Download Low Molecular Weight Heparin (Enoxaparin).

Title of Guideline (must include the word “Guideline” (not protocol,
policy, procedure etc)
Author: Contact Name and Job Title
Directorate & Speciality
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and exclusion criteria, diagnosis)
Version
If this version supersedes another clinical guideline please be
explicit about which guideline it replaces including version number.
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guideline been peer reviewed by colleagues?
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
4
well –designed non-experimental descriptive
studies (ie comparative / correlation and case
studies)
5
expert committee reports or opinions and / or
clinical experiences of respected authorities
6
recommended best practise based on the clinical
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Target audience
Guideline for the Subcutaneous
Administration of Low Molecular Weight
Heparin (Enoxaparin)
Thromboprophylaxis committee. Original
author: Maria Rodriguez, Deputy Ward
Manager F19 no longer within NUH
DIAGNOSTICS & CLINICAL SUPPORT
January 2015
Medical and surgical patients suffering with or
at risk of having a deep-vein thrombosis DVT
and or a pulmonary embolism (PE).
All patients should be assessed for risk of
bleeding before offering prescribed
pharmacological VTE thromboprophylaxis
(NICE 2010).
2
Version 1: Guideline for the Subcutaneous
Administration of Low Molecular Weight
Heparin
(Enoxaparin)
1,5 and 6
Nursing Practice Guidelines Group, Matrons,
Heamostasis and Thrombosis nurses.
Thromboprophylaxis committee (no e-mail
group). Clinical Leads, Ward/ Department
Sisters/ Charge Nurses, specialist nurses,
Infection Control
Matron’s Forum
Feb 2015
All registered nurses and allied health
professionals
Review Date: (to be applied by the Integrated Governance Team)
A review date of 5 years will be applied by the Trust. Directorates
can choose to apply a shorter review date, however this must be
managed through Directorate Governance processes.
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician.
If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review
date.
1
Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
NURSING PRACTICE GUIDELINES
Subcutaneous Administration of Low Molecular Weight
Heparin
(Enoxaparin)
INTRODUCTION
Enoxaparin is a low molecular weight heparin (LMWH) that is
used in the prevention and treatment of medical and surgical
patients suffering with or at risk of having a deep-vein thrombosis
DVT and or a pulmonary embolism (PE). Thrombus formation can
cause death, disability and chronic ill health. All patients should
be assessed for risk of venous thromboembolism (VTE) on
admission.
All patients should be assessed for risk of bleeding before offering
prescribed pharmacological VTE thromboprophylaxis (NICE
2010).
This guidance refers to the use of Clexane enoxaparin
sodium, currently in use at NUH.
Best Practice
All adult medical inpatients will have a VTE risk assessment on
admission to hospital Commissioning for Quality and Innovation
(CQUIN) payment framework (Department of Health 2008). At
NUH the completion of the VTE risk assessment is carried out by
medical staff
PROCEDURE FOR ADMINISTERING SUBCUTANEOUS LOW
MOLECULAR WEIGHT HEPARIN
EQUIPMENT
Patient prescription chart with prescribed enoxaparin
Enoxaparin syringe of appropriate dose
Gauze and water to clean skin if soiled
Sharps bin
Gloves
Apron
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Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
Refer to general principles for all guidelines.
PREPARATION OF EQUIPMENT – NURSING RESPONSIBILITIES
1
2
3
4
5
6
7
8
ACTION
Assist the patient if required to
sit comfortably in bed or chair
Prepare the injection in a
designated clean area of the
clinical area/department.
Check the medication in
accordance with the local Drug
Code of Practice.
Check that the packaging of all
equipment is intact.
Perform hand decontamination,
If dose contained in the syringe
has to be adjusted to match
prescribed dose, discard excess
enoxaparin holding needle facing
downwards
RATIONALE
To access the abdominal area
To reduce the risk of
contaminating the equipment or
medication used.
To reduce the risk of error in
administration.
To reduce the risk of cross
infection.
To minimise risk of bruising by
preventing the drug coating the
needle and penetrating the skin
tissue as the needle pierces the
skin, (Balci and Celebioglu 2008,
Chan 2001)
By holding the needle downwards
the air bubble within the solution
remains. Removal of the air
bubble prior to administration
could alter the dose of the drug
(Sanofi Aventis package leaflet,
information for user 2008)
If dose contained in the syringe
matches the prescribed dose, do
not purge the syringe to remove
the air bubble
Removal of the air bubble prior to
administration could alter the dose
of the drug (Sanofi Aventis
package leaflet, information for
user 2008)
Choose an area on the right or left To avoid umbilical veins and
side of the abdomen 5cm away
reduce risk of bleeding (Zayback
from the umbilicus, scars and or
and Khorshid 2008, Balci and
bruises.
Celebioglu 2008, Kockrow 2003,
Chan 2001, Kuzu and Ucar
2001,Stewart Fahs and Kinney
1991, Wooldridge and Jackson
1988).
3
Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
Enoxaparin should only be
administered in the abdominal
wall.
The abdominal skin usually has a
thicker subcutaneous tissue
(>25mm) than that of arms and
legs and has minimal muscular
activity. Therefore the risk of
injecting the drug into the muscle
is reduced.
The abdominal site provides a
larger area to accommodate and
alternate a greater number of
injections (Zeerakiti, Karimi,
Shahrzad and Changiz 2005,
Chan 2001, McGowan and Wood
1990,Kroon, De Boer , Kroon
Schoenmaker, Meer and Cohen
1991)
9
If this area is not suitable for
injection e.g. cachexia or surgery
an alternative drug should be
sought by discussion between
medical and pharmacy staff
Enoxaparin is currently only
licensed by the manufacturers for
administration into the abdominal
area.
To remain within manufacturer
licensing policy for administration.
10
Site selection should be alternated To avoid injecting into an area
from right to left.
where bruising is developing.
Development of bruising from
previous injections peak by 48
hours and start to resolve 72
hours post injection (Sanofi
Aventis 2008, Vanbree,
Hollerbach and Brooks 1984)
11
Raise a skin fold between
forefingers and thumb and hold
the skin throughout the duration of
the injection
12
Insert the needle vertically at 90°
To maintain contact with the
subcutaneous tissue and avoid
deeper vascular areas (Zaybak
and Korshid 2008, Vanbree et al
1984, Hadley, Chang and Rogers
1996, McConnell 2000, Chan
2001, Sanofi Aventis 2008)
To reach the deep subcutaneous
tissue (Balci and Celebioglu
2008, Kuzu and Ucar 2001,
4
Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
Chan 2001, Klingman 2000,
Ross and Soltes 1995, Stewart
Fahs and Kinney 1991)
13
Avoid any movement of the
needle once inserted.
14
Administer the injection slowly
over a minimum of 10 seconds
15
Remove the needle maintaining a
90° angle.
16
Once the needle is removed, if
required gentle pressure can be
applied to the site with clean
gauze. Advise the patient not to
rub the injection site
17
Dispose of equipment according
to hospital policy
To reduce risk of bleeding
(Vanbree, Hollerbach and Brooks
1984, McConnell 2000,
The slower the process the more
time is allowed for the absorption
of the injectate and less pain is
experienced (Wooldridge and
Jackson 1988, Hall 2004, Smith
and Duell 1997, Balci and
Celebioglu 2008). Enoxaparin
given over 30 seconds can reduce
pain further and minimise the risk
of bruise formation (Chan 2001,
Zaybak and Korshid 2008).
To avoid traumatizing the tissue
surrounding the injection site,
minimising risk of bruising and
therefore preserving tissue for
future injections (Chamberlain
1980, Aguilera Manrique 2002,
Gomez et.al 2005, Balci and
Celebioglu 2008)
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Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
REFERENCES:
Aguilera G, Granados G, Belmonte MT, Muňoz MJ, Aguilera F
and Garcia ER (2002) Administracion de heparinas de bajo peso
molecular
y
aparición
de
hematoma.
Low molecular weight heparins and hematoma. Enfermeria
Clinica Vol 12 (3) pp 89-93. Supplied by The British Library “The
World’s knowledge”. Via the interlibrary Loan Service at the
Nottingham University Library. Request number 57767SED99
REAPP date 03/12/2009.
Balci Akpinar R and Celebioglu A (2008) Effect of injection
duration on bruising associated with subcutaneous heparin: A
quasi-experimental within subject design. International Journal of
Nursing Studies. Vol. 45 pp 812-817. [On line] Available at
www.sciencedirect.com.
Chan H (2001) Effects of injection duration on site-pain intensity
and bruising associated with subcutaneous heparin. Journal of
Advanced
Nursing
Vol
35
(6)
pp
882-892.
[online]
Available
at:
th
http://www.blackwellpublishing.com Accessed 13
February
2008.
Chamberlain S.L. (1980) Low-dose heparin therapy. American
Journal
of
Nursing.
80:6 pp 1115-1117.
Department of Health (2008) Impact assessment of
commissioning for quality and innovation payment framework.
Version 3.7 Published December 2008.
Gomez MJ, Martinez MA, and Garcia I (2005) Cual es la tecnica
idonea
para
disminuir las complicaciones locales secundarias a la
administración
subcutánea
de enoxaparina? Ensayo clínico aleatorizado. What is the ideal
technique to reduce local complications secondary to
subcutaneous enoxaparin administration? A randomized clinical
trial. Enfermeria Clinica 15 (6) pp 329-334. Supplied by The
British Library “The world’s knowledge” via interlibrary Loan
Service at Nottingham University Library. Request number
57770SED99 REAPP date 03/12/2009.
6
Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
Hadley S, Chan M, and Rogers K (1996) Effect of syringe size on
bruising following subcutaneous heparin injection. American
Journal
of
Critical
Care.
Vol.5,
pp
271276. CITED IN: Balci Akpinar R and Celebioglu A (2008) Effect of
injection duration on bruising associated with subcutaneous
heparin:
A
quasi-experimental
withinsubject design. International Journal of Nursing Studies. Vol. 45
pp 812-817.
Hall A. M (2004) Administration of injections. CITED IN: Elkin
M.K.Perry
A.G.
Potter PA (eds). Nursing Interventions and clinical skills. St. Louis
Missouri. Pp 471-474.
Kockrow C (2003) Foundations of Nursing. St. Louis Missouri,
page 592.
Kroon C, De Boer A, Kroon JM, Schoenmaker HC, Meer FJ and
Cohen AF (1991) Influence of skinfold thickness on heparin
absorption.
The
Lancet.
Vol
337,
April
20th. Pp945-946.
Kuzu N and Ucar H, (2001) The effect of cold on the occurrence
of bruising, haematoma and pain at the injection site in
subcutaneous low molecular weight heparin. International
Journal of Nursing Studies. Vol. 38 (1) February, pp 51-59.
Klingman L, (2000) Effects of changing needles prior to
administering heparin subcutaneously. Heart & Lung Vol 29, pp
70-75.
McConnell E (2000) Do’s & Don’ts: Administering Subcutaneous
heparin. Nursing. June 2000. [online] Available from
http://findarticles.com/p/articles/mi.
McGowan W and Wood A (1990) Administering heparin
subcutaneously:
an
evaluation of techniques used and bruising at the injection site.
The
Australia
Journal of Advanced Nursing Vol. 7(2) pp30-39, February.
National Institute of Clinical Excellence (2010) VTE Prevention
Quality
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Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
Standard.
June
2010.
[online]
Available
from:
http://www.nice.org.uk/aboutnice/qualitystandards/vteprevention/
VTE
Ross S (1995) Heparin and haematoma: does ice make a
difference? Journal of Advanced Nursing, Vol. 21 pp 434-439.
Sanofi Aventis- www.sanofi-aventis.com One Onslow Street.
Guildford. Surrey. GU1 4YS.
Smith S, Duell D (1997) Clinical Nursing Skills: Basic to
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Skills,
4th ed. Appleton and Lange, East Norwalk, pp 328-329.
Stewart Fahs P and Kinney M, (1991) The Abdomen, Thigh, and
Arma
as
Sites for Subcutaneous Sodium Heparin Injections. Nursing
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40 (4) pp 204-207. July/August.
Vanbree N, Hollerback A and Brooks GP, (1984) Clinical
Evaluation of Three Techniques for Administering Low-Dose
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33 No.1 pp 15-19.
Wooldridge J B, and Jackson J G, (1988) Evaluation of bruises
and areas of induration after two techniques of subcutaneous
heparin
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Heart
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Zaybak A, and Khorshid L (2008) A Study on the effect of the
duration of subcutaneous heparin injection on bruising and pain.
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Publishing Ltd. Doi: 10.1111/j.1365-2702.2006.01933.x.
Zeraatkari K, Karimi M, Shahrzad M, and Changiz T (2005)
Comparison of heparin subcutaneous injection in thigh, arm &
abdomen.
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8
Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.
BIBLIOGRAPHY:
Rodriguez-Juarez M.D (2010) Is there a recommended technique
for the administration of subcutaneous Enoxaparin? A review of
existent
literature. Unpublish Document: Submitted as a Dissertation for
BSc (Hons) in Health Care Studies.
Author: Thromboprophylaxis committee ( Original author) Maria
Rodriguez
NMPGG Link Member: Ellie Dring
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Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin
(Enoxaparin) Ratified Feb 2015 Review 2020.