肌內(nèi)、皮下注射是臨床診療、預(yù)防的常見操作，一般的技術(shù)要求是：右手不動(dòng)，固定針頭，左手抽動(dòng)活塞，見無回血后以勻速推注藥液。
就是這個(gè)“回血操作”，導(dǎo)致注射時(shí)間延長(zhǎng)、疼痛增加、降低了治療依從性，尤其對(duì)于孩子，更是如此！
佑好（小編）仔細(xì)搜索了“回血操作”的來源，發(fā)現(xiàn)都是出于《基礎(chǔ)護(hù)理學(xué)》，它是注射操作的原則之一，也就是說是必須的。沒有發(fā)現(xiàn)中國對(duì)于 “回血操作”的文獻(xiàn)研究、其他規(guī)范性文件或指南。
然后佑好進(jìn)一步搜索其他臨床指南或者國家規(guī)范，發(fā)現(xiàn)《中國糖尿病藥物注射技術(shù)指南（2016年版）》完全沒有提到糖尿病皮下注射需要回血；國家衛(wèi)計(jì)委發(fā)布的《預(yù)防接種工作規(guī)范（2016版）》（國衛(wèi)辦疾控發(fā)〔2016〕51號(hào)）中提到的皮下、肌內(nèi)注射操作方法，也都沒有了回血的操作，也是提都沒提！
也就是說，最新的國家級(jí)文件都已經(jīng)與國際接軌，廢棄了“回血操作”。（出生在新時(shí)代的小朋友有福了，以后打預(yù)防針又快、又好，疼痛肯定也會(huì)減少，會(huì)不會(huì)打針也沒那么恐怖了?但是如果不是打預(yù)防針，生病了去醫(yī)院注射，是不是還是要遭罪??！中國還沒有文件說醫(yī)療肌內(nèi)、皮下注射不需要“回血操作”呢。）
美國疾控中心最新的注射指南，更加明確，進(jìn)一步提出在推薦的部位進(jìn)行注射，不需要“回血操作”，并說明了理由。
基于臨床及護(hù)理專家安全考慮的“回血操作”，如果棄之不用，到底會(huì)不會(huì)引起安全問題呢？
下文的作者也是站在類似角度提出了這個(gè)問題，并進(jìn)行了基于證據(jù)的探討。（佑好翻譯水平有限，如有錯(cuò)漏，還請(qǐng)各位父老鄉(xiāng)親斧正!）
Evidence-based Injection Practice:
To Aspirate or Not
基于證據(jù)的注射實(shí)踐：回血是否必要
Deb Hettinger BS RN Clinical Education &Training Specialist;
Priscilla Jurkovich MSN, RN, CNORClinical Nurse Educator
SanfordMedical Center, Sioux Falls, SD
PICO Question
臨床問題
AtSMC, will the elimination of aspiration prior to subcutaneous or intramuscularinjections (except for those given in the dorsal gluteal site) remain a safepractice for all patients receiving injections?
在桑福德（SMC，Sanford USD Medical Center美國桑福德醫(yī)療中心），對(duì)于所有接受注射的患者來說，取消皮下或肌內(nèi)注射之前的“回血操作”（除了背側(cè)臀肌注射點(diǎn)）是否是一個(gè)安全措施？
Abstract Summary
摘要
The Sanford USD Medical Center policystated to aspirate for all intramuscular (IM) injections and subcutaneous (SQ)injections except for heparin and insulin. Our practice at SUSDMC was notconsistent with the Center for Disease Control (CDC) recommendations to notaspirate prior to injection.
桑福德的政策規(guī)定，除了肝素和胰島素之外，所有肌內(nèi)注射（IM）和皮下注射（SQ）之前均要實(shí)施“回血操作”。我們?cè)谏８５碌膶?shí)際操作與CDC（美國疾病控制與預(yù)防中心，其發(fā)布的規(guī)范或標(biāo)準(zhǔn)，全美醫(yī)生都要遵循<譯者注>）推薦的方法不一致，CDC推薦注射前不需要實(shí)施“回血操作”。
Areview of literature was performed . The Iowa Model for Evidence-Based PracticeProjects was used. An educational presentation was developed for the ClinicalReasoning Committee (CRC). A policy change was recommended and subsequentlyimplemented through the CRC. This change in practice was communicated throughCRC,NursingSenate and unit meetings.
通過查閱文獻(xiàn)，發(fā)現(xiàn)基于事實(shí)依據(jù)的操作項(xiàng)目Iowa模式被使用，形成了一個(gè)有教育意義的報(bào)告呈給了CRC（臨床倫理委員會(huì)），并建議調(diào)整政策，隨后CRC頒布執(zhí)行了新政策。這項(xiàng)新的改變被CRC、Nursing Senate and unit meetings（護(hù)理協(xié)會(huì)和相關(guān)機(jī)構(gòu)會(huì)議）傳達(dá)。
Review of Literature
文獻(xiàn)綜述
External Evidence
外部證據(jù)
?Thereis lack of published data regarding syringe aspiration (2)。
? 目前缺乏有關(guān)注射 “回血操作”公開報(bào)道的數(shù)據(jù)(2)。
? Thereis no reported evidence that aspiration with or without blood return
? 沒有證據(jù)表明：“回血操作”抽到了血或沒有抽到血。
? Eliminationof the aspiration technique has potential to:
? 取消“回血操作”有潛在價(jià)值:
?Reduce injection duration time
?減少注射持續(xù)時(shí)間
?Decrease injection pain
?減少注射疼痛
?Increase medication injection compliance (3)
?增加藥物注射順應(yīng)性(3)
? Aspirationduring SQ or IM injection (except for the dorsal gluteal) is not necessarysince there are no major blood vessels in these sites.（4）
? 除背側(cè)臀肌外，皮下或肌內(nèi)注射期間的“回血操作”是不必要的，因?yàn)檫@些部位沒有大的血管。(4)
? Dorsalgluteal site is not recommended for IM injection because of the sciatic nerveand vessels in the area.
? 由于坐骨神經(jīng)和血管的存在，因此背側(cè)臀肌是不建議實(shí)施肌內(nèi)注射的
?ventrogluteal,deltoid, and vastus lateralis are the preferred sites for IM injections sincethey avoid nerves and blood vessels.(1)
?側(cè)臀、三角肌和股肌外側(cè)是肌內(nèi)注射的首選部位，因?yàn)樗鼈儽荛_了神經(jīng)和血管。
? Recommendedaspiration injection duration time of 5-10 seconds for confirmation of no blood return is not performedconsistently. (3)
? “回血操作”的目的是確認(rèn)沒有血液回流，推薦操作時(shí)間需持續(xù)5-10秒，但這并沒有得到完全的執(zhí)行。
? Centerfor Disease Control (CDC) recommends that aspiration before injection ofvaccines or oxoids is not necessary because no large blood vessels are presentat the recommended injection sites, and a process that includes aspirationmight be more painful for infants. (1)
? CDC（美國疾病控制與預(yù)防中心）推薦，在注射疫苗或藥物之前，“回血操作”是不必要的，因?yàn)樵谕扑]的注射部位沒有大的血管，而且“回血操作”的過程對(duì)小兒可能更加痛苦。(1)
? Overa 4-year period 36,000 allergy injections were administered using aspirationfor blood return before administration with no blood aspirated during thoseinjections. (5)
? 一個(gè)為期超過四年的項(xiàng)目被執(zhí)行，36000名患者在進(jìn)行過敏注射時(shí)進(jìn)行“回血操作”，沒有人被抽出血液。
Practice Change &Implementation
操作改變和實(shí)施
1.Apolicy change was recommended and implemented through the Clinical ReasoningCommittee:
1、CRC（臨床倫理委員會(huì)）推薦和實(shí)施政策變更：
? Foradministration of subcutaneous (SQ) and intramuscular (IM) medications, proceedaccording to urses’ Guide to Clinical Procedures except for the followingsteps:
? 對(duì)于皮下和肌內(nèi)注射的實(shí)施，除了以下步驟，都按照臨床操作指南進(jìn)行:
? AdministerSQ injections in the various sites depicted in Nurses’ Guide to ClinicalProcedures but aspiration prior to injection is not recommended.
? 在護(hù)理臨床操作指南中描述的各個(gè)部位實(shí)施皮下注射之前，不推薦實(shí)施“回血操作”。
? AdministerIM injections into the deltoid, vastus lateralis or ventrogluteal sites asdepicted in the Nurses’ Guide to Clinical Procedures. Aspiration prior toinjection in these sites is not recommended.Unless it is indicated in thepackage insert for a specific medication, injection into the dorsal gluteal isnot recommended since this site is close to the sciatic nerve. If the dorsalgluteal site is selected, aspirate prior to the injection.
? 在護(hù)理臨床操作指南中描述側(cè)臀、三角肌和股肌外側(cè)部位的肌內(nèi)注射之前，不推薦“回血操作”。除非藥品說明書中有特別說明，否則不建議注射到背側(cè)臀肌，因?yàn)樵摬课豢拷巧窠?jīng)。如果選擇背側(cè)臀肌，則在注射前需要“回血操作”。
? AdministerSQ or IM vaccines without aspiration prior to injection (1).
? 皮下或肌內(nèi)注射疫苗之前不需要“回血操作”。
2. This change in practice was communicated through CRC,Nursing Senate and unit meetings.
2、這項(xiàng)操作改變是被CRC、Nursing Senate and unit meetings（護(hù)理協(xié)會(huì)和相關(guān)機(jī)構(gòu)會(huì)議）傳達(dá)。
Outcomes 結(jié)果
Preferred sites 優(yōu)先位置
翻譯水平有限，如有錯(cuò)漏，敬請(qǐng)斧正！
References
參考文獻(xiàn)
1.General Recommendations on Immunization: Recommendations of the AdvisoryCommittee on Immunization Practice (ACIP). MMWR; January 28,2011, 60 (RR02);1-60.
2.Crawford, Ceclia, Johnson, Joyce. To Aspirate or Not to Aspirate: That is theQuestions: An Integrative Review of Evidence. STTI International NursingResearch Congress. Vancouver, July 2009.
3.Ipp, M., Taddio, A., Sam, J., Goldbach, M., &Parking, P.C. (2007). Vaccinerelated pain: randomized controlledtrial of two injection technique. Archives of Disease in Childhood, 92,1105-1108.
4.Middleton, D.B., Zimmerman, R.K. & Mitchell, K.B (2003). Vaccine schedulesand procedures, 2003. The Journal of Family Practice, 52 (1), S36-S46.
5.Waibel KH. Aspiration before immunotherapy injection is not required. JAllergyClin Immunol 2006; 118: 525-6.
