Today a new-graduate nurse taught me how to give an intramuscular injection.
No, really….

After studiously watching one of our senior staff give an intramuscular (IM) injection, the new-grad informed us that, in fact, she was not taught to give injections into the upper-outer quadrant.
This is were I have been sticking my needles for many years now, and I have given thousands (if not millions) of injections this way.
We were about to re-orient her….but as this student is no dummy,  the senior staff member and I thought we had better get our facts straight before engaging our mouths.
We quickly slipped away under the pretext of ‘going to check for leaks in the pan room’ to find out what exactly is best practice for selecting a site for an adult IM injection in the buttocks.
Turns out she was right.

OUT: The Dorsogluteal IM injection site.

This site been used by nurses for years as the target of choice for IM injections.
It is found in the area of the superior lateral aspect of the gluteal muscles, commonly known as the ‘upper outer quadrant’.
It is located by dividing the buttock into four equal quadrants. This is usually done by drawing an imaginary cross (bisecting it vertically and horizontally).

Problems that have been identified with using this site include:

  • Presence of major nerves and blood vessels in this area, including the sciatic nerve and superior gluteal artery.
    It has been taught that you will probably avoid this by further dividing the upper outer quadrant into another quadrant and giving the injection into the upper outer of the upper outer.
    Despite this, there have been reports of injuries to the sciatic nerve leading to problems ranging from foot drop to paralysis of the lower limb.
  • Thickness of fat in this area. A number of studies have found that the depth of muscle in the dorsogluteal region is often greater then the length of a standard needle used for IM injections, resulting in a failure to achieve intramuscular deposition of the medication.
    In fact, one study found the success rate of IM injections to be 32% (which fell to 8% in female patients)!
    With the increasing incidence of obesity amongst our patients we are probably going to be delivering subcutaneous injections if we choose this location.
  • Pain receptors are located in the subcutaneous layer, not in muscle tissues and so medication delivered into this area may be more painful.
  • Dorsogluteal site has a decreased absorption rate increasing the possibility of a depot effect with drug build up and potential for overdose.

IN: The Ventrogluteal IM injection site.

The ventorgluteal (VG) site has less subcutaneous fat and a thicker muscle mass than the dorsogluteal site with an almost certain probability of penetrating muscle with a standard needle.
The VG site is also sparse of any major innervating nerves or blood vessels whilst remaining well perfused from smaller branches.

Locating the VG site.
The ventrogluteal site is located halfway between the hip and the head of the femur. One method to locate the correct site is:

  1. First, place the heel of your  hand (use your L hand if injecting into the patients R VG and vice-versa) over the patients greater trochanter, and feel for the anterior superior iliac spine with your index finger.
  2. The middle finger then slides across to make a peace-sign pointing up to the iliac crest.
  3. The injection site is in the middle of this peace-sign.
  4. Wipe site with alco-wipe in a circular motion and allow to dry.
  5. Use your peace sign to spread skin taut.
  6. Insert needle at 90 degree angle. Take care as you are inserting needle in proximity to your fingers.
  7. There is no evidence for the need to aspirate the plunger when using the VG site.
  8. Inject medication slowly (around 10 seconds per ml), remove needle quickly, and gently apply pressure to site for 10 seconds.

So, the ventrogluteal site is indeed the best practice location for delivering an adult IM injection.
You live and learn.

References:
Intramuscular injections: a review of best practice for mental health nurses:
COCOMAN A. & MURRAY J. (2008) Journal of Psychiatric and Mental Health Nursing 15, 424–434

Are techniques used for intramuscular injection based on research evidence? (NursingTimes.net)

31 Responses to “Where (exactly) to stick a needle into your patients bum.”

  1. I was taught at WSU some twenty years ago to place the index finger of your non dominant hand toward the greater trochanter of the femur and your thumb toward the posterior superior iliac crest. Those with large hands like me can usually place my finger and thumb over the landmarks. Just sayin’

  2. Let me say this about putting needles in the WRONG spot. I have lived my entire life with a weak left leg and partial foot drop, because of someone not taking the time to learn how to give a proper needle to a young child. (I was four) I had repeated surgeries, and unpleasant shock treatments, to try and fix this problem. It is worth the time and effort to learn to do this procedure correctly. The failure of that pediatric nurse, to learn and follow procedure, has impacted my life daily, and negatively, for my entire life. I cannot impress upon you strongly enough that everything you do affects those you care for, forever. Be CAREFUL, please!

  3. We have been teaching that for sometime to student nurses here in Glasgow

  4. Shows that we should be listening to the grads coming through. Makes sense that ,technically, they would be coming into nursing with the latest best practice/research. I seriously do not want to become one of “those” nurses who have done the same thing the same way for many years and wont listen to anyone younger or newer than me. Nursing is one of the fastest changing/evolving careers.

  5. very informative for my students ……thanks
    Nursing lecturer

  6. I am a nursing student and had the opportunity to administer my first ventrogluteal injection today during my clinical rotation in the ER. I have enjoyed this rotation now that I can actually perform a few tasks and feel somewhat helpful at times rather than a pure shadow.

    I have also created a website called EMThow for those interested in becoming an EMT. Check it out, let me know if you are interested in swapping links I think we could all use a little more website exposure.

    Keep up the good work, I love your site.

  7. Thanks for this, I give a lot of IM pabronex, we are told this has to be in the dorsogluteal site due to large volume and are taught to use upper outer of upper outer quadrant, looking for ways to make this safer.

  8. I have just graduated and was taught upper-outer quadrant.
    Seems not all unis are up with the changes. Although not surprising
    of the one I went to.

  9. Ian,
    It’s amazing what the new grads will teach you, huh? This happened to me earlier this year as well. I am so right-handed, I hated giving injections using ventrogluteal. Oh, well…I guess it’s not about me. ;)

  10. I’m doing one of the new entry to nursing masters courses. (I have a BSc in microbiology, but have decided to move away from the lab to work with people). The preferred site that we have been taught is the thigh, 1/3 of the way down.

    Reasons:
    A large muscle with the ability to disperse the medication
    Less likely to hit bone (a problem i see with using the ventrogluteal site)
    Less subcutaneous fat
    Less pain (as it is a large muscle, able to disperse the drug quicker)
    No requirement to expose patient’s buttocks

    • I understand that the thigh site is the anterior lateral thigh, thats where i go these days…but i prefer ventro-gluteal as rich blood supply, no bone…honest!
      actually the only place ive ever hit bone is the outer aspect middle 1/3 thigh! (on a very emaciated patient when I was a student 30 years ago!) practice has changed from the middle 1/3 outer aspect of thigh to the ant. lat thigh, a nice meaty bit!
      ventro-gluteal site doesn’t need buttocks to be exposed since it is quite high … long way from buttocks only needs top edge of trousers to be dropped…every one teaches different but i think the evidence for ventro-glut site is sound. and in practice it works…not painful at all.

  11. I was studying the BA of Nursing up until the end of 2009 to which I did a change of degree to journalism due to health issues that made me question if I could continue studying nursing. To make a long story short I have had positive comments from my cardiologist regarding my situation which should not be a concern from working in the field of nursing. That being said, I will have to see if the university will allow me to change back to nursing again or book me into a dementia unit :)

    In regards to the topic of the “intramuscular (IM) injection sites” the ventorgluteal site was taught when doing theoretical foundations in nursing. The textbook we used in this unit was Potter & Perry’s fundamentals of Nursing edn 2 (2005).

    On pages 868-869 it provides information regarding the various IM sites to which the ventorgluteal site is also shown in detail. This textbook should be available at most university libraries teaching nursing or tertiary hospital libraries. I think there are more current editions of this book as well which may pay to look at as well.

    Pete.

  12. Go the New Grads and Students! I was shown this technique by a group of 1st year students this week. Just goes to show how important it is to listen to ALL our colleagues, not just the old ones!. Will take some practice though.

  13. I got my BSN in 1991 in the US. We were taught the ventral gluteal technique, but I rarely, if ever, saw anyone use it.

  14. Just wanted to say that the ventrogluteal site is what was taught at my University in Canada as far back as 2001.

  15. Very useful, thanks. I will pass this on to some of my colleagues who do those psychiatric medication injections.
    One note re:”Pain receptors are located in the subcutaneous layer, not in muscle tissues and so medication delivered into this area may be more painful.”
    Yes there are pain fibers in muscles; otherwise, you would not have muscle aches and pains. IM injections can be painful, and it partly depends on what you are injecting, and also on how much volume and how rapidly you inject it. Here in the USA, doctors and nurses are so busy that not all are willing to take 30 seconds for a 3 ml. injection. The above quote should read,
    “the subcutaneous layer is highly innervated with pain fibers, more so compared to muscle tissues so that medication delivered into the subcutaneous tissue may be more painful.” My son brought this to my attention when he was studying high school biology. Another lesson from a student. He used the example of the pain from a skin abrasion compared to a more serious muscle injury. A minor abrasion can hurt a lot worse.
    By the way, I read a study some years ago comparing pain during vaccination. The group that was instructed to cough during the injection reported much less pain compared to the control group. I have tried this distraction technique with great success myself and try to pass it on to others.

  16. thanks…i was one of those taught upper outer quadrant too…i have had a hard time changing because i just didn’t feel like I was going to ever figure out the ventral gluteal area….thanks again!! great info

  17. ED nurse of 10 years now and that’s the first I’ve heard of it . . . ever! Makes sense to use that nice little superficial pocket of rump though – away from all the nasties. Cheers Ian – and go new grad nurses!

  18. Last year i attended a conference with approx 60 nurses.
    one presenter had a similar story such as yours, not one of the very experienced nurses put their hand up to admit they had no idea what he was talking about.
    Afterwards several conversations were overhead about “where do you stick it?”

    Big thumbs up to the new-grad who stood up & said something!

  19. I am glad that this method is discussed but a little bemused by the excitement about this great ‘discovery’. In Germany, we taught this method from the 1970s/80s onwards. You still need a needle of appropriate length, though!

    • Thanks! And that needle length for infant, child, adults is..?
      Also, I’d like to hear more distraction techniques or everyone. Coughing is new idea to me.

      • I get them to wiggle their toes. You can see the cogs of the brain going round but by the time they ask why? the injection is usually over.

  20. I was taught this as well. All other sites were actually discouraged to be honest (including the arm), and we’d better not even think about injecting in the bum!

  21. This is what uni’s are teaching in the US, too.

  22. I’m not a nurse, but I am always glad to hear that techniques are improving. We all have been patients and it is appreciated when the medical community shares better ways to do things. I hope this is a practice in the States. Haven’t had a shot in the bum for a while, so don’t know. Keep up the good work.

  23. Hey guys, thanks for the feedback/conversation!! Have a great day!

  24. I know the ventrogluteal site has been the preferred site taught in the US, for a while now. Good to know it’s now being used here as well. They should do a best practice on it to make it official. :)

  25. This is now taught in all Universities. We were told it was because too many nurses were sticking needles through the sciatic nerve. I’m glad you were brave enough to look it up Ian. On placements I had educators criticising the technique without doing their own research first.

    In regards to the reference to mental health, this is because they give more IMI then med/surg nurses now days.

  26. Hi Wendy, I was taught this way at James Cook Uni in QLD, I graduated in 2008, not sure how many other unis are teaching it this way though.

  27. The video idea would be great

  28. Hey Ian, wow, this would be a major change in practice and habit for me. I notice the reference is for mental health nurses. Have you read other research studies that back this one? Are any Uni’s now teaching this? One of your home videos would be fabbo on this. Thanks and cheers.

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