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Clinical Practice Keywords Subcutaneous injection/ Medicine administration/Absorption Practical procedures This article has been Injection technique double-blind peer reviewed Injection technique 2: administering drugs via the subcutaneous route

rugs administered by the sub- upper arm and thigh, and the umbilical Author Eileen Shepherd is clinical editor cutaneous route are deposited region of the abdomen (Ogston-Tuck, at Nursing Times. into subcutaneous tissue 2014; Hunter, 2008). The back and lower D(Fig 1); small volumes (up to loins can also be used (Fig 2). Abstract The subcutaneous route 2ml) of non-irritant, water-soluble drugs Injection sites should be: allows drugs such as insulin and heparin can be administered by subcutaneous l Clean; to be absorbed slowly over a period of injection (Dougherty and Lister, 2015). l Free of infection, skin lesions, scars, time. Using the correct injection Unlike muscle, subcutaneous tissue birthmarks, bony prominences, and technique and selecting the correct site does not have a rich blood supply, and large underlying muscles, blood vessels will minimise the risk of complications. absorption of drugs delivered via that or nerves (Dougherty and Lister, 2015). This is the second article in a two-part route is therefore slower than via the intra- As the amount of subcutaneous fat series on injection techniques. Part 1 muscular route (see part 1) (Dougherty and varies between patients, individual patient covered the intramuscular route. Lister, 2015). This slower rate of absorption assessment is vital before carrying out the is beneficial when continuous absorption procedure. It is important to avoid inad- Citation Shepherd E (2018) Injection of a drug is required; for example, with vertently injecting the drug into muscle, technique 2: administering drugs via insulin or heparin (Hunter, 2008). as intramuscular injection can affect drug the subcutaneous route. Nursing Times Factors affecting blood flow to the skin, absorption; for example, inadvertent [online]; 114: 9, 55-57. including exercise and changes in environ- administration of insulin into the muscle mental temperature, can affect drug can lead to accelerated insulin absorption absorption. The subcutaneous route may be and lead to hypoglycaemia (Down and unreliable in patient with conditions that Kirkland, 2012). result in impaired blood flow, such as circu- A lifted skinfold technique (pinching or latory shock (Dougherty and Lister, 2015). bunching the skin) can be used to lift It is often suggested that the subcuta- the subcutaneous layer away from the neous route is relatively pain free (Zijlstra underlying muscle (Down and Kirkland, et al, 2018; Srivastava and Robson, 2012) 2012) (Fig 3). This method reduces the risk but the evidence supporting this assertion of inadvertent intramuscular injection is poor and further research is required. A when undertaken correctly; however, Cochrane review in 2017 looked at the dura- releasing the skin too quickly before the tion of pain and bruising after subcuta- injection is completed or lifting it incor- neous heparin injection and reported that rectly can increase that risk (Down and a slow injection – taking 30 seconds to Kirkland, 2012). administer – may reduce pain but there is no difference in bruising compared with a Needles fast injection (Mohammady, 2017). The Safety needles should be used for subcuta- researchers noted that the evidence was of neous injections to reduce the risk of needle- low quality. stick injury (Health and Safety Executive, Complications associated with subcuta- 2013). Some drugs such as heparin come in a neous injections include abscesses and, in pre-loaded syringe and patients prescribed patients who require frequent injections, insulin may use insulin delivery devices. there is a risk of lipohypertrophy; this is Needle size is measured in gauges characterised by an accumulation of fat (diameter of the needle) – a 25G is com- under the skin. Lipohypertrophy occurs monly used for subcutaneous injections when multiple injections are repeatedly (Dougherty and Lister, 2015; Public Health Box 1. ‘Five rights’ of administered into the same area of skin. It England, 2013). Needle size depends on the medicines administration can be painful and unsightly, and affect drug viscosity of the liquid being injected absorption, but can be prevented by rotating (Dougherty and Lister, 2015). l Right patient injection sites (Down and Kirkland, 2012). Needles need to be long enough to l Right drug inject the drug into the subcutaneous l Right time Preparation tissue. They come in lengths of 4-8mm. l Right dose Site selection Dougherty and Lister (2015) suggest the l Right route Recommended sites for subcutaneous required needle length can be estimated by injection include the lateral aspects of the pinching the skin using the lifted skinfold

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Fig 1. Tissue structure and Fig 2. Subcutaneous injection sites subcutaneous injection Dermis layer Anterior Posterior Subcutaneous layer

Muscle layer Lateral aspect of Posterior the lower part of aspect of the the upper arm upper arms

Abdomen in technique (Fig 3) and selecting a needle Back that is 1.5 times the width of the umbilical Lower region the skinfold. loins

Skin preparation There is debate around the use of alcohol- Thighs impregnated swabs to clean injection sites. The World Health Organization (2010) suggested that if a patient is physi- cally clean and generally in good health, swabbing of the skin before injection is not required. This was supported by Hicks et al (2011) in the First UK Injection Technique Recommendations. skin of both health worker and patient l Receiver or tray to carry the drug; In older patients and those who are is intact. It also notes that gloves do not l Sharps container. immunocompromised, skin preparation protect against needlestick injury. 1. Explain the procedure to the patient and using an alcohol-impregnated swab (70% Nurses need to assess risk in each indi- gain consent. isopropyl alcohol) may be recommended vidual patient (Royal College of Nursing, (Dougherty and Lister, 2015). The patient’s 2018) and be aware of local policies for 2. Screen the patient to ensure privacy condition should be individually assessed glove use. during the procedure. and local policies should be followed. Angle of injection 3. Check whether the patient has any allergies. Aspiration It is recommended that subcutaneous It is common practice to draw back on a injections, particularly of insulin, are 4. Check the prescription is correct and syringe after the needle has been inserted administered at a 90o angle to ensure that follow the ‘five rights’ of medicines admin- to check whether it is in a blood vessel. the medication is delivered into the subcu- istration (Box 1) and local medicines admin- This is not recommended for subcuta- taneous tissue (Down and Kirkland, 2012; istration policy to reduce the risk of error. neous injections, as there are no major Hunter, 2008). However, patient assess- blood vessels in the subcutaneous tissue ment is vital – patients who are cachectic 5. Wash and dry hands to reduce the risk of and the risk of inadvertent intravenous and therefore have minimal amounts of infection. administration is minimal (Public Health subcutaneous tissue may require injec- England, 2013). tions to be delivered at a 45o angle. 6. Assemble the syringe and needle and PHE (2013) recommends that subcuta- then draw the required amount of drug Gloves neous vaccinations are given with the from the ampoule. Some drugs are avail- The WHO (2010; 2009) stated that gloves needle at a 45o angle to the skin and the skin able in pre-filled syringes and manufactur- need not be worn for this procedure if the should be pinched together (PHE, 2013). er’s instructions should be followed.

Procedure 7. Disperse any air bubbles from the syringe. Professional responsibilities Equipment: This procedure should be undertaken l Needles (one of which should be a 8. Change the needle to ensure that the one only after approved training, supervised safety-engineered device) and syringe you are about to use for injecting the drug practice and competency assessment, or prefilled syringe; is sharp, thereby reducing pain (Agaç and and carried out in accordance with local l Drug for administration; Günes, 2011). To reduce the risk of sharps policies and protocols. l Medicines administration chart/ injury, a safety-engineered needle should

PETER LAMB PETER prescription; be used for injection.

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Fig 3. Lifted skinfold technique sharps bin and dispose of the syringe according to local policy.

25. Ensure the patient is comfortable and wash hands. 3a. Lift the skin between thumb and 3b. Incorrect technique two fingers with one hand, pulling 26. Record administration on the prescrip- the skin and fat away from the tion chart. Also record administration site underlying muscle so that the same site is not repeatedly used. This is to avoid lipohypertrophy.

27. Monitor the patient for any effects of the prescribed medicine and any problems with the injection site.

28. Patients receiving injection in a health centre or outpatient department may need to wait for a period of time to monitor for any reaction to the drug. Local policies should be followed. NT

References Ağaç E, Güneş UY (2011) Effect on pain of changing the needle prior to administering medicines intramuscularly: a randomized controlled trial. Journal of Advanced Nursing; 67: 3, 563-568. Dougherty L, Lister S (2015) The Royal Marsden Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Down S, Kirkland F (2012) Injection technique in insulin therapy. Nursing Times; 108: 10, 18-21. 9. Dispose of the needle used to draw the to carry out the injection. Use distraction Health and Safety Executive (2013) Health and drug in a sharps container according to and relaxation techniques to reduce anx- Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for Employers and local policy. iety if needed. Employees. Bit.ly/HSESharps2013 Hicks D et al (2011) Diabetes Care in the UK. The 10. Place the injection in a tray and take it 19. Hold the syringe and needle in your First UK Injection Technique Recommendations. to the patient, along with a sharps bin so dominant hand and pinch the skin Bit.ly/FIT2011 Hunter J (2008) Subcutaneous injection the used needle can be disposed of imme- together using the non-dominant hand to technique. Nursing Standard; 22: 21, 41-44. diately after the procedure. lift the tissue away from underlying Mohammady M et al (2017) Slow versus fast muscle (Fig 3) (Dougherty and Lister, 2015). subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database 11. Check the patient’s identity according of Systematic Reviews; 10: CD008077. to local medicines management policy. 20. Insert the needle at the required angle Ogston-Tuck S (2014) Subcutaneous injection (usually 90o) using a dart-like action. Aspi- technique: an evidence-based approach. Nursing Position the patient comfortably with ration to check whether the needle is in a Standard; 29: 3, 53-58. 12. Public Health England (2013) Immunisation the selected injection site exposed (Fig 2). blood vessel is not necessary (PHE, 2013). Procedures: The Green Book, Chapter 4. Bit.ly/GreenBookCh4 13. Check the site for signs of oedema, 21. Depress the plunger and inject the drug Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Care Staff on Glove Use infection or skin lesions. If any of these are slowly over 10-30 seconds (Dougherty and and the Prevention of Contact Dermatitis. present, select a different site. Lister, 2015). Bit.ly/RCNGloves Srivastava L, Robson P (2012) Pain from subcutaneous injections: myth or reality. 14. Wash and dry hands. 22. Wait 10 seconds before withdrawing BMJ Supportive and Palliative Care; 2: A62. the needle (Down and Kirkland, 2012) – this World Health Organization (2010) WHO Best 15. If gloves are considered necessary will prevent backtracking of the drug Practices for Injections and Related Procedures following risk assessment, put gloves on. (Hunter, 2008) – and then withdraw the Toolkit. Bit.ly/WHOInjection World Health Organization (2009) WHO needle. Do not massage the area, as this Guidelines on Hand Hygiene in Health Care. 16. Ensure the skin is clean or follow local can lead to bruising following administra- Bit.ly/WHOHands2009 policy on skin cleansing. tion of heparin (Ogston-Tuck, 2014) and Zijlstra E et al (2018) Impact of injection speed, volume, and site on pain sensation. Journal of speed up absorption times with insulin Diabetes Science and Technology; 12: 1, 163-168. 17. If skin cleansing is considered neces- (Down and Kirkland, 2012).

sary, swab for 30 seconds with isopropyl CLINICAL alcohol and then allow to dry for 30 sec- 23. Release the lifted skinfold (Down and SERIES Injection technique series onds (Dougherty and Lister, 2015). Kirkland, 2012). Part 1: Intramuscular route Aug Part 2: Subcutaneous route Sep

PETER LAMB PETER 18. Inform the patient that you are going 24. Dispose of sharps directly into the

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