Epinephrine Auto-Injector Needle Length (Does Height or BMI add Valuable Information in Adults?)
Keywords:Auto-injector; epinephrine; intramuscular; subcutaneous; intraosseous; skin to bone distance; skin to muscle distance; clothing; overweight; obese; adults; women; men.
Background: Some overweight and obese adults have an increased risk of subcutaneous injection using epinephrine autoinjectors (EAIs). Needle lengths of EAIs vary between brands and lots. Objective: To study if BMI or height adds information to define adults at risk of having intraosseous or subcutaneous injection. Methods: Ninety-nine (99) food allergic adult patients, 32 men and 67 women, 18 - 72 years of age, prescribed EAIs were included. The skin to muscle and skin to bone distances were measured by ultrasonography. The effect of injection on naked skin or through thick clothing was analyzed. High and minimal pressure was applied to the ultrasound probe. Results: Two of three men and 1/5 women with BMI <20 had a risk of intraosseous/periosteal injection using the high pressure autoinjector Epipen®, thick clothing, 5/8. Injecting through naked skin using the shortest needle, 14/17 obese women had a high risk of subcutaneous injection (overweight 14/23), through thick clothing all 17 obese women would have a risk of subcutaneous injection (overweight 20/23). Injecting with LPEAIs through naked skin, using the shortest needle 8/17 obese and 4/23 overweight women would have a risk of subcutaneous injection, wearing thick clothing, 10/17 obese and 7/23 overweight women. Height had no predictive value. Conclusion: Using high pressure EAIs, high BMI predicted a very high risk for subcutaneous injection in women and in some men. Even injection with low pressure EAIs had some risk of subcutaneous injection, especially when injected through thick clothing. Height had no predictive value.
Tsai G, Kim L, Nevis IF, Dominic A, Potts R, Chiu J, et al. Auto-injector needle length may be inadequate to deliver epinephrine intramuscularly in women with confirmed food allergy. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology. 2014;10(1):39. https://doi.org/10.1186/1710-1492-10-39
Dreborg S, Kim L, Tsai G, Kim H. Epinephrineautoinjector needle lengths: Can both subcutaneous and periosteal/intraosseous injection be avoided? Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2018;120(6):648-53 e1. https://doi.org/10.1016/j.anai.2018.02.028
Dreborg S, Kim H. Tissue compression and epinephrine deposition. The journal of allergy and clinical immunology In practice. 2019;7(6):2096-7. https://doi.org/10.1016/j.jaip.2019.03.038
Dreborg S, Tsai G, Kim H. Implications of variation of epinephrine auto-injector needle length. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2019;123(1):89-94. https://doi.org/10.1016/j.anai.2019.04.027
Dreborg S, Kim H. Epinephrine autoinjectors - the needle length matters. Annals. 2020;Submitted. https://doi.org/10.1016/j.anai.2019.12.014
Dreborg S, Tsai G, Kim H. Epinephrine auto-injector needle length. The impact of winter clothing Accepted for publication AACI 2020. 2020. https://doi.org/10.1186/s13223-020-00422-4
Dreborg S, Kim H. Epinephrine auto-injectors. Is there an ideal needle length? 2020;submitted. https://doi.org/10.1186/s13223-020-00422-4
Lockey SD. A new method of administering aqueous epinephrine: the EpiPen, an automatic syringe. The Journal of asthma research. 1980;17(4):153-5. https://doi.org/10.3109/02770908009105665
Kim L, Nevis IF, Tsai G, Dominic A, Potts R, ChiuJ, et al. Children under 15 kg with food allergy may be at risk of having epinephrine auto-injectors administered into bone. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology. 2014;10(1):40. https://doi.org/10.1186/1710-1492-10-40
Dreborg S, Wen X, Kim L, Tsai G, Nevis I, Potts R, et al. Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy? Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology. 2016;12:11. https://doi.org/10.1186/s13223-016-0110-8
Dreborg S, Kim H. Authors' response. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2018;121(5):644-5. https://doi.org/10.1016/j.anai.2018.09.456
Worm M, Nguyen D, Rackley R, Muraro A, Du Toit G, Lawrence T, et al. Epinephrine delivery via EpiPen((R)) Auto-Injector or manual syringe across participants with a wide range of skin-to-muscle distances. Clinical and translational allergy. 2020;10:21. https://doi.org/10.1186/s13601-020-00326-x
Diacono D, Pumphrey RS, Sharma V, Arkwright PD. The deep fascia of the thigh forms an impenetrable barrier to fluid injected subcutaneously by autoinjectors. The journal of allergy and clinical immunology In practice. 2015;3(2):297-9. https://doi.org/10.1016/j.jaip.2014.11.016
Duvauchelle T, Robert P, Donazzolo Y, Loyau S, Orlandini B, Lehert P, et al. Bioavailability and Cardiovascular Effects of Adrenaline Administered by Anapen Autoinjector in Healthy Volunteers. The journal of allergy and clinical immunology In practice. 2018;6(4):1257-63. https://doi.org/10.1016/j.jaip.2017.09.021
Guo T, Dou Z, Eshraghi J, Veilleux J, Duffy K, Shi G, et al. Performance characterization of spring actuated autoinjector devices for Emgality®¬ and Aimovig®. Current Medical Research and Opinion 2020;3(4). https://doi.org/10.1080/03007995.2020.1783219
Administration. In: Hamborsky J, Kroger A, Wolfe S, editors. The pink book, Epidemiology and prevention of vaccin-preventable diseases. 13 ed. Washington D.C.: Centers for Disease Control and Prevention, Public Health Foundation; 2015. p. 79 - 106.
Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. 1998;101(1 Pt 1):33-7. https://doi.org/10.1016/s0091-6749(98)70190-3
Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001;108(5):871-3. https://doi.org/10.1067/mai.2001.119409
Jeimy S, Wong-Pack A, Veettil S, Kim H. Point-ofcare ultrasonography in the allergy and immunology clinic. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2019;123(1):42-7. https://doi.org/10.1016/j.anai.2019.02.010