Community Health Research Center, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran.
Department of Nursing, Dezful Branch, Islamic Azad University, Dezful, Iran.
Cochrane Database Syst Rev. 2021 Jun 8;6(6):CD008077. doi: 10.1002/14651858.CD008077.pub6.
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. Several studies have been carried out to determine if speed of injection affects the amount of pain and bruising where the injection is given; however, the results of these studies have differed, and study authors have not reached a clear final conclusion. This is the second update of a review first published in 2014.
To assess the effects of duration (speed) of subcutaneous heparin injection on pain 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). We also looked at haematoma at the injection site.
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 June 2020. We undertook reference checking of included studies to identify additional studies.
We searched for randomised controlled trials (RCTs) comparing the effects of different durations of subcutaneous injection of heparin on pain, bruising, and haematoma at the injection site.
For this update, two review authors independently selected studies and extracted data via Covidence software and assessed methodological quality using Cochrane's risk of bias tool. The primary outcomes of interest were pain intensity at injection site and size and incidence of bruising. The secondary outcomes of interest were size and incidence of haematoma at injection site. We calculated the odds ratio (OR), mean difference (MD), or standardised mean difference (SMD) with corresponding 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE criteria.
We identified one new study for this update, resulting in a total of five included studies with 503 participants who received subcutaneous injections of LMWH into the abdomen. Given the nature of the intervention, it was not possible to blind participants and caregivers (personnel) in any of the included studies. Two studies described blinding of outcome assessors. 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. Four studies reported site pain intensity after each injection at different time points. Two studies assessed site pain intensity immediately after each injection; meta-analysis showed no evidence of a difference in site pain intensity immediately after slow injection when compared to fast injection (MD -1.52, 95% CI -3.56 to 0.53; 140 participants; low-certainty evidence). Meta-analysis of three studies indicated that site pain intensity may be slightly reduced 48 hours after the slow heparin injection compared to fast injection (MD -1.60, 95% CI -2.69 to -0.51; 103 participants; low-certainty evidence). Five studies assessed bruise size at 48 hours, and two studies assessed bruise size at 60 hours. Meta-analysis showed there may be a reduction in bruise size 48 hours (SMD -0.54, 95% CI -1.05 to -0.02; 503 participants; 5 studies; very low-certainty evidence) and 60 hours (SMD -0.49, 95% CI -0.93 to -0.06; 84 participants; 2 studies; low-certainty evidence) after slow injection compared to fast injection. There was no evidence of a difference in bruise size 72 hours after slow injection compared to fast injection (SMD -0.27, 95% CI -0.61 to 0.06; 140 participants; 2 studies; low-certainty evidence). Three studies evaluated incidence of bruising and showed there may be a reduction in bruise incidence 48 hours (OR 0.39, 95% CI 0.26 to 0.60; 444 participants; low-certainty evidence) and 60 hours (OR 0.25, 95% CI 0.10 to 0.65; 84 participants; 2 studies; low-certainty evidence) after slow injection compared to fast injection. We downgraded the certainty of the evidence due to risk of bias concerns, imprecision, and inconsistency. None of the included studies measured size or incidence of haematoma.
AUTHORS' CONCLUSIONS: Administering medication safely and enhancing patient comfort are the main aims of clinical nurses. In this review, we identified five RCTs that evaluated the effect of subcutaneous heparin injection duration on pain intensity, bruise size and incidence. We found that pain may be slightly reduced 48 hours after slow injection. Similarly, there may be a reduction in bruise size and incidence after slow injection compared to fast injection 48 and 60 hours postinjection. We downgraded the certainty of the evidence for all outcomes to low or very low due to risk of bias concerns, imprecision, and inconsistency. Accordingly, new trials with a more robust design, more participants, and a focus on different injection speeds will be useful in strengthening the certainty of the available evidence.
肝素是一种通常皮下注射的抗凝药物。皮下注射肝素可能导致瘀伤、血肿和注射部位疼痛等并发症。可能影响疼痛、血肿和瘀伤的一个因素是注射速度。已经进行了多项研究以确定注射速度是否会影响注射部位的疼痛和瘀伤程度；然而，这些研究的结果有所不同，研究作者也没有得出明确的最终结论。这是 2014 年首次发表的一篇综述的第二次更新。
评估皮下肝素注射持续时间（速度）对接受普通肝素（UFH）或低分子肝素（LMWH）治疗的住院或诊所患者注射部位疼痛和瘀伤的影响。我们还观察了注射部位的血肿。
Cochrane 血管信息专家检索了 Cochrane 血管专题登记册、CENTRAL、MEDLINE、Embase 和 CINAHL 数据库以及世界卫生组织国际临床试验注册平台和 ClinicalTrials.gov 试验注册中心，检索时间截至 2020 年 6 月 22 日。我们通过纳入研究的参考文献检查确定了其他研究。
我们检索了比较不同皮下肝素注射持续时间对注射部位疼痛、瘀伤和血肿影响的随机对照试验（RCT）。
对于本次更新，两位综述作者独立选择了研究，并通过 Covidence 软件提取数据，并使用 Cochrane 的偏倚风险工具评估方法学质量。主要结局是注射部位疼痛强度和瘀伤大小及发生率。次要结局是注射部位血肿大小和发生率。我们计算了比值比（OR）、平均差异（MD）或标准化平均差异（SMD）及其相应的 95%置信区间（CI）。我们使用 GRADE 标准评估证据的确定性。
本次更新我们确定了一项新的研究，总共纳入了 5 项研究，共 503 名接受 LMWH 皮下注射的患者。由于干预的性质，在任何纳入的研究中都不可能对参与者和护理人员（人员）进行盲法。两项研究描述了对结果评估者的盲法。总的来说，纳入研究的方法学质量为中等。快速注射的持续时间为 10 秒，所有纳入研究的慢速注射持续时间均为 30 秒。四项研究在不同时间点报告了每次注射后的部位疼痛强度。两项研究立即评估了每次注射后的部位疼痛强度；meta 分析显示，缓慢注射后立即与快速注射相比，部位疼痛强度没有差异（MD -1.52，95% CI -3.56 至 0.53；140 名参与者；低确定性证据）。三项研究的 meta 分析表明，与快速注射相比，48 小时后缓慢肝素注射可能会略微降低部位疼痛强度（MD -1.60，95% CI -2.69 至 -0.51；103 名参与者；低确定性证据）。五项研究在 48 小时评估了瘀伤大小，两项研究在 60 小时评估了瘀伤大小。meta 分析显示，48 小时（SMD -0.54，95% CI -1.05 至 -0.02；503 名参与者；5 项研究；非常低确定性证据）和 60 小时（SMD -0.49，95% CI -0.93 至 -0.06；84 名参与者；2 项研究；低确定性证据）后，缓慢注射组的瘀伤大小可能会减少，而快速注射组的瘀伤大小没有差异（SMD -0.27，95% CI -0.61 至 0.06；140 名参与者；2 项研究；低确定性证据）。三项研究评估了瘀伤发生率，结果显示，48 小时（OR 0.39，95% CI 0.26 至 0.60；444 名参与者；低确定性证据）和 60 小时（OR 0.25，95% CI 0.10 至 0.65；84 名参与者；2 项研究；低确定性证据）后，缓慢注射组的瘀伤发生率可能会降低。由于偏倚风险、不精确性和不一致性，我们降低了证据的确定性等级。纳入的研究均未测量血肿的大小或发生率。
安全给药和增强患者舒适度是临床护士的主要目标。在本综述中，我们确定了 5 项 RCT，评估了皮下肝素注射持续时间对疼痛强度、瘀伤大小和发生率的影响。我们发现，与快速注射相比，48 小时后缓慢注射可能会稍微减轻疼痛。同样，与快速注射相比，48 小时和 60 小时后，缓慢注射可能会减少瘀伤的大小和发生率。由于偏倚风险、不精确性和不一致性，我们对所有结局的证据确定性等级均降低为低或非常低。因此，具有更稳健设计、更多参与者且关注不同注射速度的新试验将有助于增强现有证据的确定性。
