Subcutaneous Administration Of Heparin Research Articles

Microsurgical training in vein anastomoses: the use of systemic heparin in a rat model.

To investigate whether the use of systemic heparin could be useful for vein microvascular anastomoses in microsurgical training on rats. Femoral end-to-end venous anastomoses were performed on both thighs of 40 wistar rats by two microsurgery trainees from October 2018 to February 2019 (80 anastomoses in total). We divided the rats into 2 groups of 20 specimens (40 femoral end-to-end anastomoses) each: group A received no heparin administration; group B received subcutaneous systemic heparin administration before starting dissection. We compared both vein patency after the procedures. Patency tests showed no difference between the two groups after 5 minutes. At the delayed test after 120 minutes, vein patency was significantly better in the systemic heparin group (85,0% vs 55,0%). Even though both trainees judged practicing on both groups very instructive, they found useful performing anastomoses when heparin was administrated. We suggest including the use of systemic heparin in microsurgery training programs, especially for the beginners. Systemic heparin administration in rat models is educative for trainees.

The effect of pharmacological treatment in combination with vitamin K on healing in an experimental rat model of osteoporosis.

This study aims to compare the effects of teriparatide, zoledronic acid, and their combination therapy with vitamin K on osteoporotic rats. We divided a total of 50 female Sprague-Dawley rats into five groups: A (the control group), B and D (the teriparatide group), and C and E (the zoledronic acid group). Following ovariectomy and subcutaneous heparin administration at a dose of 2 IU/kg for four weeks, osteoporosis was created. Groups A, B, and C were fed with standard feed, while Groups D and E were fed with vitamin K-rich feed. After four weeks of treatment, sacrification was performed. The right and left femurs were separated for histopathological and biomechanical evaluation, respectively. For histopathological evaluation, the femurs were decalcified, and the sections were stained with hematoxylin-eosin and evaluated under a light microscope. Fracture healing was evaluated using the classification system as described previously. For biomechanical evaluation, the 3-point stress test and torsion stress test were applied to 10 femurs from each group. Groups B-E were histopathologically and biomechanically superior to Group A in fracture healing of osteoporotic rats; however, it was not statistically significant (p>0.05). The group that received additional vitamin K was histopathologically and biomechanically superior to the group which was fed with standard feed, although it was not statistically significant (p>0.05). Our study results indicated that both teriparatide and zoledronic acid had beneficial effects on osteoporotic fractures with comparable histological and biochemical results. Vitamin K promoted teriparatide and zoledronic acid treatment on osteoporotic fracture healing. Based on these findings, combination therapies may yield the most optimal results in biomechanical and histological examinations.

Use of Heparin Cream for Venous Congestion in the Extended Reverse Metacarpal Artery Flap: A Case Report.

Finger dorsum defects are a challenging situation. Many reconstruction methods are used in these defects. Extended reverse dorsal metacarpal artery (RDMA) flap is used in dorsal finger reconstruction. Venous congestion in this flap is most important cause of flap failure. In this case, we presented a case in which we used heparin cream due to development of venous congestion in our patient who underwent an extended RDMA flap. A 24-year-old female patient presented to the emergency department with a defect of dorsal of left-hand fourth finger. Defect was covered with an extended RDMA flap. On postoperative first day, venous congestion was observed, and heparin cream was applied three times a day on flap. The signs of venous congestion were regressed. Tissue healed as a result of superficial epidermolysis and skin grafting. No functional limitation was observed in sixth-month postoperative control. Venous congestion is the most important cause of flap failure of extended RDMA flaps. Generally, subcutaneous heparin administration and leech therapy are used. In our case, heparin was applied as a cream instead of subcutaneously, and flap healing was observed as a result of superficial epidermolysis. Heparin cream application can also be used as a treatment option in flaps with venous congestion.

CLRM-03 INCIDENCE OF INTRACRANIAL HEMORRHAGE IN GLIOMA PATIENTS WITH VENOUS THROMBOEMBOLISM CONVERTED FROM LMWH TO APIXABAN

Venous Thromboembolism (VTE) occurs in approximately 15-30% of patients with glioma 1,2 who are treated with therapeutic anticoagulants. Anticoagulation treatment increases the incidence of intracranial hemorrhage (ICH) with variable incidence between studies 1.9% to 20s% 3-6. The “common practice” treatment for VTE in glioma patients includes subcutaneous administration of low molecular weight heparin (LMWH, enoxaparin) injection, which requires daily self-injection. Switching glioma patients with VTE from LMWH to oral anticoagulants would limit the difficulty and the inconvenience of daily self-injecting in primary brain tumor patients and decrease the room for error in administering the dose along and the risk for heparin induced thrombocytopenia7. The goal of this project is to evaluate the incidence of intracranial hemorrhage in glioma patients with VTE converted from LMWH to Apixaban. We hypothesize that patients with brain tumors and Venous Thromboembolism can be converted safely from LMWH to Apixaban. To examine this hypothesis, we will enroll adult patients with pathologically confirmed supra-tentorial glioma and VTE, patient must have been treated with LMWH for ≥ 5 days. We will exclude patients with bleeding diathesis, severe hypersensitivity to Apixaban or pregnant or unable to provide informed consent. To assess the validity of our hypothesis: Primary Objective: To estimate the incidence of ICH in glioma patients with history of VTE after the conversion from LMWH to oral Apixaban. Secondary Objective: To estimate the incidence of recurrent VTE in glioma patients with history of VTE after the conversion from LMWH to oral Apixaban. To our knowledge, this is the first of its kind study to estimate the risk of ICH in glioma patients with VTE treated with oral anti-coagulation. Successful completion of our trial will provide answers to an important clinical question that could allow our patients using more convenient yet effective treatment by establishing and implementation of best practices.

Pharmacokinetic profiles of intravenous versus subcutaneous administration of low molecular weight heparin for thromboprophylaxis in critically ill patients: A randomized controlled trial.

Low molecular weight heparins (LMWH) are recommended for thromboprophylaxis in ICU patients but often fail to reach adequate peak anti-Xa activity. To compare the pharmacokinetic profiles of intravenous (IV) versus subcutaneous (SC) route of administration of LMWH. This was a prospective, monocentric, randomized trial. Patients were randomized to the IV route of administration with a 4-h infusion of nadroparin 3800 IU or to the SC route of administration. Randomization was stratified according to the need for vasopressor or not. Anti-Xa activity was measured at baseline, and at 1, 2, 4, 6, 8, 12 and 24 h after the administration was started. Sixty patients were included, of whom 30 were randomized to the IV group and 30 to the SC route. Pharmacokinetic profiles were significantly different. Mean peak anti-Xa activity was 0.38 IU/ml in the IV group vs 0.20 IU/ml in the SC group (p < 0.001). Trough values and AUC (0-24 h) were similar in both groups. Pharmacokinetic profiles were similar whether patients received vasopressors or not. The IV route of administration with a 4-h infusion lead to a significantly higher peak anti-Xa activity without affecting trough value or the AUC (0-24 h). Whether the IV administration of LMWH might improve the efficacy of thromboprophylaxis requires further research. ClinicalTrials.gov, NCT04982055, retrospectively registered 08 July 2021, https://clinicaltrials.gov/ct2/show/NCT04982055?cond=NCT04982055&draw=2&rank=1.

Antithrombotic drugs and patients’ outcomes at Cairo University Hospitals

Background Antithrombotic agents are widely used for thrombotic disorder management among critically ill patients. Subcutaneous administration of heparin is a repeated clinical practice done by nurses, which may cause adverse outcomes. Aim To investigate critical care nurses’ knowledge and practices regarding subcutaneous antithrombotic drugs and associated patients’ outcomes at Cairo University Hospitals. Research questions What do critical care nurses know regarding subcutaneous antithrombotic administration? What are critical care nurses’ practices regarding subcutaneous antithrombotic administration? What are the outcomes associated with subcutaneous antithrombotic drug administration among critically ill patients? Research design A descriptive exploratory research design. Setting Selected ICU affiliated to Cairo University Hospitals. Sample A convenience sample of 30 nurses and purposive sample of 60 adult male and female critically ill patients. Tools of data collection Four tools were utilized. Tool 1: critically ill patients’ personal characteristics and medical data sheet, tool 2: nurses’ knowledge-assessment questionnaire regarding subcutaneous antithrombotic drugs, tool 3: nurses’ practice observational checklist regarding subcutaneous antithrombotic drug administration, and tool 4: subcutaneous antithrombotic drug administration observational sheet of critically ill patients’ outcomes. Results About 60% of the studied nurses were females, 53.3% of the sample’s age ranged from 20 to less than 30 years. As well, 51.7% of critically ill patients were females, 38.3% of the sample’s age ranged from 60 to less than 70 years. The studied nurses were having unsatisfactory general knowledge level about subcutaneous anticoagulants, subcutaneous anticoagulants’ adverse effects, and nurses’ responsibilities concerning subcutaneous anticoagulants in percentages of 96.7, 96.7, and 90%, respectively. Also, unsatisfactory practice level as regards preinjection, during, and postinjection of subcutaneous anticoagulants in percentage of 100%. The most frequent adverse outcomes were localized pain, bruising, itching, and hematoma in percentages of 93, 85, 70, and 58%, respectively, where less frequent adverse outcomes were systemic thrombocytopenia, hematuria, and epistaxis in percentages of 6, 4, and 3.3%, respectively. Conclusion All critical care nurses had unsatisfactory knowledge and practice regarding antithrombotic therapy, inspite of their vital role in assessment, drug administration, care of critically ill patients, and monitoring drug-adverse effects. Also, the most frequent adverse outcomes among critically ill patients were pain, bruising, itching, and hematoma. Recommendations Updating ICU nurses’ knowledge and practice about antithrombotic drugs and maintaining close observation and record for both local and general patient’s response to antithrombotics by staff nurses during and after drug administration are highly recommended to safeguard critically ill patients against such complications.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity.

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. 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.

Effect of Cold Application on Bruising and Pain Following Heparin Subcutaneous Injection: A Systematic Review and Meta-Analysis.

We performed this review systematically to assess the effect of cold application at the heparin subcutaneous injection site on incidence and size of bruising, hematoma, and pain intensity. A systematic review and meta-analysis were utilized as the study design. To retrieve the relevant randomized controlled trials (RCTs) published up to July 2019, the databases of PubMed, Scopus, Web of Science, ScienceDirect, Cochrane Library, Google Scholar, TRIP, and Elmnet.ir were searched. Those RCTs were selected in which the participants had received any type of heparin via subcutaneous injections at least once a day, as were those comparing the effect of cold application (i.e., moist or dry ice packs or vapocoolant spray) on injection sites with no interventions or placebos. The types of outcomes measured included pain intensity, bruising, and hematoma at injection sites. Furthermore, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were employed to measure the pooled data. A total of nine studies recruiting 896 patients with a mean age range of 37 to 62 years were ultimately included in this study. The findings revealed that eight studies had used low-molecular-weight heparin, but unfractionated heparin had been administered in one study. The quality of the studies was also assessed in seven domains. Overall, risk of bias in the included articles was low to moderate. Pooling data of six studies showed that the patients had experienced less pain intensity once cold had been applied at the heparin injection sites (MD = -1.67; 95% CI -3.03 to -0.31; p = .02; I2 = 92%). Bruising had been correspondingly reported in eight and six studies in terms of size and incidence, respectively. In particular, the results had demonstrated no statistically significant difference between either group in terms of bruising size or incidence at 48 to 72 hr following heparin injection. Furthermore, hematoma incidence had been reported in two studies, and one trial had reported hematoma size only. The results had suggested that the patients had smaller hematomas (MD = -0.87; 95% CI -1.63 to -0.11; p = .03) and a lower incidence of hematomas (OR = 0.35; 95% CI 0.16 to 0.76; p = .008) in the cold application group 48 hr after injection. The results of this systematic review and meta-analysis showed that patients could experience less pain and fewer hematomas once the cold had been applied for 3 to 5 min at the injection sites before or after subcutaneous heparin administration. During this period, clinicians should also consider the patient's comfort; if some patients feel discomfort at the cold application site, the minimum possible time should be considered. This study's results could be used as evidence for all hospitalized and outpatients who need to receive any form of heparin and may suffer from local complications of this medicine.

Subkütan Heparin Uygulamalarında Beden Kitle İndeksine Göre Ekimoz ve Hematom Farklılıklarının Değerlendirilmesi

Subkütan Heparin Uygulamalarında Beden Kitle İndeksine Göre Ekimoz ve Hematom Farklılıklarının Değerlendirilmesi

Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain.

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).

Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient

IntroductionEcchymosis and/or haematoma are the most common adverse events after subcutaneous administration of low molecular weight heparin. There is no strong recommendation as to the puncture site. ObjectiveTo evaluate the adverse events, ecchymosis and/or haematoma after the administration of prophylactic subcutaneous enoxaparin in the abdomen vs the arm in the critically ill patient. MethodologyA randomised, two-arm clinical trial (injection in the abdomen vs the arm), performed between July 2014 and January 2017, in an 18-bed, polyvalent intensive care unit. Patients receiving prophylactic enoxaparin, admitted >72h, with no liver or haematological disorders, a body mass index (BMI) >18.5, not pregnant, of legal age and with no skin lesions which would impede assessment were included. We excluded patients who died or who were transferred to another hospital before completing the evaluation. We gathered demographic and clinical variables, and the onset of ecchymosis and/or haematomas at the injection site after 12, 24, 48 and 72h. A descriptive analysis was undertaken, with group comparison and logistic regression. The study was approved by the ethics committee with the signed consent of patients/families. Results301 cases (11 excluded): 149 were injected in the abdomen vs 141 in the arm. There were no significant differences in demographic and clinical variables, BMI, enoxaparin dose or antiplatelet administration [ecchymosis, abdomen vs arm, n (%): 66 (44) vs 72 (51), P=0.25] [haematoma abdomen vs arm, n (%): 9 (6) vs 14 (10), P=0.2]. Statistical significance was found in the size of the haematomas after 72h: [area of haematoma (mm2) abdomen vs arm, median (IQR): 2 (1–5.25) vs 20(5.25–156), P=0.027]. ConclusionsIn our patient cohort, prophylactic subcutaneous enoxaparin administered in the abdomen causes fewer haematomas after 72h, than when administered in the arm. The incidence rate of ecchymosis and haematoma was lower than the published incidence in critically ill patients, although patients receiving anti-platelet agents present a higher risk of injury. No relationship was observed in relation to BMI.

Formación de equimosis y/o hematoma tras la administración profiláctica de enoxaparina subcutánea en abdomen o brazo en pacientes críticos

IntroductionEcchymosis and/or haematoma are the most common adverse events after subcutaneous administration of low molecular weight heparin. There is no strong recommendation as to the puncture site. ObjectiveTo evaluate the adverse events, ecchymosis and/or haematoma after the administration of prophylactic subcutaneous enoxaparin in the abdomen vs the arm in the critically ill patient. MethodologyA randomised, two-arm clinical trial (injection in the abdomen vs the arm), performed between July 2014 and January 2017, in an 18-bed, polyvalent intensive care unit. Patients receiving prophylactic enoxaparin, admitted >72h, with no liver or haematological disorders, a body mass index (BMI) >18.5, not pregnant, of legal age and with no skin lesions which would impede assessment were included. We excluded patients who died or who were transferred to another hospital before completing the evaluation. We gathered demographic and clinical variables, and the onset of ecchymosis and/or haematomas at the injection site after 12, 24, 48 and 72hours. A descriptive analysis was undertaken, with group comparison and logistic regression. The study was approved by the ethics committee with the signed consent of patients/families. Results301 cases (11 excluded): 149 were injected in the abdomen vs 141 in the arm. There were no significant differences in demographic and clinical variables, BMI, enoxaparin dose or antiplatelet administration [ecchymosis, abdomen vs arm, n(%): 66(44) vs 72(51), P=.25] [haematoma abdomen vs arm, n(%): 9(6) vs 14(10), P=.2]. Statistical significance was found in the size of the haematomas after 72h: [area of haematoma (mm2) abdomen vs arm, median (IQR): 2(1-5.25) vs 20(5.25-156), P=.027]. ConclusionsIn our patient cohort, prophylactic subcutaneous enoxaparin administered in the abdomen causes fewer haematomas after 72hours, than when administered in the arm. The incidence rate of ecchymosis and haematoma was lower than the published incidence in critically ill patients, although patients receiving anti-platelet agents present a higher risk of injury. No relationship was observed in relation to BMI.

Subcutaneous hematomas from prophylactic heparin use.

Key Clinical MessageHeparin is an anticoagulant, which is frequently used in hospitalized patients for prophylaxis of deep vein thrombosis (DVT). Subcutaneous administration of heparin may lead to complications such as bruising, hematoma, and pain at the injection site. Hematomas can develop without visible bruising, as in our case.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity.

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. 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.

Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity.

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. 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.

Despite Guidelines, Preoperative Administration of Subcutaneous Heparin for Venous Thromboembolism Prophylaxis Is Severely Underutilized

Despite Guidelines, Preoperative Administration of Subcutaneous Heparin for Venous Thromboembolism Prophylaxis Is Severely Underutilized

The latest recommendations on the use of new oral anticoagulants in routine practice

The use of non-vitamin K antagonist oral anticoagulants (NOACs) has become a breakthrough in anticoagulant treatment and it is expected to rise significantly in upcoming years. The use of conventional anticoagulants have several limitations: subcutaneous administration of heparin, or close monitoring of INR during application of vitamin K antagonists. In the last decade, target-specific oral anticoagulants (TSOAC) including dabigatran, rivaroxaban, apixaban, edoxaban have been marketed for prophylaxis and treatment. Therefore, it is crucial to understand the potential uses, side effects, and management of these agents in routine practice. NOACs have major pharmacologic advantages, including a rapid onset and offset of action, fewer drug interactions than conventional anticoagulants, and predictable pharmacokinetics. These agents are gaining popularity among both physicians and patients because of their easiness of administration and the eliminating the requirement for regular coagulation monitoring. In this review, we focus on discussing practical recommendations for the use of NOACs and the risks and benefits of incorporating them into routine practice.

Bilateral Cortical Blindness due to Bilateral Occipital Infarcts without Anosognosia

Bilateral cortical blindness refers to the total loss of vision in the presence of normal pupillary reflexes and in the absence of Ophthalmological disease resulting from bilateral lesions of the striate cortex in the occipital lobes. In most cases, these patients deny their blindness and their behavior is as if they have an intact vision. We report the case of an 84-year-old man with bilateral cortical blindness resulting from bilateral occipital lobe infarcts. The patient presented this infrequent clinical condition after acute bilateral infarction of the occipital lobes possibly due to cardiac embolism resulting from atrial fibrillation of unknown duration. Subcutaneous administration of low molecular weight heparin in therapeutic doses resulted in neurological improvement in the first four days. Interestingly, the visual symptoms were complicated neither by anosognosia nor by memory impairment. Cortical blindness and Anton’s syndrome should be considered in patients with atypical visual loss and evidence of occipital lobe injury. Cerebrovascular disease could be the background in a bilateral cortical blindness, as in our patient. To our knowledge, this is the first reported case with bilateral cortical blindness due to simultaneous bilateral occipital infarcts but without anosognosia. Bilateral cortical blindness refers to the total loss of vision in the presence of normal pupillary reflexes and in the absence of Ophthalmological disease resulting from bilateral lesions of the striate cortex in the occipital lobes. In most cases, these patients deny their blindness and their behavior is as if they have an intact vision. We report the case of an 84-year-old man with bilateral cortical blindness resulting from bilateral occipital lobe infarcts. The patient presented this infrequent clinical condition after acute bilateral infarction of the occipital lobes possibly due to cardiac embolism resulting from atrial fibrillation of unknown duration. Subcutaneous administration of low molecular weight heparin in therapeutic doses resulted in neurological improvement in the first four days. Interestingly, the visual symptoms were complicated neither by anosognosia nor by memory impairment. Cortical blindness and Anton’s syndrome should be considered in patients with atypical visual loss and evidence of occipital lobe injury. Cerebrovascular disease could be the background in a bilateral cortical blindness, as in our patient. To our knowledge, this is the first reported case with bilateral cortical blindness due to simultaneous bilateral occipital infarcts but without anosognosia.

Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus.

Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer.

Risk Factors for DVT/PE in Patients with Stroke and Intracranial Hemorrhage.

Objective: Deep venous thrombosis (DVT) and pulmonary embolus (PE) are serious problems for patients admitted to the hospital with stroke, subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and transient ischemic attack (TIA). The purpose of this paper is to further understand the factors that place certain patients at increased risk of DVT/PE.Methods: At a 600 bed hospital, a retrospective analysis of data from 2613 patients admitted with a diagnosis of stroke, SAH, ICH or TIA in the time range 1/2008 through 3/2012 was carried out. The data was taken from the hospital’s Get with the Guidelines database and included 28 variables. These included initial NIH stroke scale, length of stay, heart failure, ambulatory by day 2 after admission, altered mental status,and renal failure among others. Multiple analyses were carried out to determine whether there were univariable or multivariable effects of any of the factors on the risk for DVT/PE.Results: The risk of DVT/PE was highest in patients with SAH and ICH and smallest with TIA. Multivariable analyses were performed and revealed only altered level of consciousness or heart failure as significant risks for DVT/PE. With the limited available data, administration of subcutaneous heparin or other chemoprophylaxis did not reduce the risk of DVT/PE. Conclusion: Although many of the variables used to describe the stroke patient are correlated, in multivariable analyses only heart failure and altered level of consciousness were important risk factors for DVT/PE. The risk of DVT/PE was 7 fold greater in patients in patients with both of these risk factors.