Mohammady Mina, Janani Leila, Akbari Sari Ali
Department of Nursing, Islamic Azad University of Isfahan (Khorasgan) Branch, Isfahan, Iran.
Cochrane Database Syst Rev. 2017 Oct 1;10(10):CD008077. doi: 10.1002/14651858.CD008077.pub4.
Heparin is an anticoagulant medication that is usually injected subcutaneously. Subcutaneous administration of heparin may result in complications such as bruising, haematoma, and pain at the injection site. One of the factors that may affect pain, haematoma, and bruising is injection speed. For patients and healthcare providers, strategies that can reduce pain and bruising are considered important. Reducing patients' discomfort and concerns whenever and wherever possible is an important aim of nursing. Several studies have been carried out to see if speed of injection affects the amount of pain and bruising where the injection is given, but results of these studies have differed and study authors have not reached a clear final conclusion. This is the first update of the review first published in 2014.
To assess the effects of duration (speed) of subcutaneous heparin injection on pain, haematoma, and bruising at the injection site in people admitted to hospitals or clinics who require treatment with unfractionated heparin (UFH) or low molecular weight heparin (LMWH).
For this update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2). The CIS also searched trials registries for details of ongoing or unpublished studies. Review authors searched two Persian databases - Iranmedex and Scientific Information Database (SID) - as well as Google Scholar.
We sought randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site.
Two review authors (MM, LJ), working independently, extracted data onto a structured form and assessed study quality. We used the criteria recommended by Cochrane to assess the risk of bias of included studies. For the outcomes, we calculated the mean difference (MD) or the standardised MD (SMD) with corresponding 95% confidence intervals (CIs). We pooled data using fixed-effect and random-effects models. We used GRADE to assess the overall quality of evidence supporting outcomes assessed in this review.
For this update, we identified three new studies and therefore included in the Review four studies with a total of 459 participants who received subcutaneous injections of LMWH into the abdomen. Only one trial reported the injected drug volume (0.4 mL). Owing to the nature of the intervention, it was not possible to blind participants and care givers (personnel) in any included study. Two studies described blinding of outcome assessors; therefore overall, the methodological quality of included studies was moderate. The duration of the fast injection was 10 seconds and the duration of the slow injection was 30 seconds in all included studies.Three studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection, and meta-analysis on 140 participants showed no clear difference in site pain intensity immediately post slow injection when compared to fast injection (low-quality evidence; P = 0.15). In contrast, meta-analysis of two studies with 59 participants showed that 48 hours after the heparin injection, slow injection was associated with less pain intensity compared to fast injection (low-quality evidence; P = 0.007). One study (40 participants) reported pain intensity at 60 and 72 hours after injection. This study described no clear difference in site pain intensity at 60 and 72 hours post slow injection compared to fast injection.All four included studies assessed bruise size at 48 hours after each injection. Meta-analysis on 459 participants showed no difference in bruise size after slow injection compared to fast injection (low-quality evidence; P = 0.07). None of the included studies measured the incidence of haematoma as an outcome.
AUTHORS' CONCLUSIONS: We found four RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity and bruise size. Owing to the small numbers of participants, we found insufficient evidence to determine any effect on pain intensity immediately after injection or at 60 and 72 hours post injection. However, slow injection may reduce site pain intensity 48 hours after injection (low-quality evidence). We observed no clear difference in bruise size after slow injection compared to fast injection (low-quality evidence). We judged this evidence to be of low quality owing to imprecision and inconsistency.
肝素是一种抗凝药物，通常通过皮下注射给药。皮下注射肝素可能会导致诸如注射部位出现瘀伤、血肿和疼痛等并发症。可能影响疼痛、血肿和瘀伤的因素之一是注射速度。对于患者和医护人员而言，能够减轻疼痛和瘀伤的策略被认为很重要。尽可能随时随地减轻患者的不适和担忧是护理工作的一个重要目标。已经开展了多项研究来探究注射速度是否会影响注射部位的疼痛程度和瘀伤情况，但这些研究的结果各不相同，研究作者尚未得出明确的最终结论。这是该综述于2014年首次发表后的首次更新。
评估皮下注射肝素的持续时间（速度）对因治疗需要而在医院或诊所接受普通肝素（UFH）或低分子肝素（LMWH）治疗的患者注射部位疼痛、血肿和瘀伤的影响。
对于本次更新，Cochrane血管信息专家（CIS）检索了专业注册库（最近一次检索时间为2017年3月）和Cochrane对照试验中心注册库（CENTRAL；2017年第2期）。CIS还检索了试验注册库以获取正在进行或未发表研究的详细信息。综述作者检索了两个波斯语数据库——Iranmedex和科学信息数据库（SID）——以及谷歌学术。
我们检索了随机对照试验（RCT），比较皮下注射不同持续时间的肝素对注射部位疼痛、瘀伤和血肿的影响。
两位综述作者（MM、LJ）独立工作，将数据提取到结构化表格中并评估研究质量。我们使用Cochrane推荐的标准来评估纳入研究的偏倚风险。对于各项结局，我们计算了平均差（MD）或标准化平均差（SMD）以及相应的95%置信区间（CI）。我们使用固定效应模型和随机效应模型合并数据。我们使用GRADE来评估支持本综述中所评估结局的证据的总体质量。
对于本次更新，我们识别出三项新研究，因此本综述纳入了四项研究，共有459名参与者在腹部接受了皮下注射LMWH。只有一项试验报告了注射药物体积（0.4 mL）。由于干预措施本身的性质，在任何纳入研究中都无法使参与者和护理人员（工作人员）设盲。两项研究描述了结局评估者设盲的情况；因此总体而言，纳入研究的方法学质量为中等。在所有纳入研究中，快速注射的持续时间为10秒，缓慢注射的持续时间为30秒。三项研究报告了每次注射后不同时间点的注射部位疼痛强度。两项研究在每次注射后立即评估注射部位疼痛强度，对140名参与者进行的荟萃分析显示，与快速注射相比，缓慢注射后立即出现的注射部位疼痛强度无明显差异（低质量证据；P = 0.15）。相比之下，对两项共涉及59名参与者的研究进行的荟萃分析表明，肝素注射48小时后，与快速注射相比，缓慢注射导致的疼痛强度更低（低质量证据；P = 0.007）。一项研究（40名参与者）报告了注射后60小时和72小时的疼痛强度。该研究表明，与快速注射相比，缓慢注射后60小时和72小时的注射部位疼痛强度无明显差异。所有四项纳入研究均在每次注射后48小时评估瘀斑大小。对459名参与者进行的荟萃分析显示，与快速注射相比，缓慢注射后的瘀斑大小无差异（低质量证据；P = 0.07）。没有一项纳入研究将血肿发生率作为结局指标进行测量。
我们发现四项RCT评估了皮下注射肝素的持续时间对疼痛强度和瘀斑大小的影响。由于参与者数量较少，我们发现没有足够的证据来确定注射后立即或注射后60小时和72小时对疼痛强度有任何影响。然而，缓慢注射可能会降低注射后48小时的注射部位疼痛强度（低质量证据）。与快速注射相比，我们观察到缓慢注射后的瘀斑大小无明显差异（低质量证据）。由于证据不精确且不一致，我们判定此证据质量较低。
