打针因为回血操作，我们遭了多少罪， 现在美国取消了！

肌内、皮下注射是临床诊疗、预防的常见操作，一般的技术要求是：右手不动，固定针头，左手抽动活塞，见无回血后以匀速推注药液。

就是这个“回血操作”，导致注射时间延长、疼痛增加、降低了治疗依从性，尤其对于孩子，更是如此！

佑好（小编）仔细搜索了“回血操作”的来源，发现都是出于《基础护理学》，它是注射操作的原则之一，也就是说是必须的。没有发现中国对于 “回血操作”的文献研究、其他规范性文件或指南。

然后佑好进一步搜索其他临床指南或者国家规范，发现《中国糖尿病药物注射技术指南（2016年版）》完全没有提到糖尿病皮下注射需要回血；国家卫计委发布的《预防接种工作规范（2016版）》（国卫办疾控发〔2016〕51号）中提到的皮下、肌内注射操作方法，也都没有了回血的操作，也是提都没提！

也就是说，最新的国家级文件都已经与国际接轨，废弃了“回血操作”。（出生在新时代的小朋友有福了，以后打预防针又快、又好，疼痛肯定也会减少，会不会打针也没那么恐怖了?但是如果不是打预防针，生病了去医院注射，是不是还是要遭罪啊！中国还没有文件说医疗肌内、皮下注射不需要“回血操作”呢。）

美国疾控中心最新的注射指南，更加明确，进一步提出在推荐的部位进行注射，不需要“回血操作”，并说明了理由。

基于临床及护理专家安全考虑的“回血操作”，如果弃之不用，到底会不会引起安全问题呢？

下文的作者也是站在类似角度提出了这个问题，并进行了基于证据的探讨。（佑好翻译水平有限，如有错漏，还请各位父老乡亲斧正!）

Evidence-based Injection Practice:

To Aspirate or Not

基于证据的注射实践：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

临床问题

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美国桑福德医疗中心），对于所有接受注射的患者来说，取消皮下或肌内注射之前的“回血操作”（除了背侧臀肌注射点）是否是一个安全措施？

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.

桑福德的政策规定，除了肝素和胰岛素之外，所有肌内注射（IM）和皮下注射（SQ）之前均要实施“回血操作”。我们在桑福德的实际操作与CDC（美国疾病控制与预防中心，其发布的规范或标准，全美医生都要遵循<译者注>）推荐的方法不一致，CDC推荐注射前不需要实施“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.

通过查阅文献，发现基于事实依据的操作项目Iowa模式被使用，形成了一个有教育意义的报告呈给了CRC（临床伦理委员会），并建议调整政策，随后CRC颁布执行了新政策。这项新的改变被CRC、Nursing Senate and unit meetings（护理协会和相关机构会议）传达。

Review of Literature

文献综述

External Evidence

外部证据

ØThereis lack of published data regarding syringe aspiration ⁽²⁾。

Ø 目前缺乏有关注射 “回血操作”公开报道的数据⁽²⁾。

Ø Thereis no reported evidence that aspiration with or without blood return

Ø 没有证据表明：“回血操作”抽到了血或没有抽到血。

Ø Eliminationof the aspiration technique has potential to:

Ø 取消“回血操作”有潜在价值:

•Reduce injection duration time

•减少注射持续时间

•Decrease injection pain

•减少注射疼痛

•Increase medication injection compliance ⁽³⁾

•增加药物注射顺应性⁽³⁾

Ø Aspirationduring SQ or IM injection (except for the dorsal gluteal) is not necessarysince there are no major blood vessels in these sites.^（4）

Ø 除背侧臀肌外，皮下或肌内注射期间的“回血操作”是不必要的，因为这些部位没有大的血管。⁽⁴⁾

Ø Dorsalgluteal site is not recommended for IM injection because of the sciatic nerveand vessels in the area.

Ø 由于坐骨神经和血管的存在，因此背侧臀肌是不建议实施肌内注射的

•ventrogluteal,deltoid, and vastus lateralis are the preferred sites for IM injections sincethey avoid  nerves and blood vessels.⁽¹⁾

•侧臀、三角肌和股肌外侧是肌内注射的首选部位，因为它们避开了神经和血管。

Ø Recommendedaspiration injection duration time of 5-10 seconds for confirmation of  no blood return is not performedconsistently. ⁽³⁾

Ø “回血操作”的目的是确认没有血液回流，推荐操作时间需持续5-10秒，但这并没有得到完全的执行。

Ø 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⁾

Ø CDC（美国疾病控制与预防中心）推荐，在注射疫苗或药物之前，“回血操作”是不必要的，因为在推荐的注射部位没有大的血管，而且“回血操作”的过程对小儿可能更加痛苦。⁽¹⁾

Ø Overa 4-year period 36,000 allergy injections were administered using aspirationfor blood return before administration with no blood aspirated during thoseinjections. ⁽⁵⁾

Ø 一个为期超过四年的项目被执行，36000名患者在进行过敏注射时进行“回血操作”，没有人被抽出血液。

Practice Change &Implementation

操作改变和实施

1.Apolicy change was recommended and implemented through the Clinical ReasoningCommittee:

1、CRC（临床伦理委员会）推荐和实施政策变更：

Ø Foradministration of subcutaneous (SQ) and intramuscular (IM) medications, proceedaccording to urses’ Guide to Clinical Procedures except for the followingsteps:

Ø 对于皮下和肌内注射的实施，除了以下步骤，都按照临床操作指南进行:

Ø AdministerSQ injections in the various sites depicted in Nurses’ Guide to ClinicalProcedures but aspiration prior to injection is not recommended.

Ø 在护理临床操作指南中描述的各个部位实施皮下注射之前，不推荐实施“回血操作”。

Ø 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.

Ø 在护理临床操作指南中描述侧臀、三角肌和股肌外侧部位的肌内注射之前，不推荐“回血操作”。除非药品说明书中有特别说明，否则不建议注射到背侧臀肌，因为该部位靠近坐骨神经。如果选择背侧臀肌，则在注射前需要“回血操作”。

Ø AdministerSQ or IM vaccines without aspiration prior to injection ⁽¹⁾.

Ø 皮下或肌内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、这项操作改变是被CRC、Nursing Senate and unit meetings（护理协会和相关机构会议）传达。

Outcomes 结果

Preferred sites 优先位置

翻译水平有限，如有错漏，敬请斧正！

References

参考文献

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.