The latest guest post on the Mental Health Nursing Lecturers Tea party comes from Bob Tummey. Bob is a mental health nurse lecturer at Coventry University and is becoming quite well known as a writer on mental health issues – see for example . In this post, Bob is carrying on an earlier post from Jim Chapman.
I would like to continue the rather interesting debate raised by Jim Chapman in an earlier posting. Jim raised concern for the administering of depot neuroleptic medication through IMI into the subcutaneous wall of fat and not the intended dorsogluteal muscle, leading to poor uptake of medication. This raises the question as to whether people receiving the medication this way are actually gaining any effect. (For a couple of research studies see Nisbet, A.C (2006) Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ. 332: 637-638 and also Chan et al (2006) Intramuscular injections into the buttocks: Are they truly intramuscular? European Journal of Radiology.)
I was very aware of this issue when working in New Zealand. The depot can be administered into the dorsogluteal muscle but the needle may not reach due the thickness of the subcutaneuous fat wall (which is becoming thicker as the population become larger/obese). However, the medication is still absorbed; it just takes a longer period of secretion into the system. The ventrogluteal is the muscle of choice across USA due to concerns for litigation (hitting the sciatic nerve and so on). Therefore it does seem to be the natural progression for all MH nurse education to consider the teaching of depot IMI into the venrogluteal. However, this does have implications for practice and will require all mentors (for instance) to be competent and taught first.
In UK, New Zealand and Australia, best practice dictates the use of the dorsogluteal (upper-outer quadrant) but mainly due to tradition and training offered (For the NZ and Australian focus please see, Wynaden, D et al. (2006) Best practice guidelines for the admin of IMI in mental health settings. Int. J MHN. 15: 195-200.) This muscle is also supported by the drug companies which I suspect is due to their dated research and the product information they share. I believe all drug trials for depot medication have used the dorsogluteal muscle, although these trials now need updating.
Another point for discussion I would like to raise is on the ethical issue of actual site. If the ventrogluteal is reportedly the best site then should we not be evidence-based and comply? However, coming from another angle, when I worked as a nurse specialist in NZ I came across a number of NZ MH nurses who administer the depot every week/two weeks into the deltoid (upper arm) muscle with the IMI needle. This ensures direct penetration of the muscle and absorption of the medication….. The UK nurses in NZ would not provide IMI this way, but maybe some research needs to be undertaken to consider any benefits to treatment. From a brief look at policy in the UK it seems that the deltoid is only to be used as a one-off/stat dose into the less-dominant arm and mainly for adolescents. However, ethically is this right? Or indeed, should we consider its use to ensure effective treatment? One thing seems quite certain, the use of the dorsogluteal IMI is now redundant.
In a recent MHN conference I attended in NZ the most subscribed plenary session by far was about administration of depot injections, facilitated by Dianne Wynaden. It is an interesting debate, but what are the answers….
Please share your thoughts and experiences.