Low-Molecular-Weight Heparin Injection in Stroke Patients

The Effect on Bruising and Pain of Different Durations of Pressure Application Following Subcutaneous Heparin Injection to the Upper Arm

Bruising as a result of heparin injection increases patients' anxiety, decreases their confidence in the effectiveness of nurses and causes them to refuse the injection. This undesirable effect can be reduced by using appropriate technique and taking a few simple precautions. In the systematic review conducted by İnangil and Şendir (2017) to systematically review the studies on the prevention of ecchymosis, hematoma and pain associated with subcutaneous heparin injection; it was determined that the number of studies investigating other techniques (pressure, site selection, etc.) was insufficient, with the highest number of studies on injection time and cold application. As a result of the research, it was recommended that local pressure should be applied to the area after injection, and the abdominal region should be preferred especially in patients who are sensitive to pain, since pain intensity is higher in the thigh and arm region. Due to the lack of literature, there is no consensus regarding the duration of compression to reduce bruising and pain after LMWH application. Based on these, this study was planned to compare the pressure applied to the injection point for 10, 35 and 60 seconds after injection in terms of pain, bruising and development of ecchymosis and hematoma at the injection sites in patients using subcutaneous heparin in the upper arm.

Study Overview

• Status: Completed
• Conditions: Stroke
• Intervention / Treatment: Other: The Effect of Different Pressure Periods on Bruising and Pain After Subcutaneous Heparin Injection Applied to the Upper Arm Region

Detailed Description

Anticoagulants are medicines that prevent blood from clotting as quickly or effectively as normal. Can be administered IV or subcutaneously. The main complications of heparin therapy are bleeding, thrombocytopenia and osteoporosis. Anticoagulants are classified as Vitamin K antagonist (VKA) (oral), Unfractionated heparin (UFH) (IV or subcutaneous), LMWHD (subcutaneous), Heparinoids (IV or subcutaneous), Fondaparinux (Subcutaneous), Oral factor Xa inhibitors, Parenteral direct thrombin inhibitors and Oral direct thrombin inhibitors. Subcutaneous administration of low-molecular-weight heparin (LMWH) may cause complications such as hematoma, bruising and pain at different injection sites. It is a goal of the nurse to reduce discomfort, anxiety, worry, refusal of treatment and lack of trust in the nurse due to bruising on the skin. Several studies have been conducted to investigate whether bruising and pain depend on injection sites; however, the results are conflicting and no clear and consistent conclusion has been reached. Subcutaneous heparin injection is a common nursing clinical intervention. Nurses often inject heparin subcutaneously and this action often causes some complications such as bruising, hematoma, pain and induration at the injection site. Bruising as a result of heparin injection increases patients' anxiety, decreases their confidence in the effectiveness of nurses and causes them to refuse the injection. This undesirable effect can be reduced by using appropriate technique and taking a few simple precautions. In the systematic review conducted by İnangil and Şendir (2017) to systematically review the studies on the prevention of ecchymosis, hematoma and pain associated with subcutaneous heparin injection; it was determined that the number of studies investigating other techniques (pressure, site selection, etc.) was insufficient, with the highest number of studies on injection time and cold application. As a result of the research, it was recommended that local pressure should be applied to the area after injection, and the abdominal region should be preferred especially in patients who are sensitive to pain, since pain intensity is higher in the thigh and arm region. Due to the lack of literature, there is no consensus regarding the duration of compression to reduce bruising and pain after LMWH application. Based on these, this study was planned to compare the pressure applied to the injection point for 10, 35 and 60 seconds after injection in terms of pain, bruising and development of ecchymosis and hematoma at the injection sites in patients using subcutaneous heparin in the upper arm.

• Study Type: Interventional
• Enrollment (Actual): 50
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey
  • Kastamonu, Turkey
    • Kastamonu University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Patients aged 18 years or older
• Hospitalized in the neurology clinic
• Who were administered at least once a day LMWH via subcutaneous injections in the arm
• Who agreed to participate in the study were included in this study

Exclusion Criteria:

• Patients who refused to participate in the study
• Patients with an INR value above 1.3 (hospital reference range was taken)
• Patients taking anticoagulant drugs were included in the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Effect of 10 second Pressure Times on Bruising and Pain; The patients were randomized according to age and gender and included in the groups. Patients were injected with heparin subcutaneously in the upper arm by the clinic nurse in accordance with the procedure of the clinic. The area was cleaned with alcohol and after the alcohol was dried, 0.6 ml of subcutaneous heparin was injected with a 27 gauge needle at a 90° angle to the tissue. The heparin was injected in approximately 10 seconds without aspirating the syringe. After injection, the area was pressurized with dry cotton wool for the specified time. After the injection, pressure was applied to the area with dry cotton for specified periods. Pain level was determined at the time of injection. Using an acetate pen, a circle of approximately 5 cm was marked around the needle insertion site and the bruising level was measured and recorded 48 hours later using a transparent film.	Other: The Effect of Different Pressure Periods on Bruising and Pain After Subcutaneous Heparin Injection Applied to the Upper Arm Region; The injection site on the upper arm of each patient was cleaned with alcohol and after the alcohol was dried, 0.6 ml of subcutaneous heparin was injected into the tissue at a 90° angle with a 27 gauge needle. The heparin was injected in approximately 10 seconds without aspirating the syringe. After the injection, pressure was applied to the area with dry cotton for specified periods (10 second, 35 second and 60 second).
Experimental: Effect of 35 second Pressure Times on Bruising and Pain; The patients were randomized according to age and gender and included in the groups. Patients were injected with heparin subcutaneously in the upper arm by the clinic nurse in accordance with the procedure of the clinic. The area was cleaned with alcohol and after the alcohol was dried, 0.6 ml of subcutaneous heparin was injected with a 27 gauge needle at a 90° angle to the tissue. The heparin was injected in approximately 10 seconds without aspirating the syringe. After injection, the area was pressurized with dry cotton wool for the specified time. After the injection, pressure was applied to the area with dry cotton for specified periods. Pain level was determined at the time of injection. Using an acetate pen, a circle of approximately 5 cm was marked around the needle insertion site and the bruising level was measured and recorded 48 hours later using a transparent film.	Other: The Effect of Different Pressure Periods on Bruising and Pain After Subcutaneous Heparin Injection Applied to the Upper Arm Region; The injection site on the upper arm of each patient was cleaned with alcohol and after the alcohol was dried, 0.6 ml of subcutaneous heparin was injected into the tissue at a 90° angle with a 27 gauge needle. The heparin was injected in approximately 10 seconds without aspirating the syringe. After the injection, pressure was applied to the area with dry cotton for specified periods (10 second, 35 second and 60 second).
Experimental: Effect of 60 second Pressure Times on Bruising and Pain; The patients were randomized according to age and gender and included in the groups. Patients were injected with heparin subcutaneously in the upper arm by the clinic nurse in accordance with the procedure of the clinic. The area was cleaned with alcohol and after the alcohol was dried, 0.6 ml of subcutaneous heparin was injected with a 27 gauge needle at a 90° angle to the tissue. The heparin was injected in approximately 10 seconds without aspirating the syringe. After injection, the area was pressurized with dry cotton wool for the specified time. After the injection, pressure was applied to the area with dry cotton for specified periods. Pain level was determined at the time of injection. Using an acetate pen, a circle of approximately 5 cm was marked around the needle insertion site and the bruising level was measured and recorded 48 hours later using a transparent film.	Other: The Effect of Different Pressure Periods on Bruising and Pain After Subcutaneous Heparin Injection Applied to the Upper Arm Region; The injection site on the upper arm of each patient was cleaned with alcohol and after the alcohol was dried, 0.6 ml of subcutaneous heparin was injected into the tissue at a 90° angle with a 27 gauge needle. The heparin was injected in approximately 10 seconds without aspirating the syringe. After the injection, pressure was applied to the area with dry cotton for specified periods (10 second, 35 second and 60 second).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Effect of Different Pressure Periods on Bruising and Pain After Subcutaneous Heparin Injection Applied to the Upper Arm Region	In this study, in patients using LMWH on the upper arm, the pressure applied to the injection point for 10, 35 and 60 seconds after the injection, and the pain at the injection site after the pressure were measured with the Visual Analog Scale. Additionally, in patients using LMWH on the upper arm, the pressure applied to the injection point for 10, 35 and 60 seconds after injection was examined for the development of bruising, ecchymosis and hematoma 48 hours later. Researchers marked an approximately 5 cm circle around the needle entry site using an acetate pen, and the level of bruising was measured and recorded 48 hours later using clear film.	48 hours

Collaborators and Investigators

• Sponsor: Kastamonu University

Study record dates

Study Major Dates

• Study Start (Actual): November 1, 2022
• Primary Completion (Actual): May 15, 2023
• Study Completion (Actual): May 15, 2023

Study Registration Dates

• First Submitted: June 6, 2023
• First Submitted That Met QC Criteria: October 6, 2023
• First Posted (Actual): October 10, 2023

Study Record Updates

• Last Update Posted (Actual): October 10, 2023
• Last Update Submitted That Met QC Criteria: October 6, 2023
• Last Verified: October 1, 2023

More Information

Terms related to this study

• Keywords: Nursing; Anticoagulants; Injection
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Stroke; Molecular Mechanisms of Pharmacological Action; Fibrinolytic Agents; Fibrin Modulating Agents; Anticoagulants; Heparin
• Other Study ID Numbers: 2022-KEAK-102

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No