of introducing a drug into the gluteal muscles
are real, they can be considerably minimized, if not eliminated, if the 43
Figure 19. The gluteal muscle-site of Figure 20. Patient should lie relaxed-
choice for intramuscular injections. Up- face down, feeUoeing in, arms hanging
per outer quadrant lies well away from over sides of table.
great sciatic nerve and superior gluteal
artery.

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 lies
well 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 may
be 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 and
thumb, steadying it by the second finger of the right hand.
3. By one quick thrust introduce the needle almost perpendicularly
to the skin. The depth of insertion varies and depends on the indi-
vidual's size.For example, an obese patient may require a penetration
as deep as 2 or 27i inches, while a child's muscle may be reached at
a depth of 72 to 1 inch. In any event, the needle should be advanced
only 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 the
needle 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 and
index finger of the right hand, draw back on the plunger. If no blood
or exudate appears, return the left hand to its former position tensing
the skin. (If blood appears in the syringe, the needle is in a vein or
artery 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 the
needle.
7. When rapid absorption is desirable, massage the site vigorously
for about two minutes. This will distribute the drug in the muscle
and prevent an accumulation at one point. When slow absorption is
indicated, do not massage. Simply sponge the area with an antiseptic.
MULTIPLE INJECTIONS. If several injections are to be given at relatively
close intervals, different sites should be selected for each puncture-
preferably in the gluteal, deltoid, or triceps groups. Whatever site is
chosen, the technique of injection remains almost the same.
ALTERNATIVES TO THE GLUTEAL MUSCLES. As an alternative to gluteal
injections, the lateral aspect of the thigh has been suggested as a safe
and convenient site.5,6 The muscle mass involved is the vastus lateralis
of the quadriceps femoris group. The attitude of the syringe and needle
should be perpendicular to the skin and on a horizontal plane. The
procedure is the same as for other intramuscular injections including
aspiration. In adults, a needle 17;2 inches long is usually suitable, while
a shorter needle should be employed for infants. Gilles7 recommends
that infants receive the injection in the distal third of the thigh.
The ventrogluteal site has also been recommended as an alternative
to dorso-intragluteal injection.s,9,lo For one methods,9 of locating the
proper site the patient stands. The anterior iliac spine is taken as a
reference point and the trochanter is palpated. In the other method 12

of locating the site the patient is recumbent. The site is defined with
index and middle fingers, usually of the left hand which rests on the
patient's hip. The ventral index finger rests on the iliac, and the middle
finger (stretching dorsally) palpates the crest of the ilium. Then the
top of this finger presses exactly below the iliac crest. The triangle
between the index finger, middle finger and the iliac crest confines the
injection site (figure 21). Curtis and Tuckerll believe that this approach
will 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 and
young children.

Into the subcutaneous tissues

When a drug is to be administered parenterally in small amounts, the


subcutaneous route may be utilized. When drugs are given other than
intravenously, the rate of absorption is an important determinant of the
intensity and duration of their activity. The speed of absorption, in turn,
is dependent on the physiochemical properties of the drug and the local
blood supply of the injected area. Water-soluble drugs are absorbed
rapidly; fat-soluble and insoluble drugs, slowly.
Unfortunately, however, irritating drugs or drugs in heavy vehicles
or suspensions so administered may produce induration, sloughing, or
abscess 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 other
parenteral 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 subcutaneous
injection is seldom greater than 2.0 ml. Thus, a 2-ml. syringe, calibrated
in minims or fractional milliliters, should usually be employed. The
length 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 a
drug beneath the surface of the skin is usually made in the loose inter-
stitial tissues of the arm, forearm, thigh, interscapular region, or the
buttocks. Edematous tissues, where absorption is poor, should be
avoided. The site of entry should be changed when injections are to be
made 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 up

a fold of the skin and hold firmly. Plunge the needle boldly into fold at
45-degree angle to the long axis of the extremity or part. As explained
on page 44, the needle should be inserted only about three-fourths of its
length. Aspirate. If blood appears in the syringe, select a new site. If
there 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 subcutaneous
injection mentioned above often do not provide the deep administration
which is sometimes desirable. For instance, concentrated aqueous solu-
tions of heparin* willproduce a prolonged therapeutic effectwith the least
likelihood of local irritation if they are injected into deep subcutaneous
tissues. A prolonged effect for as long as twelve hours may be obtained
by 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. There
is little or no pain, and local reactions are rare and minor. The patient
himself may be taught to make these injections.
Into the skin (Intradermal)

For diagnostic purposes, desensitization, or immunization, a number


of substances may be injected into the corium, the more vascular layer
of skin just beneath the epidermis. By intradermal administration of
certain antigens, the body's response or lack of response to specific
allergens can be evaluated and the need for prophylactic therapy indi-
cated. A tuberculin syringe with 26-gauge needle % inch long is usually
employed. 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 literature
availabie on request from Abbott Laboratories, North Chicago, illinois. 47
the thumb and forefinger of the other hand, seat the plunger against
the heel of the palm. First, expel the air from the needle by slightly
contracting the thumb and forefinger. Then, at an angle to the long
axis of the forearm, place the syringe and needle horizontally flat against
the skin with the bevel of the needle facing upward. Depress the syringe
and needle until there is no more give and advance the syringe and needle
until the bevel just disappears into the corium. Contract the hand
slowly so that the thenar eminence advances the plunger and the desired
amount (usually about 0.1 ml.) of fluid is injected to raise a wheal.
Remove the needle and wipe the site.

Figure 23

48
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, December
1952.
7. Gilles, F. H. and French, J. H., Postinjection Sciatic Nerve Palsies in Infants
and 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 Untersuchung
und Klinische Prufung der Neuen Intraglutaalen Injecktionstechnik nach von
Hochstetter, 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 Nerve
Injury in Infants: Recognition and Prevention of Impairment Resulting from
Intragluteal 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.