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June 2023, Volume 73, Issue 6

Research Article

Neuropathy following intramuscular injections: a clinical and neurophysiological study from a tertiary care centre in Pakistan

Adnan Tariq  ( Department of Neurology, King Edward Medical University (KEMU), Lahore, Pakistan. )
Ayesha Aslam  ( Department of Neurology, King Edward Medical University (KEMU), Lahore, Pakistan. )
Nukhbatullah Awan  ( ENT Department, King Edward Medical University, Lahore, Pakistan. )
Safia Bano  ( Department of Neurology, King Edward Medical University, Lahore, Pakistan. )
Ahsan Numan  ( Department of Neurology, King Edward Medical University, Lahore, Pakistan. )

Abstract

Objective: To assess the clinical and neurophysiological profile of peripheral nerve injuries in patients following intramuscular injections.

 

Method: The descriptive, cross-sectional study was conducted at the Department of Neurology, Mayo Hospital, Lahore, Pakistan, from July 2019 to January 2021, and comprised adult patients of either gender with isolated peripheral nerve injuries following intramuscular injections. Nerve conduction studies were performed for each patient. Data was analysed using SPSS 26.

 

Results: Of the 99 patients, 59(59.6%) were males and 40(40.4%) were females. The mean age was 26.7+/-18.1 years, 34(34.3%) patients were under weight and 78(78.8%) were either illiterate or had low literacy level. Radial nerve was involved in 56(56.6%) cases, followed by sciatic in 39(39.4%) and axillary nerve 4(4.04%). Overall, 14(14.14%) injection had been administered by doctors, while the other 85(85.85%) were given by paramadics. Marked reduction in compound muscle action potential 72(72.7%) and sensory nerve action potential 82(82.8%) was noted, while re-innervation was seen in 78(78.7%).

 

Conclusion: Intramuscular nerve injuries can be greatly minimised by spreading awareness regarding safe injection techniques and strict implementation of standard operating procedures in hospitals and clinics.

 

Key Words: Intramuscular injections, (M, Peripheral nerve injuries, PNI, Neuropathy.

 

(JPMA 73: 1179; 2023) DOI: 10.47391/JPMA.4794

Introduction

 

Intramuscular injection (IM) has been used for centuries as a mode of parenteral drug delivery. However, reasons for using the IM route for administration of drugs and the technique adopted vary worldwide.1 IM injection may be necessary when there is a need to ensure the delivery of medication, such as when the patient is uncooperative or non-responder to oral treatment or when oral administration is not possible.2 In developing countries, like Pakistan, injections are frequently used to treat common ailments. IM injections may damage peripheral nerves at the injection site.3 The World Health Organization (WHO) has estimated that nearly 16 billion injections are administered globally every year, but 90% of them are given in medical care and most of them are given unnecessarily.4

It is a dilemma of developing countries, such as Pakistan, that injections are frequently used to treat minor ailments, altogether ignoring the risks associated with it. This malpractice can be attributed to multiple factors, including cultural norms, social myths, misbeliefs, lack of education, unawareness and quackery, to name a few.1

Neurological sequelae can range from minor transient sensory disturbances to severe sensory disturbances and paralysis with poor recovery.5 The most common causes of injection nerve palsy are unnecessary injections, faulty techniques and administration of injections by unqualified personnel.6,7,8

Several mechanisms are associated with injection-related nerve injury, like direct needle trauma, toxic effects of injected agents on nerve fibres and surrounding tissues, nerve compression due to haematoma or oedema formation, and many others.

Among them, direct needle trauma is the most frequent factor. Therefore, sufficient knowledge of anatomy, an understanding of the injection procedure, and proper skills in needle placement are essential to avoid these complications.9,10

The current study was planned to assess the clinical and neurophysiological profile of peripheral nerve injuries (PNIs) in patients following IM injections.

 

Patients and Methods

 

The descriptive, cross-sectional study was conducted at the Department of Neurology, Mayo Hospital, Lahore, Pakistan, from July 2019 to January 2021. After approval form the institutional ethics review committee, the sample size was calculated with 95% confidence level, 9% absolute precision and expected percentage of PNIs 67% using the formula.11

n=Z21-a/2 .p(1-p)

       d2

where; Z21-a/2= confidence level, p= prevalence, q=1-p and d=absolute precision.

“Sample size determination in health studies” was used to calculate sample size.

Patients were collected by Non-probability consecutive sampling technique. Those included were adult patients of either gender with isolated PNIs following IM injections. Those who did not want to participate were excluded.

After taking informed consent from the patients, demographic data was collected using a predesigned proforma. Patients were specifically inquired about the site of injection and who had dispensed the injection. Patients who had neurological pain immediately or soon after IM injection in upper arm or buttock, or weakness of arm and foot were referred to the electromyography (EMG) laboratory. The nerve conduction study (NCS) was done using Cadwell Excel Electromyography (Kennewick, WA, United States). The electrophysiological findings were recorded, and compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) were categorised into grade I (amplitude not affected), grade II (amplitude 50-100% of the reference lower limit or 40-50% of the intact side) and grade III (amplitude <50% of the lower reference limit).12,13

Data was analysed using SPSS 26. Data was expressed as frequencies and percentages. The comparison of nerve damage among various factors was performed using the chi-square likelihood ratio test. P≤0.05 was considered statistically significant.

 

Results

 

Of the 105 patients enrolled, 99(94.3%) finished the study. Of them, 59(59.6%) were males and 40(40.4%) were females. The mean age was 26.7+/-18.1 years, 34(34.3%) patients were underweight and 78(78.8%) were either illiterate or had low literacy level. The cause of injection was analgesia for 58(58.6%), antibiotic 23(23.2%) and 13(13.1%) had no apparent reason. Also, 73(73.7%) had no knowledge of the drug administered, and 31(31.3%) had requested the injection themselves. Overall, 14(14.14%) injections had been administered by doctors, and 28(28.2%) injections had been administered in a hospital setting. Motor findings were noted in 32(32.3%) cases, while in 61(61.6%) case both motor and sensory clinical findings were noted (Table 1).

 

 

Radial nerve was involved in 56(56.6%) cases, followed by sciatic in 39(39.4%) and axillary nerve 4(4.04%) (Figure).

 

 

Gender was significant in terms of the nerve involved in the injury (p<0.05), while majority of the radial nerve damage was caused by dispensers and nurses (Table 2).

 

 

Marked reduction in CMAP 72(72.7%) and SNSP 82(82.8%) was noted, while re-innervation was seen in 78(78.7%) cases (Table 3).

 

 

Discussion

 

IM nerve injuries are a lingering problem even in this day and age. Of 16 billion injections administered worldwide annually, 90% given in curative care are unsafe and most of them are unnecessary.4 Nerve injuries are perceived to be a constant health and economic burden for patients and healthcare systems in developing countries, like Pakistan. In the current study, almost half (50%) of the patients affected with nerve injury routinely had IM injections for ailments, and 30% insisted on having an injection instead of tablet even without their physician’s recommendation. Analgesia was the most common cause for an IM injection, followed by antibiotic usage and antiemetic administration. The findings are similar to that of Pandian et al.11

In the current study, 53% patients had had injection from dispensers and nurses, and 70% had low or no basic education. Lack of education has an obvious association with poverty. In a study in India, 82% patients suffering from nerve injuries were associated with low socioeconomic status.11 Lack of education and poverty could be linked to the increased tendency to visit unqualified dispensers.14 A total of 73% patients in the current study had no information about the drug administered to them. This can be attributed to low education level. A similar study reported 18% cases with severe nerve injury were due to IM injections.15 The current study showed that most of the patients with PNIs were male (59.6%) and had low BMI (34.3%). The injuries may have been due to lack of protective pad of fat among such subjects.16 This male predominant trend was similarly seen in another study12.

The most common nerve affected was radial, followed by sciatic and axillary in the current study. This observation is contrary to those of other reported studies in which the sciatic nerve was more commonly affected than the radial nerve.14 The increased tendency of radial nerve damage in Pakistan could be due to reluctance for gluteal region exposure in Pakistani population attributable to religious and cultural norms.

In the current study, there was no significant association between clinical and electrophysiological findings. This is in contrast to a study in South Korea where significant association was found between the two.17 In contrast, other studies show no association between clinical and electrophysiological findings which is similar to the current study.12

The small sample size of the current study was a limitation, and, also, patients were not followed up to monitor progress of recovery in these cases.

 

Conclusion

 

IM nerve injuries can be greatly minimised by spreading awareness regarding safe injection techniques and strict implementation of standard operating procedures in hospitals and clinics across Pakistan.

 

Disclaimer: None.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

References

 

1.      Strohfus PK, Paugh O, Tindell C, Molina-Shaver P. Evidence calls for practice change in intramuscular injection techniques. J Nurs Educ Pract 2017; 8: 83.

2.      Theofiles M, Marcelin JR, Herges L, Marcelin A, Maxson J, Angstman KB. Intramuscular Ceftriaxone with Oral Antibiotic Therapy in the Treatment of Outpatient Cellulitis. J Infect Dis Ther 2016; 4: 284.

3.      Hewson DW, Bedforth NM, Hardman JG. Peripheral nerve injury arising in anaesthesia practice. Anaesthesia 2018; 73: 51-60.

4.      World Health Organization. WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care settings. World Health Organization; 2016. [Online] [Cited 2022 May 22]. Available from: URL:  https://apps.who.int/iris/handle/10665/250144.( 9789241549820-eng.pdf (who.int))

5.      Alves K, Godwin CL, Chen A, Akellot D, Katz JN, Sabatini CS. Gluteal fibrosis, post-injection paralysis, and related injection practices in Uganda: a qualitative analysis. BMC Health Serv Res 2018; 18: 892.

6.      Geyik S, Geyik M, Yigiter R, Kuzudisli S, Saglam S, Elci MA, et al. Preventing sciatic nerve injury due to intramuscular injection: ten-year single-center experience and literature review. Turk Neurosurg 2017; 27: 636-40.

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8.      Raju B, Ashraf O, Jumah F, Gowda NM, Gupta G, Sun H, et al. Nicolau Syndrome, Masquerader of Postinjection Sciatic Nerve Injury: Case Report and Review of Literature. World Neurosurg 2020; 143: 51-5.

9.      Kim HJ, Park SK, Park SH. Upper limb nerve injuries caused by intramuscular injection or routine venipuncture. Anesth Pain Med 2017; 12: 103-10.

10.    Casas-Arroyave FD, Ramírez-Mendoza E, Ocampo-Agudelo AF. Complications associated with three brachial plexus blocking techniques: Systematic review and meta-analysis. Rev Esp Anestesiol Reanim (Engl Ed) 2021; 68: 392-407.

11.    Pandian, J.D, Bose S, Daniel V, Singh Y, Abraham AP. Nerve injuries following intramuscular injections: a clinical and neurophysiological study from Northwest India. J Peripher Nerv Syst 2006; 11: 165-71.

12.    Fidancı H, Öztürk İ. The relationship between nerve conduction studies and neuropathic pain in sciatic nerve injury due to intramuscular injection. Korean J Pain 2021; 34: 124-31.

13.    Chen S, Andary M, Buschbacher R, Del Toro D, Smith B,  Yuen So, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve 2016; 54: 371-7.

14.    Wahidi N, Johnson KM, Brenzel A, Leon JD. Two sudden and unexpected deaths of patients with schizophrenia associated with intramuscular injections of antipsychotics and practice guidelines to limit the use of high doses of intramuscular antipsychotics. Case Rep Psychiatry 2016; 2016: 9406813.

15.    Tak SR, Dar GN, Halwai MA, Mir MR. Post-injection nerve injuries in Kashmir: a menace overlooked. J Res Med Sci 2008; 13: 244-7.

16.    Devi BI, Konar SK, Bhat DI, Shukla DP, Bharath R, Gopalakrishnan MS. Predictors of surgical outcomes of traumatic peripheral nerve injuries in children: An institutional experience. Pediatr Neurosurg 2018; 53: 94-9.

17.    Gürsoy AE, Kolukısa M, Yıldız GB, Kocaman G, Celebi A, Koçer A. Relationship between electrodiagnostic severity and neuropathic pain assessed by the LANSS pain scale in carpal tunnel syndrome. Neuropsychiatr Dis Treat 2013; 9: 65-71.

18.    Caleyachetty R, Barber TM, Mohammed NI, Cappuccio FP, Hardy R, Mathur R, et al. Ethnicity-specific BMI cutoffs for obesity based on type 2 diabetes risk in England: a population-based cohort study. The Lancet Diabetes Endocrinol 2021; 9: 419-26

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