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

Abstract

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

Adverse effects of dorsogluteal intramuscular injection versus ventrogluteal intramuscular injection: A systematic review and meta‐analysis

“…One of the studies (Larkin et al, 2018) reported the outcome with a dichotomous variable (theoretical subcutaneous or intramuscular injection with a 21G needle‐38 mm needle) and the other two described cases in which the SAT was ˃33.1 mm (Zaybak et al, 2007) or ˃35 mm (Nisbet, 2006). With 21G needle‐38 mm (1.5 inch), approximately 5 mm does not penetrate the skin (Strohfus et al, 2021) so data of these studies was considered appropriate to discriminate theoretical subcutaneous injection when a 21G needle‐38 mm (1.5 inch) was used. A random effects model was adopted because there was evidence of significant between‐study heterogeneity ( p < 0.0001, I 2 = 91%).…”

“…Some outcomes related to safety and accuracy of VS and DS intramuscular injection have not been studied clinically (bioavailability or clinical effects of medication on these two injection sites); however, using diagnostic techniques, CT-scans, or ultrasound, it is possible to evaluate skin to muscle depth. Hypovascularity of SAT compared with muscle tissue could result in a reduction of bioavailability or slower uptake of medication (Strohfus et al, 2021).…”

“…the length of needle (Strohfus et al, 2021). These recommendations are in fact already proposed in some drug leaflets like common antipsychotic long-acting IM injections (Soliman et al, 2018).…”

“…In women who are obese (BMI 35 and over), the combined studies pointed to a 50 mm needle with the guidance of an ultrasound (Strohfus et al, 2021). In overweight women, to ensure an intramuscular injection in 100% of the cases a 50 mm needle should be used, however, only Razzouki et al, 2013).…”

“…One of the studies (Larkin et al, 2018) reported the outcome with a dichotomous variable (theoretical subcutaneous or intramuscular injection with a 21G needle-38 mm needle) and the other two described cases in which the SAT was ˃33.1 mm (Zaybak et al, 2007) or ˃35 mm (Nisbet, 2006). With 21G needle-38 mm (1.5 inch), approximately 5 mm does not penetrate the skin (Strohfus et al, 2021) so data of these studies was considered appropriate to et al, 2008;Larkin et al, 2018;Zaybak et al, 2007). We found homogeneity in outcomes of participants with BMI <25: the injection would be intramuscular in both VS and DS.…”