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Subcutaneous injection technique

Categories: Injection Technique
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About Course

Injections are routinely administered by practitioners in private and acute care settings and in the community. Practitioners require a thorough understanding of anatomy and physiology, pharmacological principles and equipment, and potential risks to the patient of injections. Practitioners should also take an active approach to patient assessment before injecting medicines. This module provides an evidence-based review of injection administration, with particular reference to subcutaneous injections, and suggests a framework for best practice.

This learning module addresses the topic of safe injection practice with particular reference to the subcutaneous technique. It draws on current research and evidence to inform a framework for best practice when injecting insulin and heparin using the subcutaneous route. It also addresses the knowledge and skills required for effective clinical decision making and a safe approach to clinical practice.
Intended learning outcomes

After reading this module and completing the time out activities you should be able to:

  • Identify aspects of injection technique that should form part of a standard assessment before administering any medications.
  • Describe why the subcutaneous route is used for certain medications, including insulin and heparin.
  • Suggest suitable sites for injection of common medications.
  • List the main steps in injection technique that minimise potential adverse effects.
  • Discuss the principles of patient assessment to maximise the success of all subcutaneous injections.
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What Will You Learn?

  • Aims & Intended learning outcomes
  • Introduction
  • Indications for subcutaneous injections
  • Site of injection
  • Equipment
  • Technique
  • Risks of subcutaneous injections
  • Heparin and insulin injections
  • Patient assessment
  • Conclusions

Course Content

Introduction
This course provides an evidence-based review of injection administration, with particular reference to subcutaneous injections, and suggests a framework for best practice.

  • Learning outcomes

Injection Skill
The course provides an overview of the subcutaneous injection skill, with a focus on two common drugs for injection: insulin and heparin. Although both of these medicines are delivered via the same route, the rationale for the injection technique and the patient assessment differ in each.

Risks
Risks of subcutaneous injections Although the subcutaneous route is relatively pain-free, over-injection can lead to these sites being more painful. Poor injection technique can lead to adverse outcomes for the patient: site pain and bruising can occur from local tissue trauma. Rotation of sites is therefore recommended to avoid scarring, hardening of tissue and pain. This also prevents fibrosis, irritation and ensures improved absorption. Incorrect injection technique (such as in insulin therapy) – even when using the correct needle length – can lead to injectable therapies being poorly absorbed.

Heparin
Heparin Low-molecular-weight heparins such as enoxaparin sodium are available in pre-filled syringes in a range of dosage forms and strengths, for example 40mg in 0.4mL. Pre-filled syringes and graduated pre-filled syringes are for one-time use only and are available with systems that shield the needle after injection. The air bubble should not be expelled from pre-filled syringes, as this is designed to remain next to the plunger to ensure the whole dose is administered (Hunter 2008). The recommended site for injection is on the right or left side of the abdomen, 5cm away from the umbilicus. This is to avoid the umbilical veins and reduce the risk of bleeding (Chan 2001, Christensen et al 2003, Zaybak and Khorshid 2008). Any area with scars or bruising should also be avoided. Enoxaparin sodium is licensed for administration into the abdominal wall only. The abdominal skin usually has thicker subcutaneous tissue (>25mm) than the arms and legs and has minimal muscular activity – therefore the risk of injection into the muscle is reduced. The abdominal site also provides a larger area to accommodate a greater number of injections (Zeraatkari et al 2005). Always follow the manufacturer’s guidance and any local protocol, but generally administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal walls. The whole length of the needle should be introduced into a skin fold held between the thumb and forefinger, and the skin fold should be held throughout the injection (Hunter 2008). It is recommended that the injection site is not rubbed following completion of the injection, to avoid bruising (Chan 2001). The volume of injectate is dependent on the dose and can range from 0.4mL up to 1-2mL. It should be administered at a speed that prevents harm and discomfort to the patient (Chan 2001). This can be achieved by injecting slowly. The manufacturer’s guidelines for enoxaparin sodium suggest a duration of 30 seconds. However, a slower injection speed can reduce the risk of bruise formation (Chan 2001, Zaybak and Khorshid 2008).

Insulin
Insulin In insulin therapy, it is vital that the correct injection technique is taught and performed by the patient or person. If insulin is injected into a muscle (which can occur when longer needles are used, or a lifted skin fold is not performed correctly) it will be absorbed more quickly and could cause hypoglycaemia (TREND-UK 2018). In addition, the rate of absorption of some insulins varies according to the site of delivery and more detailed guidelines are valuable in ascertaining best practice and safety in this area, such asTREND-UK (2018). For example, the abdomen is the preferred site for the injection of soluble insulin (as it absorbed faster in this area) (TREND-UK 2018). The crucial factor is to ensure the injection is given into subcutaneous tissue to avoid issues with rapid absorption and subsequent hypoglycaemia (TREND-UK 2018, Smyth 2020). A further consideration with insulin is the site of injection. The main sites used for injecting are the abdomen, outer aspect of the thighs, buttocks and, for some people, the upper arm. To prevent lipohypertrophy, which can affect absorption, it is important to regularly rotate the areas within the sites and the sites themselves (TREND-UK 2018, Smyth 2020). Self-administration of insulin is common practice, with the ‘insulin pen’ now popular due to its convenience, with each cartridge lasting on average about four weeks (Smyth 2020). However, there is still a skill to be learned when considering the subcutaneous route and safe injection technique. Patients who self-administer should be educated on the importance of rotating and assessing injection sites for daily and multiple injections. For insulin therapies to work optimally, correct injection technique is essential. Making a lifted skin fold decreases the chance of injecting into the muscle. The best way to do this is to lift the skin between the thumb and two fingers of one hand (King 2003, Hicks et al 2011). The skin should be held until the solution has been injected; releasing the skin fold too soon can increase the risk of injecting into the muscle (Hicks et al 2011). This is also known as the ‘site and time rule’ (Hicks et al 2011), which means waiting at least ten seconds before removing the needle from the skin. This minimises any leakage of the injected drug. When injecting with a pen device, the same technique should be adopted: the needle should be kept in the skin, with a lifted skin fold, for at least ten seconds after delivering the drug (Hicks et al 2011), to reduce risk of leakage or dribbling from the pen. Insulin should always be injected at a 90° angle to the skin. TREND-UK (2018) guidelines advise using 4mm or 5mm needles, but state that 4mm needles should only be used for children, young people or very slim adults. Needles longer than 6mm can increase the risk of injecting into the muscle. If short needles are used, there is no need to create a lifted skin-fold, unless the person is very slim (Smyth 2020). Insulin injections into the subcutaneous tissue allow for optimal absorption and a more predictable rate of insulin absorption, which can result in better glycaemic control (Hofman et al 2007).

Patient Assessment
Patient assessment is vital when considering the site and angle of injection to ensure the site is free from (Hicks et al 2011): Any signs of inflammation. Swelling. Redness. Lipohypertrophy. Lipoatrophy (wasting of subcutaneous tissue). Areas of lipohypertrophy Any areas of inflammation, scarring, abrasions or lesions must not be used for injections because this will affect absorption. Where areas of lipohypertrophy are identified, these sites should not be used for at least three months (Hicks et al 2011); however, these areas may be less painful than less commonly used sites, which may explain why patients inject into them (King 2003). Examining the patient and regularly inspecting used injection sites should include careful palpation, because not all areas of lipohypertrophy are obvious (Hicks et al 2011). In addition, if the patient’s weight has changed or if the patient is an older person (Hicks et al 2011), needle length might need to vary, depending on the injection site. This assessment is also necessary for obese, cachectic or thin patients. Discussion with the patient Assessment should include a discussion of technique with the patient and exploration of any adverse effects he or she may be experiencing, especially if these are new or different. It is vital that there is good communication between the nurse and patient (or parent and child) before the procedure begins. If a patient experiences bruising or bleeding, this might indicate he or she is injecting into the muscle or reusing needles (Hicks et al 2011). Patients should be aware of the most suitable injection sites and be informed about the medication itself, its action and side effects (Hunter 2008). Sharing information with the patient informs the patient and also provides an opportunity to reveal any concerns, poor technique and anxieties, as well as assessing the patient’s knowledge. Box 1 lists a proposed framework for safe practice for administering subcutaneous injections. Box 1. Framework for safe practice for subcutaneous injections Wash hands to minimise risk of infection to the patient. Check the patient’s identification, as per hospital policy. Prepare the patient and obtain consent. Position patient either sitting or lying down. Check the drug, formulation, indication, route, volume and side effects. Assess the skin and the patient’s condition. Consider rotation of injection sites and assess those that are repeatedly used for injection. Consider equipment and familiarity with insulin pens and pre-filled heparin syringes, and follow the manufacturer’s guidelines. Consider the recommended injection site: abdomen or thigh. Inject at a 90° angle, dart-like, into the hub of the needle and at 1mL per second (Chan 2001, Hofman et al 2007, Hunter 2008). Ensure the fold of skin is injected into and released only when the needle is removed. Wait at least ten seconds before withdrawing the needle, following the ‘site and time’ rule. Do not massage or rub the site afterwards unless otherwise indicated. Reassess for therapeutic effect and/or any side effects. Document accurately and appropriately.

Conclusion
Conclusions This module has provided an overview of the subcutaneous injection technique using insulin and heparin subcutaneous injections, and has outlined a framework on safe practice for practitioners. This technique requires skill, knowledge and a good understanding of the implications for administering the injection. Disposable gloves and an apron are not needed for administering subcutaneous injections unless there is a risk of exposure to body fluids, or the administrator has non-intact skin.

References
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