Subcutaneous administration technique of low-molecular-weight heparins: An integrative review

Abstract

Anti-coagulant drugs for subcutaneous injection, like low-molecular-weight heparins (LMWH), are increasingly used to prevent and treat thromboembolic events, with local adverse reactions. The aim in this integrative review was to identify and analyze knowledge production about the most appropriate SC injection technique of LMWH to reduce hematomas, bruising and local pain. The following inclusion criteria were used: papers published in English, Spanish and Portuguese; between the first week of August 2001 and the last week of August 2012. Papers in which LMWH was compared with unfractionated heparin in the assessment of the outcomes and papers without statistical data analysis were excluded. The searches were undertaken in the electronic databases PubMed/MedLine, CINAHL, Scopus, Web of Science and LILACS/IBECS. The quality of the articles was assessed with the critical appraisal tool JBI MAStARI. The incidence of bruising ranged between 20%, when the application time of the injection was 30s, and 88.9% when it took 10s. In 50% of the studies, the authors concluded that LMWH injections taking 30s caused lower levels of bruising, with statistically significant differences, as well as a reduction in pain intensity in the injection site by up to 50%. The group that received LMWH through a prefilled syringe, with or without aspiration, showed lower levels of bruising. The formation of a skinfold, the 90º angle and the abdomen as the application site have been well documented in the literature. These findings are important for clinical nursing practice, as they found the elaboration of evidence-based care protocols and contribute to the improvement of patient care quality.

Effect of local cold and hot pack on the bruising of enoxaparin sodium injection site: a randomized controlled trial

“…This finding was consistent with the finding of previous studies (Chan, 2001;Balci Akpinar & Celebioglu, 2008;Varghes et al, 2006, de Campos, 2013Dadaeen, 2015). However, contrary to the findings of those studies, the current study's control group also demonstrated increasing bruise size 72 hours after the injections.…”

“…However, when enoxaparin is administered subcutaneously, it may also cause adverse effects including pain, local irritation, erythema, hematoma and bruising at the site of injection (Karch, 2010). The incidence levels of local hematomas after LMWH administration is reported between 40% and 88%, and between 26.6% and 88.9%, for bruising (de Campos et al, 2013). These problems are disturbing to patients, can endanger patient safety and result in the patient's avoidance of future injections (Kuzu & Ucar, 2001).…”

Comparison of 3 Methods to Prevent Pain and Bruising After Subcutaneous Heparin Administration

“…Thus, it is important to use ''correct injection technique'' during medication administration into SC tissue. 2,3,12,13 With regard to the ''correct injection technique,'' studies have suggested that the abdomen is probably the most common site of choice for heparin, as abdominal skin has thicker SC tissue than other areas of the body. 10Y12 According to the literature, SC LMWH injections should be administered 5 cm (2 inches) beyond the umbilicus to avoid the large umbilical veins.…”

“…According to various studies, the recommended duration of SC LMWH injections is over 10 seconds. 6,10,13 In addition, the importance of choosing the optimal injection site for the prescribed medication and matching the site with the needle length and injection technique is discussed. 9,18 A few studies have investigated the effects of the injection duration and cold application in SC heparin administration on injection site pain and the development of bruising or hematomas.…”

Study on enhanced lymphatic exposure of polyamidoamin-alkali blue dendrimer for paclitaxel delivery and influence of the osmotic pressure on the lymphatic targeting

“…Because of the little s.c. humoral fluid and limited contact areas compared to gastrointestinal and hematological system, dissolution and the absorption rate of the drug administrating s.c. injection were limited by comparison with oral or intravenous administration (McDonald et al, 2010;De Campos et al, 2013). The lymphatic system was the network of liquid system which was similar to hematological system.…”