Safe and Effective Administration of Vaccines and Epinephrine Autoinjection

Indications

Patient education is a vital portion of any health care encounter, especially including vaccines and immunizations. Understanding the patient's vaccination schedule is essential and can help alleviate any misunderstandings and associated anxiety with the patient's vaccination.[1][2] 

The vaccination schedule is different for each age group. The US Centers for Disease and Control Prevention (CDC), in coordination with The Advisory Committee on Immunization Practices (ACIP),  provides updated guidelines annually for health professionals to understand when and what vaccinations are necessary. The CDC has vaccination schedules for infants, children and teenagers, and adults on their website. For patients that have missed vaccinations or have special needs due to autoimmune diseases and the like, guidelines are available on the CDC website.[3]

Contraindications

Before administering any immunization, it is crucial to complete a history and physical and review the patient's medical and immunization records. It is vital to know the patient's medications, allergies, or previous vaccination reactions before their current encounter. If a patient has ever had anaphylaxis or a severe allergic reaction to any parts of a specific vaccine or prior vaccination, further investigation must be performed before inoculation.[4] 

Certain vaccines have components that can provoke allergies, and individual patients may have a medical history that contraindicates vaccination. Below is a list of some common allergies and cautions to be aware of for particular vaccines:

Rotavirus:

• Severe combined immunodeficiency disorder
• History of intussusception.[5][6]

Influenza:

• Younger than six months of age
• Severe egg allergy[7]

MMR, Varicella, Herpes Zoster:

• Pregnancy
• Severe immunodeficiency (including HIV with CD4 count <200)[8][9]

After gathering all the information necessary, including a comprehensive history and physical, a list of allergies, and prior medical history, the immunization schedule can be consulted for that patient's individual needs. Once the immunizations to be given during the encounter are discussed and confirmed, consent should be obtained from the patient or the patient's guardian regarding the vaccinations.

Equipment

There are varying modes of delivery for vaccines to be administered. The methods include oral, intranasal spray, subcutaneous, nasal, and intramuscular. The methods of delivery with administration instructions are usually outlined on the labels of the vaccines themselves. A majority of vaccines are given intramuscularly. Below is a list of vaccines that have other modes of delivery:[10]

• Oral - rotavirus
• Intranasal spray - live attenuated influenza.
• Subcutaneous – MMR and MMRV, varicella, meningococcal
• Intramuscular (IM) injections should be given with a 22 to 25 gauge hypodermic needle. A patient's age and weight determine the length and position of the injection.[11][12]

Age

• Less than one month: 5/8" length needle into the anterolateral (upper, outer) portion of either thigh bilaterally
• 1 to 12 months: 1" length needle into the anterolateral part of either thigh
• 1 to 2 years: 1 to 1.25" length needle into the anterolateral area of either thigh or 5/8 to 1" length needle into the upper outer portion muscle of the arm (deltoid) on either side.
• 3 to 18 years: 5/8 to 1" length needle into the deltoid or 1 to 1.25" length needle into the anterolateral portion of the thigh bilaterally

Weight

• Weightless than 130 lbs: 5/8-1" length needle into the deltoid
• Weight between 130 to 152 lbs: 1" length needle into the deltoid
• Weight above 150 lbs (below 200 lbs for women, below 260 lbs men): 1 to 1.5" length needle into the deltoid
• Weight above 200 lbs women, 250 lbs men: 1.5" length needle into the deltoid

Personnel

Healthcare professionals qualified by their state licensing boards are authorized to give immunizations. Depending on individual state laws, this personnel can include but are not limited to medical assistants, nurses, nurse practitioners, physician assistants, pharmacists, and physicians.

Preparation

All immunizations and vaccines should be stored and managed in a manner that has been outlined by their manufacturers. When handling vials for the vaccines, make sure to read the labels carefully to ensure that the vaccinations are the correct immunizations for the patient. Be sure to document in the patient's chart and records as outlined by state or local entities.

Before injecting any site with a vaccination, make sure to observe universal precautions by washing hands and placing on protective equipment such as gloves before touching the patient.[13] Clean the injection site using a sterile alcohol wipe. Be sure to wipe the area in small concentric circles extending at least 2 inches from the site to be injected. Wait until the area has dried, usually 45-60 seconds after cleaning with the alcohol wipe. Have clean cotton balls or gauze pads ready for after the injection has finished. An epinephrine auto-injector should be on hand in case of anaphylaxis.

Technique or Treatment

The IM injection should be performed at a 90-degree angle to a large muscle's belly. Insertion of the needle should be perpendicular to the patient's body. Make sure to stabilize the limb that will be inoculated. Place the appropriate needle on the syringe that has the prepared vaccination in it. Hold the syringe needle approximately one inch in the air the injection, then inject the site using a quick, smooth motion. Once inserted into the muscle, use stable pressure on the needle's plunger (the top portion of the syringe that can be pushed up and down) to inject the vaccine into the patient. Plunger aspiration after insertion is no longer recommended as injection sites are not near large blood vessels, and this technique increases vaccination associated discomfort.[14] Once finished, remove the needle from the patient's muscle and place it into a sharps container.[15][16] Apply gentle pressure to the injection site with the cotton gauze or balls to slow any subsequent bleeding. Following this, place a bandage on the area. Let the patient know they can remove the application at their leisure at a later point that day.

For subcutaneous injections, a 5/8" length needle that is 22 to 25 gauge is necessary. In contrast to intramuscular injection, the syringe contents should be injected into the skin's fatty layers, such as the anterior lateral thigh for children ages 1 to 12 months. Alternatively, inject into the fatty tissue layer area over the triceps muscle, the posterior portion of the upper arms, bilaterally in anyone above 12 months of age.[17]

Gently pinch the skin above any of the previously mentioned areas after it has been cleaned properly. Hold the needle at a 45-degree angle, approximately one inch from the pinched skin where the patient is inoculated. Insert the needle into the tissue layer underneath the skin, pressing down on the syringe's plunger firmly and slowly to empty the contents into the subcutaneous layer. Remove the needle from the inoculation site and place it into a sharps bin.[17] As before, apply gentle pressure to the area if there is bleeding and bandage it as necessary.

For oral and intranasal vaccinations, follow the manufacturer's guides on their respective labels for instructions on how to administer.

Complications

After applying a bandage or gauze with medical tape to the inoculation site, it is crucial to monitor and educate the patient on issues that can arise due to recent vaccinations. Make sure the patient is under watch for at least five-ten minutes following vaccination. It is common to have a low-grade fever and some mild fatigue following a vaccination. For soreness or redness in the area, a cold compress can be applied, or the patient can take ibuprofen. If the symptoms persist for longer than 48 hours, advise the patient to seek help from their primary care physician or go to an emergency room for further care.

Anaphylaxis and Epinephrine Autoinjector

 One of the more problematic issues that arise from vaccinations is anaphylaxis. Anaphylaxis is a severe allergic reaction when an individual is exposed to an irritant or foreign substance called an allergen. Typical indicators of anaphylaxis include global pruritis, the sudden global onset of urticaria (raised bumps of skin that are surrounded by erythema), swelling of the face, tongue, or throat, wheezing with associated shortness of breath, cough, sudden hypotension with a sudden loss of consciousness, or dizziness.[18] It is crucial to monitor for signs of anaphylaxis, as a quick intervention with epinephrine via auto-injector may be necessary.[19][20]

Remember that anaphylaxis is a treat first, then call for help type of medical emergency. Make sure to ask the patient who is suffering from anaphylaxis if they can inject themselves or need assistance to do the injection. The instructions for operating an epinephrine auto-injector are labeled on the side of the apparatus itself for ease of use. When using the device, there is usually a viewing window where the medication can be seen inside. If the solution is opaque or murky appearing, it is likely that the medication has been exposed to extreme temperatures and is therefore not viable. In this case, another epinephrine auto-injector must be procured. The expiration date is also located on the side of the apparatus itself; if the medication has expired, it will not help save the patient's life if implemented.

To use an epinephrine auto-injector, first firmly grasp the device around its middle. Do not place the hands over the top or the bottom of the device, which can accidentally trigger the device and inject the user. Pull off the blue activation cap at the top of the device. The orange tip holds the needle inside of it. Make sure to press the orange tip perpendicular to the mid anterolateral (outer mid) thigh of either leg and push firmly to activate the auto injecting device. An audible click should be heard when this occurs. Hold in place for at least 5 seconds. Remove the device from the injection site. At this point, the needle should have been automatically covered by its orange tip. Once this is confirmed, the device can be safely discarded.[19][20] 

The patient may feel tremulous and experience palpitations; this is an expected side effect of epinephrine. At this point, make sure to call emergency services and have the patient moved to a hospital setting where physicians can monitor them. Emergency services must observe the patient in case of a biphasic anaphylactic reaction, a secondary anaphylactic crisis that occurs after the initial onset.

Clinical Significance

The general public must have access to vaccines and immunizations. By further educating various healthcare professionals on the safe administration of immunizations and epinephrine auto-injectibles, we improve access and allow patients to find different vaccine delivery options to suit their individual needs.

Enhancing Healthcare Team Outcomes

Interprofessional teams continue to provide a holistic and integrated approach to safe and effective vaccine administration and better protect the growing population through immunization. All health care team members from medical assistants, nurses, nurse practitioners, physician assistants, pharmacists, and physicians should be trained equally in the safe administration of vaccines. Understanding that an adverse outcome, such as anaphylaxis, can be acted upon by using an epinephrine auto-injector device better prepares the health team to serve the patient in a larger capacity.