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 Health  Vol.10 No.3 , March 2018
Efficacy and Safety in Intramuscular Injection Techniques Using Ultrasonographic Data
Abstract: Delivered by intramuscular (IM) injections, Long Acting Injections (LAI), offering comparatively long term medicinal effects from several weeks to several months, are gaining much attention. The aim of this article was to indicate a safe and effective IM injection technique based on evidenced data derived from ultrasonographic data. Accurate anatomical knowledge is necessary in order to administer IM injections. It is possible to gain an adequate understanding of injection site anatomical structures by using ultrasound diagnostic devices. In particular, ultrasonography offers real-time diagnostic data allowing for observation of injection site, subcutaneous tissues, fat layers, muscle membrane, muscles and bones. To deliver the drug accurately into the muscle is essential, to achieve maximum drug efficacy and prevent injection site reactions. Therefore, when administering IM injections to the buttocks area, a suitable injection needle between 23G 25 mm to 21G or 22G 38 mm must be chosen depending on physique and drug characteristics. Needles determined as safe and effective through ultrasonographic evidence are needed such as in the case of a deltoid injection site, in which a 23G 25 mm injection needle is used in the absence of notable obesity. Not only the needle type is essential, but also the IM procedure itself. It is important to stretch the skin, inserting the needle at 90 degree angle to ensure depth of needle insertion to the muscle. Until new con-firmed evidence becomes available, it is necessary to increase the understanding of injection site selection methods, needle insertion depth, needle angle, and established IM injection techniques. The application of ultrasound devices in the development of next-generation techniques for IM injection is promising. Importantly, these techniques provide critical information from a risk management perspective.
Cite this paper: Tanioka, T. , Takase, K. , Yasuhara, Y. , Zhao, Y. , Noda, C. , Hisashige, S. and Locsin, R. (2018) Efficacy and Safety in Intramuscular Injection Techniques Using Ultrasonographic Data. Health, 10, 334-350. doi: 10.4236/health.2018.103027.
References

[1]   Brissos, S., Veguilla, M.R., Taylor, D. and Balanzá-Martinez, V. (2014) The Role of Long-Acting Injectable Antipsychotics in Schizophrenia: A Critical Appraisal Psychopharmacology. Therapeutic Advances in Psychopharmacology, 4, 198-219.
https://doi.org/10.1177/2045125314540297

[2]   Choktanasiri, W., Boonkasemsanti, W., Sittisomwong, T., Kunathikom, S., Suksompong, S., Udomsubpayakul, U. and Rojanasakul, A. (1996) Long-Acting Triptorelin for the Treatment of Endometriosis. International Journal of Gynecology & Obstetrics, 54, 237-243.
https://doi.org/10.1016/0020-7292(96)02698-7

[3]   Kaunitz, A.M. (1998) Injectable Depot Medroxyprogesterone Acetate Contraception: An Update for U.S. Clinicians. International Journal of Fertility and Women’s Medicine, 43, 73-83.

[4]   Ravenstijn, P., Remmerie, B., Savitz, A., Samtani, M.N., Nuamah, I., Chang, C.T., De Meulder, M., Hough, D. and Gopal, S. (2016) Pharmacokinetics, Safety, and Tolerability of Paliperidone Palmitate 3-Month Formulation in Patients with Schizophrenia: A Phase-1, Single-Dose, Randomized, Open-Label Study. The Journal of Clinical Pharmacology, 56, 330-339. https://doi.org/10.1002/jcph.597

[5]   Takada, S. and Kawanishi, C. (2006) Injection Skills Based upon Evidence. Nakayama Shoten Co. Ltd., Tokyo, 123-128. (In Japanese)

[6]   Hamann, G.L., Egan, T.M., Wells, B.G. and Grimmig, J.E. (1990) Injection Site Reactions after Intramuscular Administration of Haloperidol Decanoate 100 mg/mL. The Journal of Clinical Psychiatry, 51, 502-504.

[7]   Duque, F.L.V. and Chagas, C.A.A. (2009). Intramuscular Accident with Drug Injection in the Deltoid Muscle: Local and Distant Lesions, Review of 32 Cases. Jornal Vascular Brasileiro, 8, 238-246. https://doi.org/10.1590/S1677-54492009000300009

[8]   Mishara, P. and Stringer, M.D. (2010) Sciatic Nerve Injury from Intramuscular Injection: A Persistent and Global Problem. The International of Journal of Clinical Practice, 64, 1573-1579. https://doi.org/10.1111/j.1742-1241.2009.02177.x

[9]   Cook, I.F. (2011) An Evidence Based Protocol for the Prevention of Upper Arm Injury Related to Vaccine Administration (UAIRVA). Human Vaccines, 7, 845-848.
https://doi.org/10.4161/hv.7.8.16271

[10]   Jones, J.C., Day, J.C., Taylor, J.R. and Thomas, C.S. (1998) Investigation of Depot Neuroleptic Injection Site Reactions. Psychiatry Bulletin, 22, 605-607.
https://doi.org/10.1192/pb.22.10.605

[11]   Zhao, Y., Tanioka, T., Yasuhara, Y., Takase, K., Tsuboi, S., Fujita, K., Locsin, R. and Iwata, N. (2017) Effects of Depth of Needle Insertion with Risperidone Long-Acting Injectable in Persons with Schizophrenia: A Randomized Double-Blind Study. Open Journal of Psychiatry, 7, 374-385. https://doi.org/10.4236/ojpsych.2017.74031

[12]   Hara, Y. and Shinozaki, E. (2017) Research on Clinical Nurses’ Intramuscular Injection Techniques and the Induration Site with Intramuscular Injection of an Oil-Based Solution. Japanese Journal of Nursing Art and Science, 16, 51-60. (In Japanese)

[13]   Palma, S. and Strohfus, P. (2013) Are IM Injections IM in Obese and Overweight Females? A Study in Injection Technique. Applied Nursing Research, 26, e1e4.
https://doi.org/10.1016/j.apnr.2013.09.002

[14]   Masuda, S., Tanioka, T., Yasuhara, Y., Tanioka, T., Atsuta, A., Motoki, K., Takase, K. and Locsin, R. (2016) Comparison of Gluteal Muscle Intramuscular Injection Sites of Japanese Healthy Subjects: Considerations for Optimal Insertion of Injection Needle Length. Open Journal of psychiatry, 6, 203-212.
https://doi.org/10.4236/ojpsych.2016.62025

[15]   Sakamaki, S., Yasuhara, Y., Motoki, K., Takase, K., Tanioka, T. and Locsin, R. (2013) The Relationship between Body Mass Index, Thickness of Subcutaneous Fat, and the Gluteus Muscle as the Intramuscular Injection Site. Health, 5, 1443-1448.
https://doi.org/10.4236/health.2013.59196

[16]   Wynadena, D., Tohotoa, J., Omari, O.A.L., Happell, B., Heslop, K., Barrd, L. and Sourinathand, V. (2015) Administering Intramuscular Injections: How Does Research Translate into Practice over Time in the Mental Health Setting? Nurse Education Today, 35, 620-624. http://dx.doi.org/10.1016/j.nedt.2014.12.008

[17]   Yasuhara, Y., Tanioka, T. Takase, K., Zhao, Y., Motoki, K. and Azekawa, T. (2017) Evaluations of Muscle Echogenicities in Patients Treated with Second Generation Long Acting Injectable Antipsychotics. Neurosonology, 30, 13-17.

[18]   Tanioka, T., Sakamaki, S., Yasuhara, Y., Tomotake, M., Takase, K., Watari, C., Makiguchi, K., Locsin, R., Motoki, K. and Inui, T. (2013) Optimal Needle Insertion Length for Intramuscular Injection of Risperidone Long-Acting Injectable (RLAI). Health, 5, 1939-1945. https://doi.org/10.4236/health.2013.512262

[19]   Yasuhara, Y., Hirai, E., Sakamaki, S., Tanioka, T., Motoki, K., Takase, K., Locsin, R., Kawanishi, C., Inui, T., Watari, C. and Makiguchi, K. (2012) Using Ultrasonography in Evaluating the Intramuscular Injection Techniques Used for Administering Drug Treatments to Schizophrenic Patients in Japan. The Journal of Medical Investigation, 59, 213-219.

[20]   Masuda, S., Sakamaki, S., Yasuhara, Y., Zhao, Y., Takase, K., Kai, Y., Tanioka, T. and Locsin, R. (2016) Explanatory Variables as Evidence for Precision in Intramuscular Long-Acting Injections of Patients with Schizophrenia. Open Journal of Psychiatry, 6, 125-134.
https://doi.org/10.4236/ojpsych.2016.61015

[21]   Tanioka, T. and Yasuhara, Y., Editorial Supervision (2016) Pocket Guide; Points for Intramuscular Injection Long Acting Injectables (LAI). Janssen Pharma Co., Ltd., Tokyo. (In Japanese)

[22]   Iwanaga, H. and Takayama, S. (2003) Study of the Suitable Sites for the Intramuscular Injection into the Deltoid Muscle or the Gluteus Medius Muscle. Tokai University, School of Health Sciences Bulletin, 9, 29-33. (In Japanese)

[23]   Pandian, J.D., Bose, S., Daniel, V., Singh, Y. and Abraham, A.P. (2006) Nerve Injuries Following Intramuscular Injections: A Clinical and Neurophysiological Study from Northwest India. Journal of the Peripheral Nervous System, 11, 165-171.
https://doi.org/10.1111/j.1085-9489.2006.00082.x

[24]   Cocoman, A. and Murray, J. (2008) Intramuscular Injections: A Review of Best Practice for Mental Health Nurses. Journal of Psychiatric and Mental Health Nursing, 15, 424-434. https://doi.org/10.1111/j.1365-2850.2007.01236.x

[25]   Small, S.P. (2004) Preventing Sciatic Nerve Injury from Intramuscular Injections: Literature Review. Journal of Advanced Nursing, 47, 287-296.
https://doi.org/10.1111/j.1365-2648.2004.03092.x

[26]   Cocoman, A. and Murray, J. (2010) Recognizing the Evidence and Changing Practice on Injection Sites. British Journal of Nursing, 19, 1170-1174.
https://doi.org/10.12968/bjon.2010.19.18.79050

[27]   Nicoll, L.H. and Hesby A. (2002) Intramuscular Injection: An Integrative Research Review and Guideline for Evidence-Based Practice. Applied Nursing Research, 15, 1490-1162. https://doi.org/10.1053/apnr.2002.34142

[28]   Coskun, H., Kilic, C. and Senture, C. (2016) The Evaluation of Dorsogluteal and Ventrogluteal Injection Sites: A Cadaver Study. Journal of Clinical Nursing, 25, 1112-1119.
https://doi.org/10.1111/jocn.13171

[29]   Bodor, M. and Montalvo, E. (2007) Vaccination-Related Shoulder Dysfunction. Vaccine, 25, 585-587. https://doi.org/10.1016/j.vaccine.2006.08.034

[30]   Takahashi, Y., Kikuchi, K., Miura, N. and Ishida, Y. (2014) Appropriate Needle Insertion Depth for Intramuscular Injection Based on Assessment of BMI. Journal of Japan Academy of Nursing Science, 34, 36-45. (In Japanese)

[31]   Nakajima, Y., Mukai, K., Takaoka, K., Hirose, T., Morishita, K., Yamamoto, T., Yoshida, Y., Urai, Y. and Nakatani, T. (2017) Establishing a New Appropriate Intramuscular Injection Site in the Deltoid Muscle. Human Vaccines & Immunotherapeutics, 13, 2123-2129.
https://doi.org/10.1080/21645515.2017.1334747

[32]   Haramati, N., Lorans, R., Lutwin, M. and Kaleya, R.N. (1994) Injection Granulomas. Intramuscle or Intrafat? Archives of Family Medicine, 3, 146-148.
https://doi.org/10.1001/archfami.3.2.146

[33]   Kikuchi, K., Takahashi, Y., Oyama, N. and Ishida, Y. (2009) Needle Length Required for Intramuscular Injection Skills: Evidence-Based Nursing. Japanese Journal of Nursing Art and Science, 8, 66-75. (In Japanese)

[34]   Sato, Y., Narita, S. and Nakano, T. (2005) A Study on the Method of Choosing Intramuscular Injection Site in the Buttocks. Japanese Journal of Nursing Research, 28, 45-52. (In Japanese)

[35]   Takahashi, Y., Kikuchi, K., Oyama, N., Yoko, I. and Sato, F. (2007) Investigation about the Intramuscular Injection Method Prevent Medication from Leaking Back onto the Skin in Psychiatry. Journal of the Faculty of Nursing, Iwate Prefectural University, 9, 103-112. (In Japanese)

[36]   Chan, V.O., Colville, J., Persaud, T., Buckley, O., Hamilton, S. and Torreggiani, W.C. (2006) Intramuscular Injections into the Buttocks: Are They Truly Intramuscular? European Journal of Radiology, 58, 480-484.
https://doi.org/10.1016/j.ejrad.2006.01.008

[37]   Yasuhara, Y., Sakamaki, S., Tanioka, T., Motoki, K., Sasakawa, C., Takase, K. and Kawanishi, C. (2013) Optimal Length of Intramuscular Injection Needle and Drug Absorption by Ultrasound Evaluation. The Japan Academy of Neurosonology, 25, 91-94.

[38]   Gopal, S., Gassmann-Mayer, C., Palumbo, J., Samtani, M.N., Shiwach, R. and Alphs, L. (2010) Practical Guidance for Dosing and Switching Paliperidone Palmitate Treatment in Patients with Schizophrenia. Current Medical Research and Opinion, 26, 377-387.
https://doi.org/10.1185/03007990903482772

[39]   Sugawara, N., Sagae, T., Yasui-Furukori, N., Yamazaki, M., Shimoda, K., Mori, T., Sugai, T., Matsuda, H., Suzuki, Y., Ozeki, Y., Okamoto, K. and Someya, T. (2018) Effects of Nutritional Education on Weight Change and Metabolic Abnormalities among Patients with Schizophrenia in Japan: A Randomized Controlled Trial. Journal of Psychiatric Research, 97, 77-83.
https://doi.org/10.1016/j.jpsychires.2017.12.002

[40]   Suzuki, Y., Sugai, T., Fukui, N., Watanabe, J., Ono, S., Tsuneyama, N., Saito, M. and Someya, T. (2014) High Prevalence of Underweight and Undernutrition in Japanese Inpatients with Schizophrenia. Psychiatry and Clinical Neurosciences, 68, 78-82.
https://doi.org/10.1111/pcn.12082

[41]   Sakamaki, S., Zhao, Y., Yasuhara, Y., Motoki, K., Takase, K., Abe, H., Miyazaki, K. and Tanioka, T. (2014) Consideration of Long Acting Injection Procedure into the Gluteal Medius Muscle by Real-Time B-Mode Ultrasonography: Case Reports of Patients Who Observed Injection Site Reactions or Blood Back-Flow. Japanese Journal of Clinical Psychopharmacology, 17, 253-260. (In Japanese)

[42]   Céspedes, I., Ophir, J., Ponnekanti, H. and Maklad, N. (1993) Elastography: Elasticity Imaging Using Ultrasound with Application to Muscle and Breast in Vivo. Ultrasonic Imaging, 15, 73-88. https://doi.org/10.1177/016173469301500201

[43]   Kikuchi, K., Oyama, N., Takahashi, Y. and Ishida, Y. (2009) Analysis of Practical Knowledge of Deltoid Intramuscular Injections by Nurses in Hospitals. Journal of the Faculty of Nursing, Iwate Prefectural University, 11, 79-85. (In Japanese)

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https://rcni.com/sites/rcn_nspace/files/ns.29.4.52.e9183.pdf

[45]   Brissos, S., Veguilla, M.R., Taylor, D. and Balanzá-Martinez, V. (2014) The Role of Long-Acting Injectable Antipsychotics in Schizophrenia: A Critical Appraisal Psychopharmacology. Therapeutic Advances in Psychopharmacology, 4, 198-219.
https://doi.org/10.1177/2045125314540297

[46]   Choktanasiri, W., Boonkasemsanti, W., Sittisomwong, T., Kunathikom, S., Suksompong, S., Udomsubpayakul, U. and Rojanasakul, A. (1996) Long-Acting Triptorelin for the Treatment of Endometriosis. International Journal of Gynecology & Obstetrics, 54, 237-243.
https://doi.org/10.1016/0020-7292(96)02698-7

[47]   Kaunitz, A.M. (1998) Injectable Depot Medroxyprogesterone Acetate Contraception: An Update for U.S. Clinicians. International Journal of Fertility and Women’s Medicine, 43, 73-83.

[48]   Ravenstijn, P., Remmerie, B., Savitz, A., Samtani, M.N., Nuamah, I., Chang, C.T., De Meulder, M., Hough, D. and Gopal, S. (2016) Pharmacokinetics, Safety, and Tolerability of Paliperidone Palmitate 3-Month Formulation in Patients with Schizophrenia: A Phase-1, Single-Dose, Randomized, Open-Label Study. The Journal of Clinical Pharmacology, 56, 330-339. https://doi.org/10.1002/jcph.597

[49]   Takada, S. and Kawanishi, C. (2006) Injection Skills Based upon Evidence. Nakayama Shoten Co. Ltd., Tokyo, 123-128. (In Japanese)

[50]   Hamann, G.L., Egan, T.M., Wells, B.G. and Grimmig, J.E. (1990) Injection Site Reactions after Intramuscular Administration of Haloperidol Decanoate 100 mg/mL. The Journal of Clinical Psychiatry, 51, 502-504.

[51]   Duque, F.L.V. and Chagas, C.A.A. (2009). Intramuscular Accident with Drug Injection in the Deltoid Muscle: Local and Distant Lesions, Review of 32 Cases. Jornal Vascular Brasileiro, 8, 238-246. https://doi.org/10.1590/S1677-54492009000300009

[52]   Mishara, P. and Stringer, M.D. (2010) Sciatic Nerve Injury from Intramuscular Injection: A Persistent and Global Problem. The International of Journal of Clinical Practice, 64, 1573-1579. https://doi.org/10.1111/j.1742-1241.2009.02177.x

[53]   Cook, I.F. (2011) An Evidence Based Protocol for the Prevention of Upper Arm Injury Related to Vaccine Administration (UAIRVA). Human Vaccines, 7, 845-848.
https://doi.org/10.4161/hv.7.8.16271

[54]   Jones, J.C., Day, J.C., Taylor, J.R. and Thomas, C.S. (1998) Investigation of Depot Neuroleptic Injection Site Reactions. Psychiatry Bulletin, 22, 605-607.
https://doi.org/10.1192/pb.22.10.605

[55]   Zhao, Y., Tanioka, T., Yasuhara, Y., Takase, K., Tsuboi, S., Fujita, K., Locsin, R. and Iwata, N. (2017) Effects of Depth of Needle Insertion with Risperidone Long-Acting Injectable in Persons with Schizophrenia: A Randomized Double-Blind Study. Open Journal of Psychiatry, 7, 374-385. https://doi.org/10.4236/ojpsych.2017.74031

[56]   Hara, Y. and Shinozaki, E. (2017) Research on Clinical Nurses’ Intramuscular Injection Techniques and the Induration Site with Intramuscular Injection of an Oil-Based Solution. Japanese Journal of Nursing Art and Science, 16, 51-60. (In Japanese)

[57]   Palma, S. and Strohfus, P. (2013) Are IM Injections IM in Obese and Overweight Females? A Study in Injection Technique. Applied Nursing Research, 26, e1e4.
https://doi.org/10.1016/j.apnr.2013.09.002

[58]   Masuda, S., Tanioka, T., Yasuhara, Y., Tanioka, T., Atsuta, A., Motoki, K., Takase, K. and Locsin, R. (2016) Comparison of Gluteal Muscle Intramuscular Injection Sites of Japanese Healthy Subjects: Considerations for Optimal Insertion of Injection Needle Length. Open Journal of psychiatry, 6, 203-212.
https://doi.org/10.4236/ojpsych.2016.62025

[59]   Sakamaki, S., Yasuhara, Y., Motoki, K., Takase, K., Tanioka, T. and Locsin, R. (2013) The Relationship between Body Mass Index, Thickness of Subcutaneous Fat, and the Gluteus Muscle as the Intramuscular Injection Site. Health, 5, 1443-1448.
https://doi.org/10.4236/health.2013.59196

[60]   Wynadena, D., Tohotoa, J., Omari, O.A.L., Happell, B., Heslop, K., Barrd, L. and Sourinathand, V. (2015) Administering Intramuscular Injections: How Does Research Translate into Practice over Time in the Mental Health Setting? Nurse Education Today, 35, 620-624. http://dx.doi.org/10.1016/j.nedt.2014.12.008

[61]   Yasuhara, Y., Tanioka, T. Takase, K., Zhao, Y., Motoki, K. and Azekawa, T. (2017) Evaluations of Muscle Echogenicities in Patients Treated with Second Generation Long Acting Injectable Antipsychotics. Neurosonology, 30, 13-17.

[62]   Tanioka, T., Sakamaki, S., Yasuhara, Y., Tomotake, M., Takase, K., Watari, C., Makiguchi, K., Locsin, R., Motoki, K. and Inui, T. (2013) Optimal Needle Insertion Length for Intramuscular Injection of Risperidone Long-Acting Injectable (RLAI). Health, 5, 1939-1945. https://doi.org/10.4236/health.2013.512262

[63]   Yasuhara, Y., Hirai, E., Sakamaki, S., Tanioka, T., Motoki, K., Takase, K., Locsin, R., Kawanishi, C., Inui, T., Watari, C. and Makiguchi, K. (2012) Using Ultrasonography in Evaluating the Intramuscular Injection Techniques Used for Administering Drug Treatments to Schizophrenic Patients in Japan. The Journal of Medical Investigation, 59, 213-219.

[64]   Masuda, S., Sakamaki, S., Yasuhara, Y., Zhao, Y., Takase, K., Kai, Y., Tanioka, T. and Locsin, R. (2016) Explanatory Variables as Evidence for Precision in Intramuscular Long-Acting Injections of Patients with Schizophrenia. Open Journal of Psychiatry, 6, 125-134.
https://doi.org/10.4236/ojpsych.2016.61015

[65]   Tanioka, T. and Yasuhara, Y., Editorial Supervision (2016) Pocket Guide; Points for Intramuscular Injection Long Acting Injectables (LAI). Janssen Pharma Co., Ltd., Tokyo. (In Japanese)

[66]   Iwanaga, H. and Takayama, S. (2003) Study of the Suitable Sites for the Intramuscular Injection into the Deltoid Muscle or the Gluteus Medius Muscle. Tokai University, School of Health Sciences Bulletin, 9, 29-33. (In Japanese)

[67]   Pandian, J.D., Bose, S., Daniel, V., Singh, Y. and Abraham, A.P. (2006) Nerve Injuries Following Intramuscular Injections: A Clinical and Neurophysiological Study from Northwest India. Journal of the Peripheral Nervous System, 11, 165-171.
https://doi.org/10.1111/j.1085-9489.2006.00082.x

[68]   Cocoman, A. and Murray, J. (2008) Intramuscular Injections: A Review of Best Practice for Mental Health Nurses. Journal of Psychiatric and Mental Health Nursing, 15, 424-434. https://doi.org/10.1111/j.1365-2850.2007.01236.x

[69]   Small, S.P. (2004) Preventing Sciatic Nerve Injury from Intramuscular Injections: Literature Review. Journal of Advanced Nursing, 47, 287-296.
https://doi.org/10.1111/j.1365-2648.2004.03092.x

[70]   Cocoman, A. and Murray, J. (2010) Recognizing the Evidence and Changing Practice on Injection Sites. British Journal of Nursing, 19, 1170-1174.
https://doi.org/10.12968/bjon.2010.19.18.79050

[71]   Nicoll, L.H. and Hesby A. (2002) Intramuscular Injection: An Integrative Research Review and Guideline for Evidence-Based Practice. Applied Nursing Research, 15, 1490-1162. https://doi.org/10.1053/apnr.2002.34142

[72]   Coskun, H., Kilic, C. and Senture, C. (2016) The Evaluation of Dorsogluteal and Ventrogluteal Injection Sites: A Cadaver Study. Journal of Clinical Nursing, 25, 1112-1119.
https://doi.org/10.1111/jocn.13171

[73]   Bodor, M. and Montalvo, E. (2007) Vaccination-Related Shoulder Dysfunction. Vaccine, 25, 585-587. https://doi.org/10.1016/j.vaccine.2006.08.034

[74]   Takahashi, Y., Kikuchi, K., Miura, N. and Ishida, Y. (2014) Appropriate Needle Insertion Depth for Intramuscular Injection Based on Assessment of BMI. Journal of Japan Academy of Nursing Science, 34, 36-45. (In Japanese)

[75]   Nakajima, Y., Mukai, K., Takaoka, K., Hirose, T., Morishita, K., Yamamoto, T., Yoshida, Y., Urai, Y. and Nakatani, T. (2017) Establishing a New Appropriate Intramuscular Injection Site in the Deltoid Muscle. Human Vaccines & Immunotherapeutics, 13, 2123-2129.
https://doi.org/10.1080/21645515.2017.1334747

[76]   Haramati, N., Lorans, R., Lutwin, M. and Kaleya, R.N. (1994) Injection Granulomas. Intramuscle or Intrafat? Archives of Family Medicine, 3, 146-148.
https://doi.org/10.1001/archfami.3.2.146

[77]   Kikuchi, K., Takahashi, Y., Oyama, N. and Ishida, Y. (2009) Needle Length Required for Intramuscular Injection Skills: Evidence-Based Nursing. Japanese Journal of Nursing Art and Science, 8, 66-75. (In Japanese)

[78]   Sato, Y., Narita, S. and Nakano, T. (2005) A Study on the Method of Choosing Intramuscular Injection Site in the Buttocks. Japanese Journal of Nursing Research, 28, 45-52. (In Japanese)

[79]   Takahashi, Y., Kikuchi, K., Oyama, N., Yoko, I. and Sato, F. (2007) Investigation about the Intramuscular Injection Method Prevent Medication from Leaking Back onto the Skin in Psychiatry. Journal of the Faculty of Nursing, Iwate Prefectural University, 9, 103-112. (In Japanese)

[80]   Chan, V.O., Colville, J., Persaud, T., Buckley, O., Hamilton, S. and Torreggiani, W.C. (2006) Intramuscular Injections into the Buttocks: Are They Truly Intramuscular? European Journal of Radiology, 58, 480-484.
https://doi.org/10.1016/j.ejrad.2006.01.008

[81]   Yasuhara, Y., Sakamaki, S., Tanioka, T., Motoki, K., Sasakawa, C., Takase, K. and Kawanishi, C. (2013) Optimal Length of Intramuscular Injection Needle and Drug Absorption by Ultrasound Evaluation. The Japan Academy of Neurosonology, 25, 91-94.

[82]   Gopal, S., Gassmann-Mayer, C., Palumbo, J., Samtani, M.N., Shiwach, R. and Alphs, L. (2010) Practical Guidance for Dosing and Switching Paliperidone Palmitate Treatment in Patients with Schizophrenia. Current Medical Research and Opinion, 26, 377-387.
https://doi.org/10.1185/03007990903482772

[83]   Sugawara, N., Sagae, T., Yasui-Furukori, N., Yamazaki, M., Shimoda, K., Mori, T., Sugai, T., Matsuda, H., Suzuki, Y., Ozeki, Y., Okamoto, K. and Someya, T. (2018) Effects of Nutritional Education on Weight Change and Metabolic Abnormalities among Patients with Schizophrenia in Japan: A Randomized Controlled Trial. Journal of Psychiatric Research, 97, 77-83.
https://doi.org/10.1016/j.jpsychires.2017.12.002

[84]   Suzuki, Y., Sugai, T., Fukui, N., Watanabe, J., Ono, S., Tsuneyama, N., Saito, M. and Someya, T. (2014) High Prevalence of Underweight and Undernutrition in Japanese Inpatients with Schizophrenia. Psychiatry and Clinical Neurosciences, 68, 78-82.
https://doi.org/10.1111/pcn.12082

[85]   Sakamaki, S., Zhao, Y., Yasuhara, Y., Motoki, K., Takase, K., Abe, H., Miyazaki, K. and Tanioka, T. (2014) Consideration of Long Acting Injection Procedure into the Gluteal Medius Muscle by Real-Time B-Mode Ultrasonography: Case Reports of Patients Who Observed Injection Site Reactions or Blood Back-Flow. Japanese Journal of Clinical Psychopharmacology, 17, 253-260. (In Japanese)

[86]   Céspedes, I., Ophir, J., Ponnekanti, H. and Maklad, N. (1993) Elastography: Elasticity Imaging Using Ultrasound with Application to Muscle and Breast in Vivo. Ultrasonic Imaging, 15, 73-88. https://doi.org/10.1177/016173469301500201

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https://rcni.com/sites/rcn_nspace/files/ns.29.4.52.e9183.pdf

 
 
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