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Research Article. JAllerg Res, 2 1 This is an open-access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The exposed needle length and pressure required to trigger the devices varies among brands and manufactured lots. With the currently available auto-injectors, the high-pressure devices have shorter exposed needle length than the low-pressure devices.

As well, injection through clothing affects the depth of tissue delivery. Methods : We assessed the likely location of injections of epinephrine autoinjectors, using ultrasound data from a study of children and adolescents and 99 adults, years old. Ultrasound was applied with high and low pressure. The skin to bone and skin to muscle distances were measured. The risk of subcutaneous injection was investigated. The longest needle length not causing intraosseous injection applying low and high pressure on the ultrasound probe and the shortest approved needle for estimation of the risk for subcutaneous injection through naked skin and through thick clothes.

: When using high pressure, the risk of subcutaneous injection was very high. Using low pressure, there was a low risk of subcutaneous injection. These are qualitative and not quantified as the original ultrasound data on pressure were not to the exact product specifications. This occurs because low pressure does not compress the muscle ificantly and the resulting the possible use of longer needles that are more likely to pass through the subcutaneous tissue into muscle.

Epinephrine is indicated for intramuscular IM injection in the treatment of anaphylaxis [1]. High and low pressure EAIs is defined in the original papers []. There are two important factors influencing the risk of i. In a pig cadaver study, Diacono et al.

Duvauchelle et al. Furthermore, we have shown that injecting through thick clothes increases the risk of SC injection and decreased the risk of i. In the original trials by Kim et al. The upper and lower limits for pressure applied to release the needle as reported by the manufacturers of some EAIs are presented in Table 1.

At the time of the original trials [], we did not have information on the exact pressure required to trigger the different EAIs brands [7] to release the injection spring, nor the brand-specific variation of pressure to be applied to release the needle. Furthermore, we had no information on the brand-specific variation in needle length due to inconsistency in production [9]. High pressure has been shown to exhibit a high risk of i. To avoid i. This device has a low risk of i. The ultrasound determinations performed by Kim et al.

We use the two pressures on the probe as defined by Kim et al [], and the variation in needle length as declared by the manufacturers of the brand with highest and lowest variation in needle length. In our opinion, it is most important to avoid i. The aim of this communication to study whether it is possible to find a needle length for EAIs that has no risk of i.

The aim was to determine the longest needle length possible to use in EAIs that would not hit the bone and then to investigate the risk of these needle lengths for SC injection. Food allergic children and adults were consecutively included until approximately patients per age group had been recruited.

Four hundred and one consecutive patients with diagnosed food allergy were included in the three original trials []. As described earlier, children and adolescents 0. Clinical data and basic statistical analyses have been published [] and the same ultrasound data have been used in papers [6,9,12]. As in our pevious studies, we used the findings by Diacono et al. This finding was supported by Duvauchelle et al. The epinephrine remained in the SC space without passing through fascia.

The length of the eye of the EAIs was estimated to be 2 mm [6]. We have ly reported on the variation in needle length and on pressure for lot release, Table 1 [7,9].

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In this study we used the shortest and longest possible needle lengths based on the greatest range allowed by manufacturers. Outcome variables. We wanted to identify whether we could find a needle length that caused no i.

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We started by estimating the longest needle that would not cause an i. In the next step, we identified which needle length would cause a SC injection in the same patients Figure 1b and 2brespectively. First, we indicated the longest needle not causing an i. Figure 2b. Figures 1b and 2b illustrate the of subjects receiving a subcutaneous injection The possible risk is illustrated using the accepted maximum variation of needle length by the manufacturers.

We estimated compressed thick winter clothing to be 3 mm thick This was based on meassurment of three pairs of winter trousers. Therefore, we decreased needle length by 3 mm when estimating the risks for SC injection wearing thick clothes. After taking the needle eye factor 2 mm and winter clothing intowe subtrated 5 mm when calculating the distance for IM injection.

No formal statistical analyses were performed. The figures are intended to qualitatively find needle lengths that would avoid i. The are illustrated in Figures 1 and 2. They have been constructed to approximately show how long the penetrating part of an EAI needle can be without hitting the bone. The next step was to describe the influence of needles of the above-mentioned lengths using the brand-specific data on the variation of needle length.

The length is reduced by 2 mm to adjust for the fascia findings by Diacono et al. In Figures 1b and 2b is illustrated the proportion of patients likely to receive a SC injection. In Figure 2b is illustrated the effect of using low pressure on the optimal needle length not causing any i.

In summary, starting out with the ideal to not cause any i. In recent years the risk of SC or i. This paper is based on data from the three original studies completed by Dr. Distances were determined by ultrasound at the mid anterolateral aspect of the thigh, the recommended area for IM injection of epinephrine using EAIs [13]. The declared variation in pressure that is accepted by companies for release of new lots of EAIs has been presented elsewhere [7] and summarized in Table 1.

This data was not known by us at the time of the original studies. There are instruments available that can apply a specified pressure to the ultrasound probe [14,15] that should be used in all future trials using ultrasound imaging for the study of STBD and STMD. Uppsala women hot pussy, the pressure applied to the probe was not sufficiently well defined in the original studies.

Therefore, we did not present any risk data for any specific EAIs currently available. Instead, we illustrated the principle that by avoiding i. Our suggest that the risk of SC injection is very high if using a needle length that would definitely not cause i. This risk is reduced when requiring a lower pressure to trigger the auto injector as the lower pressure would allow a longer needle to be used.

This occurs because less pressure compressing the muscle will provide a greater STBD and therefore allow the use of longer needles. Then, we believe more patients will receive IM injections. Using this qualitative approach to this important issue, we were able to estimate the needle lengths for EAIs that would deliver the epinephrine to the IM compartment. These findings should be useful in future studies and future EAI des. The findings from our study should be confirmed in well-deed prospective studies.

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With future larger studies, the chance of avoiding i. Currently, 15 kg and 30 kg are the weight thresholds most often used for EAI prescribing. But we propose the intervals of 10, 50 and 80 kg be used for estimating successful IM injection based on our data. In closing, if we have the primary goal of avoiding i. Therefore, when deing future EAIs or modifying currently available EAIs, we recommend devices that require less force to release the needle and drug.

This lower force will allow for the deers to find the proper needle lengths for different weight ranges that will deliver the epinephrine properly.

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