,#,浅谈垂直腹部皮下注射,低分子,肝素与传统注射法的比较,张家港第一人民医院,心内科,顾佳宇,摘要,ABSTRACT,通过对比两种不同注射方法总结应用低分子肝素的注射方法及护理干预，提高使用低分子肝素的安全性，减少相关并发症发生,。,To investigate the correlation between regularity changing subcutaneous injection location of Low molecular-weight heparin and the incidence and size of subcutaneous hemorrhage，and to find out the effective way to reduce incidence and area of subcutaneous hemorrhage,.,2,普通肝素,酵素化,低分子肝素,1-2,更稳定,3-4,优点：,1.,每天皮下用药一次或两次就可维持相对稳定的抗凝作用。,2.,LMWH,抗凝作用稳定，大部分患者无需实验室监测,。,生物利用度高,临床广泛使用,【5】,疗效显著,并发症少,半衰期长,关键字,KEY WORDS,4,Company Logo,传统注射法的弊端,MALPRACTICE,注射前,排气,预灌针剂排气易造成,药液流失,，,造成实际给,药剂量不足,排气后针头尖端沾有,药液,，,接触皮肤后易造,成皮肤瘀斑,、出血,是,5,Company Logo,改进方法,无需排气,注射前针头朝下，把空气弹至药液上方,预灌针剂针筒内有,0.1ml,空气,注射器针头及乳头内残余量为,0.07-0.08ml,是,6,Company Logo,关键字,KEY WORDS,8,Company Logo,传统注射法的弊端,注射部位,传统的注射部位主要在上臂三角肌外缘，其次是前臂外侧、后背、大腿外侧,6,但这些部位皮下组织较薄针头易刺入肌肉层，引起皮下出血及瘀斑,7,。,是,9,Company Logo,改进方法,腹部皮下组织丰富，注射范围相对较大，是皮下注射低分子肝素的首选部位,8,。,除去严重腹水患者，,LMWH,最适宜注射部位是避开脐周,5,cm,左右两侧腹外侧壁,。,交替,轮换,注射,但也有国外研究者,9,认为，腹部并不是唯一推荐的注射部位。,是,10,Company Logo,传统注射法的弊端,进针角度,传统斜角,20,-30,度,进针稳定性差,，,容易移位,，,而且,涉及部位较多，如针头不慎刺入血管，只压迫穿刺点不能有效的压迫止血，又因低分子肝素为抗凝药，损伤小血管易引起出血使腹壁皮下组织形成淤血，瘀斑。,对于,BMI,不同指数的人群,进针过浅：,药液进入皮内引起出血,、疼痛,进针过深：,药液进入肌层引起深部血肿,是,11,Company Logo,改进方法,国内外研究者,10-13,提出了垂直进针、保持皮肤皱褶的注射方法：,注射时用左手拇指和食指以,5,6cm,范围捏起皮肤成一皱褶，,右手以笔试持针，,在皮肤皱褶顶部以,90,度角垂直进针，,针头刺入深度,。,优点：提起腹壁皮肤垂直刺入，对局部皮下组织损伤小，不易引起出血。,是,12,Company Logo,关键字,KEY WORDS,14,Company Logo,传统注射法的弊端,注射时间,传统注射方法中强调“两快一慢”的注射技巧，,进针快、拔针快，缓慢推药，对于注射时间并未给,出明确的规定。,但注射完毕时,，,针尖,常常,会残留一滴余液,，,拔针时由于重力作用,，常会将这些余液漏入真皮及皮下组织,是,15,Company Logo,垂直腹部皮下注射,方法,有研究报告表明,注射,时间持续,30s,可以有效降低出血的发生率，在注射,完毕,后,可以稍停,35s,，使皮下组织充分吸收余液,，注射完毕顺进针角度拔针,（垂直拔针,）,采用预留,0.1ml,空气法避免药液渗入皮下组织，从而减少瘀斑发生机会。,是,16,关键字,KEY WORDS,17,Company Logo,传统注射法的弊端,按压时间和方法,局部按压,5min,：血液凝固需,5-10min,（,错,）,局部按压,10min,：,LMWH,皮下注射,10min,后即 可延长凝血机制（,错,）,局部棉签按压：棉签受力面积小、易移位,是,18,Company Logo,Company Logo,改进方法,使用棉球局部按压,15-20min,，力度以皮肤下陷,1cm,为准,注意不要揉搓注射部位,是,20,21,传统,：拔针时余液会渗入真皮及皮下组织，损伤的毛细血管就会导致瘀斑的发生。,Company Logo,改进注射法,采用垂直注射低分子肝素,，可减轻患者疼痛不适,减少对药物的吸收和皮下瘀斑。,是,22,Company Logo,低分子肝素,垂直,注射,法,的,注意,要点,关于注射部位、进针角度和注射时间国内外研究结果较统一，均认为选择腹部脐周左右,10,cm,范围内进行注射，轮换注射部位，同时避开脐周,5,cm,，捏起皮肤皱褶垂直进针，注射时间在,30,s,左右，注射完毕停留,3,5s,拔针后按压时间,15,min,以上可减少皮下出血和注射部位疼痛。,8,14,15,16,17,18,是,23,Conclusion,:Improved subcutaneous injection method of enoxaparin can obviously reduce the incidence of bleeding and the subcutaneous scleroma,and reduce the degree of pain in the injection site.It is worth being used clinically.,结论,：通过改良皮下注射法可明显减少注射部位皮下出血、皮下硬结形成及注射部位的疼痛程度，值得临床推广应用。,24,小结,Samama MM,，,Desnoyers PC,Low,molecular,weight heparins,：,Biochemistry and pharmacology,In Sasahara AA,，,Loscalzo J,（,eds,）：,New,Therapeutic Agents in Thrombosis and Thrombolysis,J,New York,：,Marcel Dekker,，：,Harenberg J,Pharmacology of low molecular weight heparins,J,Semin Thromb Hemost,；：,Weitz J,Low,molecular,weight heparins,J,N Engl J Med,；,：,Hirsh J,Heparin,J,N Engl J Med,；：,参考文献,reference,5Barras MA,，,Kirkpatrick CMJ,，,Green B,Current dosing of low,molecularweight hepafins does not reflect licensed product la,bels,：,an international surveyJ,Br J Clin Pharmaeol,，,2010,，,69,(5),：,520528,6,李小寒，尚少梅基础护理学,M,北京：人民卫生出版社，,2012,：,340,341,7Annersten M,，,Willman A,Performing subcutaneous injections,：,a,literature reviewJ,Worldviews Evid Based Nurs,，,2005,，,2(3),：,122,一,130.,8de Campos JDF,，,da Silva JB,，,Beck ARM,，,et a1,Subcutaneous,administration technique of lowmolecularweight hepafins,：,An,integrative reviewJ,Clin Nurs Stud,，,2013,，,1(4),：,36-44,参考文献,reference,9Fahs loS,，,Kinney MR,The abdomen,，,thigh and alTO as sites for,subcutaneous sodium heparin injectionsJ,Nurs Res,，,1991,，,40,10Hunter J,Subcutaneous injection techniqueJ,Nursing Stan,dard,，,2008,，,22(21),：,4l,一,44,11Gray T,，,Miller H,Injection techniqueJ,The Foundation Years,，,2008,4(6),：,252-255,12,焦呖，陈景侠，孙友芳，等低分子肝素钙皮下注射法的改良与,研究,fJ,中华全科医学，,2012,，,tO(12),：,19751976,13,李淑珍，陈爱兰，岳焕菊不同方法皮下注射低分子肝素对患,者疼痛感的影响,J,国际护理学杂志，,2013,，,32(t),：,197198,14Palese A,，,Aidone E,，,Dante A,，,et a1,Occurrence and extent of,bruising according to duration of administration of subcuta,neous LowMolecularWeight Heparin,：,a quasiexperimental,casecrossover studyJ,J Cardiovasc Nurs,，,2013,，,28(5),：,473,482,参考文献,reference,15,狄红月王志伟低分子肝素不同皮下注射方式不良反应的,Meta,分析,J,天津护理，,2010,，,18(5),：,249252,16,邓倩曦，李蓉琼，李霞低分子肝素皮下注射持续时间对皮下,出血和疼痛的影响,J,华西医学，,2009,，,24(2),：,300302,分析,J,天津护理，,2010,，,18(5),：,249252,17,薛花，刘海荣低分子肝素皮下注射持续时间对注射部位皮,下出血的影响,J,解放军护理杂志，,2009,，,26(24),：,71,72,18Dehghani KH,，,Dehghani H,，,Najari Z,Effect of subcutaneous,enoxapafin injection duration 011 sitepain intensity in acute,coronary syndrome patients hospitalized in CCU Afshar Hospital,，,Yazd,，,201 1J,Shahid Sadoughi University Medical Sci,ences,，,2012,，,20(4),：,517-523,参考文献,reference,Thank You!,请 批 评 指 正！,