Effect of syringe size on bruising following subcutaneous heparin injection

Avoiding the needle: A quality improvement program introducing apixaban for extended thromboprophylaxis after major gynecologic cancer surgery

OBJECTIVE

Patients undergoing gynecologic cancer surgery at our centre are recommended up to 28 days of enoxaparin for extended post-operative thromboprophylaxis (EP). Baseline survey revealed 92% patient adherence, but highlighted negative effects on patient experience due to the injectable route of administration. We aimed to improve patient experience by reducing pain and bruising by 50%, increasing adherence by 5%, and reducing out-of-pocket cost after introducing apixaban as an oral alternative for EP.

METHODS

In this interrupted time series quality improvement study, gynecologic cancer patients were offered a choice between apixaban (2.5 mg orally twice daily) or enoxaparin (40 mg subcutaneously once daily) at time of discharge. A multidisciplinary team informed project design, implementation, and evaluation. Process interventions included standardized orders, patient and care team education programs. Telephone survey at 1 and 6 weeks and chart audit informed outcome, process, and balancing measures.

RESULTS

From August to October 2022, 127 consecutive patients were included. Apixaban was chosen by 84%. Survey response rate was 74%. Patients who chose apixaban reported significantly reduced pain, bruising, increased confidence with administration, and less negative impact of the medication (p < 0.0001 for all). Adherence was unchanged (92%). The proportion of patients paying less than $125 (apixaban cost threshold) increased from 45% to 91%. There was no difference in bleeding and no VTE events.

CONCLUSIONS

Introduction of apixaban for EP was associated with significant improvement in patient-reported quality measures and reduced financial toxicity with no effect on adherence or balancing measures. Apixaban is the preferred anticoagulant for EP at our centre.

Quality of life in cancer patients undergoing anticoagulant treatment with LMWH for venous thromboembolism: the QUAVITEC study on behalf of the Groupe Francophone Thrombose et Cancer (GFTC)

BACKGROUND

Clinical guidelines recommend at least 3-months low molecular weight heparin (LMWH) treatment for established venous thromboembolism (VTE) in cancer patients. However, no study has analyzed the impact of 3-6 months of LMWH therapy on quality-of-life (QoL) in cancer patients.

RESULTS

Among 400 cancer patients included at M0, 88.8% received long-term LMWH. Using a random-effects linear regression model with time as covariate, QoL scores in the MOS SF-36 (Global HRQoL, 1.3-fold per month [95% confidence interval (CI) 0.81-1.79], p < 0.0001) and EORTC QLQ-C30 (global health status/qol, 2.25-fold per month [95% CI 1.63-2.88]; p < 0.0001) questionnaires significantly improved over the 6-month study period in patients treated with LMWH, while VEINES-QOL scores did not change. In the MOS SF-36 and EORTC QLQ-C30, the following factors were associated with change in QoL: symptomatic VTE, cancer dissemination and histological type. Factors pertaining to reduced mobility were also identified as significant predictors of QoL outcomes, including being bedridden in the MOS SF-36 and ECOG score ≥ 2 in the EORTC QLQ-C30. Presence of acute infection and not undergoing anti-angiogenic therapy were additional factors associated with QoL improvement in the EORTC QLQ-C30.

METHODS

QUAVITEC, a prospective, longitudinal, multicenter study, recruited all consecutive eligible adult cancer patients with objectively confirmed VTE between February 2011 and 2012. Patients were asked to answer three QoL questionnaires at anticoagulant treatment initiation (M0) and at 3 (M3) and 6 (M6)-month follow-ups.

CONCLUSION

QUAVITEC is the first study to show that QoL was improved in cancer patients receiving long-term LMWH treatment for established VTE.

The Effect of Administration Protocol of Subcutaneous Enoxaparin Injection on Formation of Ecchymosis

Subcutaneous heparin administration is routinely used for many patients in orthopaedic clinics. Nurses frequently encounter ecchymosis formation with heparin administration. Previous research indicates that the administration protocol may have effect on ecchymosis formation. The study was performed to determine and compare the effect of three different approaches of subcutaneous enoxaparin injection on ecchymosis formation in patients who underwent joint replacement surgery. Three protocols were compared: (1) injecting enoxaparin in 10 seconds, (2) injecting enoxaparin in 30 seconds, and (3) injecting enoxaparin in 30 seconds and waiting for an additional 10 seconds before withdrawing the needle. Ecchymosis formation was assessed in both size and frequency. Descriptive statistics, Kruskal-Wallis analysis, Mann-Whitney U test, and Spearman rank correlation test were used to assess the data. The ecchymosis frequency was higher in the 10-second administration. Ecchymosis size was smaller when the enoxaparin was administered in 30 seconds and the needle was kept in the tissue for 10 seconds after injection. The enoxaparin should be administered in a longer duration (30 seconds). Keeping the needle in the tissue for 10 seconds may further decrease the size but not the incidence of ecchymosis.

Continuation of low-molecular-weight heparin treatment for cancer-related venous thromboembolism: a prospective cohort study in daily clinical practice

Essentials Low-molecular-weight heparin (LMWH) injections for venous thromboembolism (VTE) may be burdensome. Patients with active cancer and confirmed VTE were included to evaluate LMWH continuation. The cumulative incidence of discontinuation was 21% after a median period of 90 days. One out of five patients discontinued LMWH injections because of side effects.

SUMMARY

Background Current guidelines recommend low-molecular-weight heparin (LMWH) monotherapy for 3-6 months as the first-line treatment for cancer-associated venous thromboembolism (VTE). However, although daily administration of LMWH injections over a course of several months may be burdensome, the number of patients who stop treatment because of LMWH side-effects is unknown. Objectives To evaluate the continuation rate and complications of daily LMWH injections in patients with cancer-associated VTE. Methods Consecutive patients with active cancer and objectively confirmed symptomatic proximal deep vein thrombosis and/or pulmonary embolism, treated at three Dutch hospitals and one Spanish hospital, were included to evaluate continuation LMWH therapy during LMWH treatment. Patients were excluded when they received other anticoagulants, were lost to follow-up, or experienced a venous catheter-associated thrombosis. Results A total of 372 patients were analyzed during LMWH treatment for a maximum of 180 days. The cumulative incidence of discontinuation was 21% (95% confidence interval [CI] 17-25) after a median period of 90 days (interquartile range 60-120 days). Only female sex was found to be significantly associated with premature LMWH discontinuation (odds ratio 1.6; 95% CI 1.03-2.5). Thirty patients (8.1%) developed recurrent VTE, 30 patients (8.3%) suffered a major bleed, and 106 patients (28%) died. Conclusion Our study reveals that one of five patients with cancer-associated VTE stopped LMWH injections because of side-effects. This finding provides relevant background information for current clinical trials investigating the efficacy and safety of direct oral anticoagulants as compared with LMWH.

Occurrence and extent of bruising according to duration of administration of subcutaneous low-molecular-weight heparin: a quasi-experimental case-crossover study

BACKGROUND

Several authors have documented the role of low-molecular-weight heparin injection techniques in bruising. However, few researchers have measured the influence of injection duration on the occurrence and extent of bruising.

PURPOSE

The aim of this study was to evaluate the influence of different durations of subcutaneous heparin injection on the occurrence and extent of bruising.

METHODS

A quasi-experimental case-crossover study design was adopted in 2010. A consecutive series of patients admitted to 2 orthopedic units in a large (600 beds) teaching hospital located in northern Italy were eligible for enrolment. Injections were administered following a standard procedure. The manipulated variable was the duration of the injection, 10 seconds (treatment A) and 30 seconds (treatment B). The evaluation of bruise occurrence and extension performed after 48 hours and data analysis were conducted in a blinded fashion.

RESULTS

A total of 150 patients receiving their first and second subcutaneous heparin injections (300 injections) were enrolled. Eighty-seven bruises were observed out of 300 injections (29%): 57 of 150 (38%) after injections lasting 10 seconds and 30 of 150 (20%) after injections lasting 30 seconds (relative risk, 1.50; 95% confidence interval, 1.21-1.86; P = .00). Of the 87 bruises that occurred, 69 (79.3%) were small (2-5 mm) and 18 (20.6%) were large (>5 mm), with no difference in size between 10- and 30-second injections (relative risk, 0.91; 95% confidence interval, 0.39-2.12; P = .83).

CONCLUSIONS

Low-molecular-weight heparin injection should be administered over 30 seconds to decrease bruising.

CLINICAL IMPLICATIONS

There is a need to reflect on the feasibility of such a practice because injecting low-molecular-weight heparin at 30 seconds requires accuracy, a steady hand, the absence of tremor, a calm environment, and the ability to administer an infinitesimally small amount of liquid (eg, 0.4 mL) per second.

The effect of local dry heat pack application on recovering the bruising associated with the subcutaneous injection of heparin

AIMS AND OBJECTIVES

To determine the effect of the local dry heat pack application on recovering or alleviating the bruising associated with the subcutaneous injection of heparin.

BACKGROUND

In studies conducted to prevent the bruising associated with the subcutaneous injection of heparin, it is observed that bruising cannot be prevented completely; however, there is a decrease in frequencies and sizes of bruising. There is no study aimed at accelerating the bruising recovery.

DESIGN

Quasi-experimental.

METHODS

Thirty-three patients, who were treated for heparin and had bruising in the injection site, were included in the study. One of their upper arms with bruising was considered as the experimental arm, and the other upper arm with bruising was considered as the control arm. 'Local dry heat pack' application was performed on the bruising area in the experimental arm 72 hours after the heparin injection. As the bruising areas in the other upper arm were considered as the control arm, no application was performed. The sizes of bruising areas were drawn on the transparent film and determined as square centimetre.

RESULTS

The size of bruising areas was 3·21 ± 3·78 cm² in the experimental arm and 5·22 ± 4·45 cm² in the control arm 120 hours after the injections. The difference between the bruising sizes of the experimental and control arms was statistically significant.

CONCLUSIONS

It was observed that 'local dry heat pack' application had a positive effect on the recovery of bruising, associated with the subcutaneous injection of heparin.

RELEVANCE TO CLINICAL PRACTICE

The acceleration of bruising recovery will enable decreasing patients' anxieties, improving their body image and increasing their adherence to therapy.

How to improve the implementation of guidelines on cancer-related thrombosis

Venous thromboembolism (VTE; defined by deep-vein thrombosis, central venous catheter-related thrombosis or pulmonary embolism) is a major therapeutic issue in cancer patients. VTE is reported in 15-20% of patients with cancer and is an independent prognostic factor and a leading cause of death. In this population, low-molecular-weight heparins have been shown to be superior to vitamin K antagonists. The Italian Association of Medical Oncology, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the French 'Institut National du Cancer', the European Society of Medical Oncology and the American College of Chest Physicians have all published specific guidelines, but their implementation is still low in clinical practice. Methodological assessment of these guidelines was performed using the Appraisal of Guidelines Research & Evaluation Instrument. None of the guidelines on thrombosis and cancer have sought for patients' preferences, nor were they tested among target users. VTE in cancer patients requires a multidisciplinary approach but downstream of the guidelines publication, the potential organisational barriers in applying the recommendations have not been discussed. Tolerance and cost-effectiveness of long-term use of low-molecular-weight heparin may account for the large heterogeneity seen in daily clinical practice. Homogenization of guidelines in international consensus working groups followed by educational and active implementation strategies would be very valuable in order to improve the care of VTE in cancer patients.

Effect of a direct thrombin inhibitor compared with dalteparin and unfractionated heparin on human osteoblasts

Purpose:

Osteoporosis is a relevant problem after long term administration of unfractionated heparin (UFH) and low molecular weight heparin. Melagatran is a representative of a new group of direct thrombin inhibitors with comparable data in the prevention of thromboembolic events after orthopaedic surgery. The aim of our in vitro study was to investigate the effect of a direct thrombin inhibitor compared with dalteparin and UFH on human osteoblasts.

Materials and Methods:

Melagatran, dalteparin and UFH were added to primary osteoblast cultures in their therapeutic range and two decimal powers below and above. Cell number, protein synthesis, mitochondrial and alkaline phosphatase activity and collagen type I synthesis were evaluated.

Results:

Melagatran showed the least influence on protein synthesis and cell proliferation with a reduction of cell number to 83.5 ± 9% (p = 0.027) of the control group only in the highest investigated concentration after 15 days of incubation.

Mitochondrial and alkaline phosphatase activity and collagen type I synthesis in osteoblasts incubated with melagatran and dalteparin showed similar patterns. UFH showed the most pronounced influence on cellular metabolism.

Conclusions:

Melagatran showed less inhibitory in vitro effects on human osteoblasts than dalteparin or UFH. The presented study gives first hints that direct thrombin inhibitors may help prevent heparin-induced negative effects on bone metabolism.

Lessons from French National Guidelines on the treatment of venous thrombosis and central venous catheter thrombosis in cancer patients

Increased prevalence of Venous thromboembolism (VTE), as defined by deep-vein thrombosis (DVT), central venous catheter (CVC) related thrombosis or pulmonary embolism (PE) in cancer patients has become a major therapeutic issue. Considering the epidemiology and each national recommendations on the treatment of VTE in cancer patients, we analysed guidelines implementation in clinical practice. Thrombosis is the second-leading cause of death in cancer patients and cancer is a major risk factor of VTE, due to activation of coagulation, use of long-term CVC, the thrombogenic effects of chemotherapy and anti-angiogenic drugs. Three pivotal trials (CANTHANOX, LITE and CLOT) and several meta-analysis led to recommend the long term (3 to 6 months) use of LMWH during for treating VTE in cancer patients with a high level of evidence. The Italian Association of Medical Oncology (AIOM), the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), the French "Institut National du Cancer" (INCa), the European Society of Medical Oncology (ESMO) and the American College of Chest Physicians (ACCCP) have published specific guidelines for health care providers regarding the prevention and treatment of cancer-associated VTE. Critical appraisal of these guidelines, difficulties in implementation of prophylaxis regimen, tolerance and cost effectiveness of long term use of LMWH may account for large heterogenity in daily clinical practice. Homogenization of these guidelines in international consensus using an adapted independent methodological approach followed by educational and active implementation strategies at each national level would be very valuable to improve the care of VTE in cancer patients.

Effect of injection duration on bruising associated with subcutaneous heparin: A quasi-experimental within-subject design

AIM

The purpose of this study was to determine and compare the effects of three different injection durations on bruising associated with subcutaneous heparin.

BACKGROUND

Subcutaneous administration of the anticoagulant heparin sodium is a frequently performed nursing intervention. Heparin preparations are widely used for the post surgical prophylaxis, deep vein thrombosis and pulmonary emboli. Subcutaneous heparin injection often causes problems such as bruise, pain, induration, and hematoma at the injection site. Bruising that result from heparin injections may lead to anxiety, disruption of body image, the rejection of the treatment in patients, and the reduction of the reliance of patient to nurse.

METHOD

The study used a quasi-experimental design. The population for the research was formed by the patients who were hospitalized at Chest Disease and Surgery Hospital and ordered to receive subcutaneous low-molecular weight heparin (LMWH). The research involved 36 chronic obstructive pulmonary disease (COPD) patients. Each subject received three injections by the same investigator using three different techniques. Site bruising was measured at 48h after each injection. The bruising size was measured using a plastic ruler. Descriptive statistics, Wilcoxon signed-rank and McNemar chi(2) tests were used to evaluate of the data. The level of significance was determined at P<0.05.

RESULT

The 30s duration injection technique and waiting 10s before withdrawing the needle after 10s injection duration resulted in significantly smaller and less bruises than 10s duration injection technique.

CONCLUSION

The 30s duration or waiting 10s before withdrawing the needle after 10s injection duration techniques should be used for subcutaneous heparin injections in clinical practice.

A study on the effect of the duration of subcutaneous heparin injection on bruising and pain

AIM

This study was carried out to determine the effect of injection duration on bruising and pain following the administration of the subcutaneous injection of heparin.

BACKGROUND

Although different methods to prevent bruising and pain following the subcutaneous injection of heparin have been widely studied and described, the effect of injection duration on the occurrence of bruising and pain is little documented.

DESIGN

This study was designed as within-subject, quasi-experimental research.

METHOD

The sample for the study consisted of 50 patients to whom subcutaneous heparin was administered. Heparin was injected over 10 seconds on the right abdominal site and 30 seconds on the left abdominal site. Injections areas were assessed for the presence of bruising at 48 and 72 hours after each injection. Dimensions of the bruising on the heparin applied areas were measured using transparent millimetric measuring paper. The visual analog scale (VAS) was used to measure pain intensity and a stop-watch was used to time the pain period. Data were analysed using chi-square test, Mann-Whitney U, Wilcoxon signed ranks tests and correlation.

RESULTS

The percentage of bruising occurrence was 64% with the injection of 10 seconds duration and 42% in the 30-second injection. It was determined that the size of the bruising was smaller in the 30-second injection. Pain intensity and pain period were statistically significantly lower for the 30-second injection than for the 10-second injection.

CONCLUSIONS

It was determined that injection duration had an effect on bruising and pain following the subcutaneous administration of heparin. This study should be repeated on a larger sample.

RELEVANCE TO CLINICAL PRACTICE

When administering subcutaneous heparin injections, it is important to extend the duration of the injection.

Performing Subcutaneous Injections: A Literature Review

BACKGROUND

Persons using daily subcutaneous injections to administer medicine perform them in different ways and thereby increase the risk of skin complications related to the injection. It is often part of nurses' role to administer medicine and educate the patient in injection technique. Course literature in nursing education, commercial patient education pamphlets, and instructional leaflets do not give consistent advice regarding subcutaneous injection technique.

AIM

The aim of this review was to identify the scientific foundation for the technical performance of subcutaneous injections. The question to be answered was: How should a subcutaneous injection be administered to achieve the right dose in the right place with minimum complications?

METHOD

The review included a search in three databases, a screening process at abstract level, followed by a quality assessment of included articles. The quality assessment was done independently by two people and followed specific protocols.

RESULT

A total of 38 articles were assessed for quality and covered information on dose, location, and complications of subcutaneous injection. The assessed studies are heterogeneous in design and describe different aspects of the subcutaneous injection technique. Therefore, the scientific foundation for technical performance is weak. However, several studies indicate that the amount of subcutaneous fat and appropriate needle length are of high importance for the drug to reach the target tissue.

CONCLUSION

More research regarding effective subcutaneous injection technique needs to be done.

Can a Journal Club Bridge the Gap Between Research and Practice?

It is imperative that nursing students learn to use research as a basis for making clinical decisions. The author discusses how a journal club was structured and designed to promote evidence-based practice and to reduce several of the barriers in utilizing research in the clinical setting. Vignettes illustrate the serendipitous events that also triggered the staff nurses' participation. An informal evaluation of the journal club is presented and suggestions for implementing future journal clubs are provided.

Comparison of two needle sizes for subcutaneous administration of enoxaparin: effects on size of hematomas and pain on injection

STUDY OBJECTIVE

To determine whether use of a smaller needle size for subcutaneous injection of enoxaparin would reduce the size of injection-site hematomas and/or decrease the pain of injection.

DESIGN

Prospective, randomized trial.

SETTING

Community hospital in North Vancouver, British Columbia, Canada.

PATIENTS

One hundred twenty-four patients with unstable angina or non-Q-wave myocardial infarction who were administered enoxaparin for anticoagulation.

INTERVENTION

Each patient was randomly assigned to one of two groups. One group received enoxaparin injections with a 30-gauge, 5/16-inch insulin syringe, and the other group was injected with a 26-gauge, 3/8-inch tuberculin syringe.

MEASUREMENTS AND MAIN RESULTS

Participating nurses used standard measuring tape to determine the largest diameter of each hematoma. Pain was assessed with a 10-unit numeric scale. The two groups did not differ significantly with regard to either the mean size of the largest hematoma/patient (4.2 cm in the insulin-syringe group vs 3.8 cm in the tuberculin-syringe group, p=0.68) or the mean pain score (0.3 in the insulin-syringe group vs 0.5 in the tuberculin-syringe group, p=0.10).

CONCLUSIONS

Use of a 30-gauge, 5/16-inch insulin syringe instead of a 26-gauge, 3/8-inch tuberculin syringe does not significantly reduce either hematoma size or pain of injection. A larger study is required to determine whether needle size affects the frequency of hematoma formation.

Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin

AIM

The research evaluated two subcutaneous heparin injection techniques to determine the effects of different injection duration (10- and 30-seconds) on site-pain intensity and bruising.

BACKGROUND

The research was instigated because nurses and patients in the hospital under investigation reported a high incidence of site-pain and bruising associated with subcutaneous heparin therapy. This research was conducted over a period of 7 months between September 1998 and April 1999. The Ethic Committees of the University and the hospital approved the research.

METHODS

The research used a within-subjects, quasiexperiment, which would yield more convincing causal inferences, owing to the assumption that pain perception and physiological factors affecting coagulation varied less in the same subject than in two comparable subjects. The research involved 34 stroke patients receiving low-molecular weight heparin. For each subject, one of the two injection techniques was used as the first injection and 12 hours later the other injection technique as the second injection. Subjects rated the level of perceived site-pain intensity using the vertical visual analogue scale (VAS). Injection-site bruising were measured at 48 and 60 hours after each injection. Digital planimetry was used to measure the surface-area of bruise tracings. The final data set for analysis consisted of 68 VAS pain scores and 136 bruise sizes. As normality of the data could not met after transformations, Wilcoxon Signed-Rank tests were used to determine the effects caused by injection duration on site-pain and bruise size. The level of significance was determined at P < 0.05.

RESULTS

Results indicated that the 30-second duration injection technique resulted in significantly less intense site-pain and fewer and smaller bruises.

CONCLUSIONS

It was concluded that administering a subcutaneous heparin injection over longer duration reduces injection site-pain and bruising. However, the convenience, relatively small sample may limit the generalisability of the research findings.

Effects of changing needles prior to administering heparin subcutaneously

OBJECTIVES

To determine if changing needles before administering subcutaneous heparin would cause less ecchymosis at the injection site.

DESIGN

A quantitative study.

SETTING

A large northeastern, urban, nonprofit, tertiary medical center.

OUTCOME MEASURES

A measurement of ecchymosis was obtained 48 hours after injection of heparin on the right side of the abdomen, where the needle was changed before injection. A second measurement was obtained 48 hours after injection on the left side of the abdomen, where the needle was not changed before injection. A comparison was then made of the two measurements.

RESULTS

The Student t test for related samples was used, and the significance was set at P <.05. The mean size of the ecchymoses for the sites where the needle was changed was 5.16 mm, and the mean size of the ecchymoses for the sites where the needle was not changed was 5.44 mm (P =.87).

CONCLUSION

Changing the needle before the administration of subcutaneous heparin did not decrease the size of ecchymoses as compared with the size to the size of ecchymoses when the investigator did not change the needle.