Jennifer Nopoulos MSNEd, RN, CPAN
Amongst the vital information upon which I focused during anesthesia provider handoff; anticoagulant dosing information was paramount. Often, this was not documented on anesthesia report sheets, and I had to listen or ask for the information. During this heightened awareness, I noticed that providers were administering these sub-cutaneous injections in the arm, not the abdomen, the site of choice specified in every drug reference I consulted (Heparin, 2022, Vallerand & Sanoski, 2015, & Burchum & Rosenthal, 2016).
The choice of the arm instead of the abdomen during the pre-operative phase makes sense: patients are prepped and draped; abdominal access may be impossible. As often occurs in empirical practice, nurses interpreted this change in administration site as an authorization to deviate from recommended practice and administer subsequent injections in the arm, regardless of surgical site or abdominal assessment.
As a former pharmacology instructor, I wanted to see research or evidence that this practice was safe for the patient and an acceptable alternative to the long-held teaching that best absorption was from abdominal administration (Wisconsin Technical College System, Nd). This direction is drawn from belief that the thicker tissue and greater surface area of the abdomen would decrease bruising and movement into surrounding tissues (Babaieasl et.al., 2018). Searching institutional policies only increased ambiguity: the two accessed did not specify sites for anticoagulation administration. Thus, one could assume that sub-cutaneous administration in locations other than the abdomen would be acceptable.
A literature search yielded a few on point studies, one over 30 years old, that validates injecting into other sub-cutaneous sites resulted in no increase in bruising and no alterations in measured coagulation studies (Stewart & Kinney, 1991). In another, focused exclusively on evaluating bruising, Ciftci & Avsar (2017) compared abdomen, thigh, and arm and concluded no site was superior to the others. More recently, Babaieasl et.al. (2018) suggests through their study that the arm is a more appropriate site, reducing bruising and increasing patient comfort.
This begs the question, why do drug references intended for nurses still advise the exclusive abdomen site for sub-cutaneous anticoagulants (Heparin, 2022, Vallerand & Sanoski, 2015, & Burchum & Rosenthal, 2016)? Policy and practice need to reflect sound research. Until then, peri-operative nurses are encouraged to follow current institutional policies, ASPAN core curriculum, and advocate for policy clarity that reflects best practice.
Of note, Carpenter (2018) submitted a challenge to the findings of Babaieasl et.al. (2018) in a letter to the editor. The authors of the original paper resubmitted their tables in response, clarifying data findings with no alteration in conclusions (Carpenter 2018).
References
Babaieasl, F., Yarandi, H., Moosazadeh, M., & Kheradmand, M. (May-June 2018). Low-molecular weight heparin and complications of subcutaneous injection: How important is injection site selection? Medsurg Nursing, Vol. 27/No.3.
Burchum, J.R., & Rosenthal, L.D. (2016). Lehne’s pharmacology for nursing care. 9th edition. Elsevier, St. Louis, MO.
Carpenter, J. (November-December 2018). Erratum: Clarifying injection site selection analysis. Medsurg Nursing, Vol. 27/No. 6.
Ciftci, B., & Avsar, G. (2017). Assessment of three sites in terms of bruising in subcutaneous heparin administration.
International Journal of Caring Sciences. Vol. 10/ Issue 1. Pg 285.
Heparin Sodium: Administration. (2022). In Micromedex (University of Arizona Library ed.) [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved December 16, 2022, from http://www.micromedexsolutions.com/
Stewart, P.S., & Kinney, M.R. (July- August 1991). The abdomen, thigh, and arm as sites for subcutaneous sodium heparin injections. Nursing Research, Vol 40, No. 4.
Vallerand, A.H., & Sanoski, C. A. (2015). Davis’s drug guide for nurses. 14th edition. F.A Davis, Philadelphia, PA.
Wisconsin Technical College System. (Nd.) Administering subcutaneous medications. Retrieved on Dec 15, 2022, from https://wtcs.pressbooks.pub/nursingskills/chapter/18-5-administering-subcutaneous-medication/