LETTERS

Training of nurses and Adverse allergic reactions after injections

This refers to a news report published in Daily DAWN related to deaths after administration of injection. There are frequent such reports published in the media that patient died because of giving wrong injection. Actually, large number of fatalities occur due to adverse allergic reactions after injection. I would like to point out that:

1. This death occurs because vast majority of nurses, their instructors in nurses training colleges and nursing sisters in teaching tertiary care and District and Tehsil Headquarter hospital and family physicians and nurses working in Private Hospitals do not know how to give test dose or testing for sensitivity to the drug to be injected.
2. I have been member of the inspection teams of University of Health Science, Lahore to inspect some Nursing Colleges and Schools. I used to ask the Tutors and Trainee nurses; how to test for sensitivity of the drug prior to its injection to the patient. None of them ever answered correctly.
3. The usual answer was that I will inject small amount of the drug
4. sub-cutaneously and then wait for ten to fifteen minutes for any allergic reaction to occur. Obviously, the answer was wrong.
5. The correct method is to inject the drug intra cutaneous also called intradermal and not sub-cutaneously. There is separate technique to give the test dose intracutaneous. Sub-Cutaneous means below the skin as we give insulin injection to diabetic patients. The intracutaneous or intra-dermal means to give the test dose in the skin.
6. The skin is tightened and test dose is injected as superficial as possible. When the drug is injected pits appear on the surface of the swelling, this indicates that test dose has been given intradermal/intracutaneous. Then a circle should be drawn exactly along the margins of the swelling which occurs in the skin due to injected test dose. Then wait for 30-45minutes to observe whether the swelling and redness goes out of drawn circle around the margin of the swelling or not. If the swelling remains with in the circle, then it is presumed that drug can be injected in the muscle or in the vein and that there is no danger of allergic reaction.
7. The deaths occurs because test dose is not injected intradermal by the nurses. If test dose is given subcutaneously, the swelling and the redness may not become evident as test dose is given too deep and swelling and redness do not manifest on the skin. This is the reason of deaths.
8. However, test dose for iron injections is not given intradermal as it will cause necrosis of skin. The test dose for iron injections is given by giving 1⁄2ml of the injection either by giving it intravenous or intramuscular according to whether the iron injection can be given intramuscular or intravenous.
9. There is need to arrange demonstration of correct technique of giving test dose in all hospitals of the Punjab and Pakistan. This will save lives of many patients.

Prof. Eice Muhammad,
Former: Principal of
Allama Iqbal Medical College, Lahore, Pakistan.
dr.eicemuhammad1944@gmail.com