I am doing some research into best practice for administration of intramuscular (IM) injections. When administering
childhood vaccines we are told not to draw back, which is different from the advice I received when I trained as a nurse.
After asking colleagues who have worked in different clinical settings I have received a number of conflicting replies
regarding the need to draw back during IM injections. Can you advise best practice for this?
Response from bpacnz editorial team:
The practice of drawing or pulling back on the plunger of a syringe (also known as aspirating) while performing an
intramuscular (IM) injection is used to avoid accidental intravenous (IV) injection. The risk to a patient of accidental
IV administration varies according to the substance being injected.
A useful rule of thumb is that drawing back is:
- Not necessary for vaccinations,
- Necessary for passive immunisation with immunoglobulins
- Likely to improve patient safety for IM injections of medicines.
For the IM administration of vaccines drawing back is usually not necessary.1 The Immunisation
Handbook (New Zealand), Centres for Disease Control (United States), Department of Health (United Kingdom) and World
Health Organisation all recommend that IM vaccinations should be made into the deltoid or vastus lateralis muscles.1–4 As
large blood vessels are not located near the recommended injection sites, drawing back before the injections of most
vaccines is not needed, as long as the correct site and needle is used.2, 3
For the IM administration of immunoglobulins used for passive immunisation, drawing back is recommended
as anaphylactic reactions, which although rare, are more likely to occur following IV administration.1 These
products include immunoglobulins derived from donated blood, such as Rh(D) immunoglobulin, hepatitis B immunoglobulin,
tetanus immunoglobulin, zoster immunoglobulin and human normal immunoglobulin for IM administration.1
For the IM administration of medicines, clinical judgement should be used when deciding whether to
draw back, taking into account:
- The risk to the patient if the medicine were to be accidentally administered IV
- The site of injection, which will influence the chance of injecting into a blood vessel
For medicines administered by IM injection where IV administration may cause significant adverse effects drawing back
should reduce the risk of harm and improve patient safety. Examples of medicines used in primary care which could cause
serious adverse effects if an IM injection is delivered IV include preparations with oily liquids or suspended particles,
such as long-acting antipsychotic or steroid depot injections. Oil-based injections may cause pulmonary oil embolism
when injected intravenously, with symptoms such as acute onset cough and respiratory distress.5, 6 Accidental
IV administration of a depot IM olanzapine injection may cause post-injection delirium/sedation syndrome due to acute
exposure to high doses.7
The potential for injection into a major blood vessel is higher with an intended IM injection in the dorsogluteal
area. The risk of sciatic nerve damage or accidental subcutaneous injection in this area is also increased. Between
2005 and 2008, eight claims for sciatic nerve injury following a dorsogluteal IM injection were made to ACC, six of
which occurred in a general practice setting.8 Even with correct injection technique many IM injections into
the dorsogluteal region result in subcutaneous administration due to variable subcutaneous tissue thickness between
people.3, 9 This can result in delayed uptake of the medicine, tissue irritation or the development of granulomas.10
The ventrogluteal injection site (also known as gluteal triangle) is an alternative site suitable for injections of
up to 3 mL in adults. It is associated with less risk of accidental IV injection, avoids the sciatic nerve and there
is also a more consistent depth of subcutaneous tissue between individuals than the dorsogluteal site, resulting in
a safer, more consistent IM administration.8, 11
Other key practice points for performing an IM injection include:
- Injections should be given at a 90° angle with the surrounding skin stretched, either between fingers or using the
Z-track technique, described below2
- If drawing back is performed, a five to ten second wait time is recommended to check for blood entry into the syringe9
- The Z-track injection technique helps prevent seepage of the injected fluid out through the injection track:12
- Use a free hand to pull the skin sideways two to three centimetres prior to injecting
- Perform the injection and withdraw the needle
- Release the skin so that the needle track through the skin is offset away from the track through the underlying
Guides to identifying the ventrogluteal IM injection site and using the Z-track
injection technique are available from: http://thenursepath.com/2014/04/23/the-ventrogluteal-im-injection-site/ | https://vimeo.com/73862611
- Ministry of Health. Immunisation Handbook 2014. Wellington, New Zealand: Ministry of Health 2014. Available from: www.health.govt.nz (Accessed
- National Center for Immunization and Respiratory Diseases. General recommendations on immunization - recommendations
of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60:1–64.
- Department of Health (UK). Immunisation procedures: the green book, chapter 4. London: Public Health England 2013.
Available from: www.gov.uk (Accessed Nov, 2015).
- World Health Organisation (WHO). Immunization in practice: A practical guide for health staff. 2015 update. Module
5: Managing and immunization session. Geneva: WHO 2015. Available from: www.who.int/en (Accessed
- Zitzmann M. Therapy: Are long-acting intramuscular testosterone injections safe? Nat Rev Urol 2015;12:248–9.
- Russell M, Storck A, Ainslie M. Acute respiratory distress following intravenous injection of an oil-steroid solution.
Can Respir J 2011;18:e59–61.
- McDonnell DP, Detke HC, Bergstrom RF, et al. Post-injection delirium/sedation syndrome in patients with schizophrenia
treated with olanzapine long-acting injection, II: investigations of mechanism. BMC Psychiatry 2010;10:45.
- Mishra P, Stringer MD. Sciatic nerve injury from intramuscular injection: a persistent and global problem. Int
J Clin Pract 2010;64:1573–9.
- Sisson H. Aspirating during the intramuscular injection procedure: a systematic literature review. J Clin Nurs
- Feetam C, White J. Guidance on the administration to adults of oil-based depot and other long-acting intramuscular
antipsychotic injections. 3rd ed. Hull: University of Hull 2011. Available from: www.hull.ac.uk/injectionguide (Accessed
- Ogston-Tuck S. Intramuscular injection technique: an evidence-based approach. Nurs Stand 2014;29:52–9.
- Floyd S, Meyer A. Intramuscular injections-what’s best practice? Nurs N Z 2007;13:20–2.