 For patients receiving heparin injections over a long period of time, pain and ecomosis in the abdominal region is a very real problem. We at William Bowman Army Medical Center have found a solution to that problem and we would like to take this opportunity to share it with you. During this program we will discuss the clinical indications and contraindications for heparin therapy, the pharmacological action of heparin, advantages and disadvantages of heparin therapy, the side effects and antidotes. We will also demonstrate the subcutaneous method of administering heparin, including procedure and follow-up care. Most, though not all, authorities agree on the following clinical indications for heparin therapy. Venus thrombosis, because of the dangers of thrombophlebitis, plebothrombosis and pulmonary embolism. Pulmonary embolism, prophylactically, if it is known that the patient is suspect. Also indicated during the recovery phase of PE to prevent further clot formation. The patients who are susceptible to embolism include those with rheumatic heart disease, atrial fibrillation, preoperative vascular surgery, including mitral or aortic valve replacement. Patients with fractures of long bones are susceptible because these patients are hypercoagulable. Another high-risk group are patients having coronary occlusion with myocardial infarction. Heparin is used to prevent extension of the clot or formation of a new clot. For patients having cerebrovascular accident caused by emboli or cerebral thrombosis, heparin is the drug of choice to reduce sludging of blood. For patients who have disseminating intravascular coagulation, heparin may be used to prevent clotting factors from being consumed. Contraindications for heparin therapy. Heparin may cause spontaneous bleeding. Therefore, should not be used when there is evidence of weakened blood vessel walls. Patients with peptic ulcer or chronic ulcerative disease are considered poor risks for heparin therapy. Heparin should not be given following neurosurgery because of the danger of hemorrhage in the brain or the spinal cord. Liver disease rules out anticoagulants because of the disease interference with the manufacture of clotting factors. Liver and kidney insufficiency diseases are considered contraindications because of the difficulty metabolizing and excreting anticoagulants resulting in toxicity and the body's hampered ability to respond to anecdotal therapy. Pharmacological action of heparin. Heparin inactivates thromboplastin, which in turn interferes with the body's ability to form thrombin. Heparin also inactivates any thrombin which manages to form. It also decreases the adhesiveness of platelets and it will promote the resolution of a newly formed clot. Heparin will not dissolve the fibrin threats of a well-established clot. Advantages of heparin therapy. Rapid action. It dissipates quickly and has little cumulative effect and it can readily be neutralized by protamine sulfate. Disadvantages of heparin therapy. Heparin must be given intravenously or by infusion which necessitates hospitalization for the patient. Side effects of heparin therapy. Bleeding from mucous membranes, nose and gums, blood in the urine and GI bleeding. Also, unusual ecomosis or a tendency to bruise easily should be immediately reported. Allergic reactions are redness, itchy skin and urticarial wheels. There are two antidotes used for heparin therapy. Protamine sulfate which neutralizes the heparin and blood transfusions which provide the patient with clotting factors. Subcutaneous method for administering heparin. When prolonged therapy is indicated, heparin may be given subcutaneously, directly into the fatty tissues. Assemble the following items. A one or two milliliters syringe. A 26 gauge needle no longer than 5 eighths of an inch. The needle should be fine and sharp. Alcohol swabs because the skin should be antiseptic. Important concepts to remember about injection sites are first, the most convenient site is along the lower abdominal fat pad. When injected here heparin will not cause pain and hematoma formation. Second, areas such as the thymus should be avoided because the drug will diffuse along fascia layers leading to retroperitoneal bleeding. Sponge the area gently with alcohol. Do not rub because rubbing or pinching the tissue initiates damage. Heparin would aggravate the problem. Accumulate a well-defined roll of skin. Do not pinch the skin. Holding the shaft of the needle in a dart-like fashion, insert the needle directly into the skin at a right angle, making sure that the needle is at a 90 degree angle to the skin. Move the index finger into position to direct the plunger. Do not move the needle tip once it has been inserted. Firmly push the plunger down as far as it will go. When the injection has been made, withdraw the needle gently at the same angle that it entered, releasing the skin roll as you withdraw. Gently press an alcohol sponge to the site for a few seconds. Follow-up care. Do not rub the area. Instruct the patient not to rub the area because rubbing enhances the likelihood of tissue damage. This graphic shows the correct technique for administering heparin. The site of the injection should be changed each time heparin is administered. This graphic depicts the ideal way in which heparin injections can be rotated and charted at the patient's bedside. First, A through N site should be used, then O through X sites. If this method is used, patients will be able to tolerate heparin injections for many weeks without bruising or discomfort. Our personnel have been amazed at the improvement in the abdominal skin condition of our patients. It's also interesting to note that for the occasional bruises we do see, the patient can explain exactly what the nurse did wrong to cause the bruise.