Epinephrine auto-injector needle length

Abstract

Background: Epinephrine auto-injectors are expected to deliver the drug intramuscularly. Objective: To study whether injection through clothing influences the frequency of subcutaneous and intraosseous/ periosteal deposition of epinephrine. Methods: Skin to muscle and skin to bone distances were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, with high or low pressure on the ultrasound probe. The risk/percentage of subcutaneous and intraosseous/periosteal injections was calculated using the lower and upper limits for the authority-approved length of EAI needles as provided by two high pressure EAI manufacturers and one low pressure EAI manufacturer. The addition winter clothing on the delivery of epinephrine was illustrated by comparing drug delivery fissue depth with no clothes. Furthermore, the riof non-intramuscular delivery for the shortest and longest approved needle length was calculated. Results: When using EpipenJr ® in children < 15 kg the risk of intraosseous/periostal injection was reduced from 1% and 59% for the shortest and longest approved needle length to 0 and 15% with winter clothes. The Auvi-Q ® 0.1 mg had no risk of intraosseous/periosteal injection. However, the subcutaneous deposition risk increased from 94% and 28% to 100% and 99% with winter clothes. The risk of subcutaneous injection using EpipenJr ® in the youngest children increased from 13% and 0% to 81% and 1% with winter clothes, and with Epipen ® in adults from 45% and 17% to 60% and 38%. Emerade ® , had a risk of subcutaneous injection in adults increasing from 14% and 10% to 28% and 21% adding winter clothes. Conclusion: The risk of intraosseous/periosteal injections decreases and the risk of subcutaneous injection increases when injecting through winter clothes for all EAIs.

Food-Induced Anaphylaxis among Children Weighing &#x3c;15 kg: A Single-Center Case Series of the Pediatric Emergency Department

“…However, there are distinct issues with the needle length and epinephrine dose delivered by EAIs in children who weigh <15 kg [1]. Dreborg et al [10][11][12][13] reported concerns about subcutaneous and intraosseous/ periosteal epinephrine injections by high-pressure EAIs (HPEAIs) in children in a study that used ultrasound to measure the distance from the skin to the muscle and bone. A study by Kim et al [14] showed that children with food allergies who weigh <15 kg, especially <10 kg, have shorter skin-to-bone distances, and are at high risk of intraosseous/periosteal injections when using HPEAIs, such as EpiPen ® Jr or Allerject ® (0.15 mg), which are widely prescribed for pediatric patients with anaphylaxis.…”

Epinephrine Auto-Injector Needle Length (Does Height or BMI add Valuable Information in Adults?)

“…injection, but there was some risk of subcutaneous injection especially in obese and overweight women. As illustrated in figure 4 and 5, obese women weighing more than 80 kg would not have any problems with longer than presently available needles up to 36 mm using LPEAI (=STBDmin) (7), corresponding to STMDmin 34 mm, and STMDmin with thick clothes, 31 mm.…”

“…However it has been proposed that the use of BMI would be a better instrument than weight and age (used in the UK) for selection of EAIs for treatment of anaphylaxis in the community. To avoid SC injection (7) without an increased risk of i.o./p. injection using LPEAIs, BMI can be used for selection of patients needing longer needles than presently available, Figure 5, right figures.…”

“…Despite that, the Cmax was reported both higher and earlier than injecting with syringe and needle. Until studies are available, we suggest that the STBD and STMD should be determined in all patients with ultrasoundand well defined pressure on te probe with the foot-print of the EAI to be prescribed, before prescribing an EAI (4,6,7,19), the STBD and STMD should be determined in all patients by ultrasoundand well defined pressure on the probe with the foot-print of the EAI to be prescribed, In summary, using HPEAIs in overweight and obese men, there was some risk of SC injectiuon, partly overcome by reducing the variation in needle length and overcome by using longer needles and or using less pressure on the EAI. In obese women, the majority would receive a SC injection.…”

“…In this paper, we will assess whether patients' BMI or height would improve the ability to identify adults who are at risk of SC or i.o./p. injection using the variation in needle length as reported by three EAIs presently available in North America and/or Europe (4) and the pressures used in the original studies by Kim et (7) by subtracting 2 mm from the penetrating needle length, i.e. 2 mm for the eye of the needle.…”