Giving LMWH shots - from Tamara on the mailing list

Some things you'll need for this procedure:

Lunch pack flexible style blue ice, found in the sporting department of walmart for 99 cents each (or a bag of regular ice..but that gets messy)
A quart size zip lock bag to put the ice pack in so it won't leak on your skin when it gets old and breaks
An old pillow case to put the icepack in to protect your skin from frostbite
An old or oversized belt to hold the icepack in place so you can get ready for work while icing in the morning
Rubbing alcohol..I use alcohol swabs, prewrapped, 100 of them are a couple dollars in the first aid section at Walmart
Curad Sensitive Skin Spots bandaids
Tissues or anything clean to apply pressure afterwards that you don't mind throwing away if it gets bloody...because it will. Paper towels work, but tissues are cheaper and already on my bedside table.
Something to dispose your syringe/needle in-I have a decorative tin on my bedside table that I empty into a larger container once a week (or a SHARPS container).

The main thing I stress is ICE before the shot. You can also ice after, but icing before is really key. It does two things. One, it significantly reduces bruising and you won't find yourself running out of bruise free places to inject in a week. Second, once iced, it doesn't hurt to give yourself the shot. With enough time on the ice, you won't even feel it. It makes it a whole lot easier to do if you are nervous about the shots. I put the blue ice inside the zip lock bag in case it leaks, then into the pillowcase, and then I tuck it in my pants or under my shirt (depending on where I'm doing the shot) and put an old belt around it to hold it in place.

(When traveling I bring zip lock bags and ask at gas stations if I can have ice to make an ice pack from the soda machine. Nobody has ever said no when I have my own container. I then drive a bit and pull off the road to inject-double bag when doing this though unless you want wet pants from a leaky bag.) With the smaller ice pack belted inside my pants at home though, I can go on getting ready for work or at night reading email or watching tv for about 15-30 minutes. When I can't feel my stomach anymore I know I'm ready.

Now for actual shot techniques that are important....as soon as you take off the ice pack wipe the area with rubbing alcohol so it will be dry by the time you inject. You want it to dry because it will sting if the alcohol gets on the needle during the injection.

Then unpackage the syringe and if you are giving yourself the full dose of the prepackaged syringe pull back just a little on the plunger before pulling off the cap. This prevents the drip of lovenox from forming on the tip of the needle. Air bubbles are ok and preferable..they help distribute the lovenox into the fat, so don't get rid of the air bubble. If you have to push out some because your dose is less than the syringe contains, gently tap the syringe against your hand to knock off the drip afterwards (don't touch the needle). You want a dry needle..no lovenox, no alcohol. This is because as the needle goes through layers of skin any lovenox spilled will cause bruising, alcohol will just sting. The goal is to get all the lovenox in the fat layer UNDER the skin, where there should be no bruising if all goes well.

Some people say to go in fast...I go in as fast as I'm comfortable. The needles are dull straight from the package (for $3,000 a month you'd think they'd get a better needle) so you'll have to jab quick initially to break through skin if you have thick skin like I do. Try to get it in the first try because each try after that dulls the needle more, however...if it hurts real bad it's ok to pull out and stick it into another spot that has been iced and wiped down with alcohol..why it's good to wipe down a wide area..you probably hit a nerve in that spot and there's no sense in continuing if it's going to hurt. After a while you'll learn which spots are the best for your body and that won't happen as much.

Don't push the lovenox in fast...go at a steady pace and if it starts to sting wait a few seconds before continuing. Turning the syringe around can also help if it's hurting..the lovenox actually comes out the side of the needle end so just directing it to another area of fat helps sometimes. You want to go slow so your body can absorb the lovenox as you inject. If you go fast it tends to spill up the needle shaft opening...going into the layers of skin..and causing bruises. Besides, it does us no good there..it needs to be in the fat to work..so take your time. At the end of the shot count to ten and then quickly pull out. The counting to ten is to make sure the lovenox has had a chance to move away from the needle-preferably being pushed by that last air bubble.

Apply pressure for about 10-15 seconds with the tissue. Do not rub, just push directly down. In most cases this will be enough to not bleed if you are not also on super high doses of Coumadin. If you are still bleeding or wearing nice clothes that day, put a Curad Sensitive Skin Spot bandage over the injection site. Even if you are not allergic to regular bandages, you want the sensitive skin ones because they come off without pulling. Removing a regular bandage will increase bruising, and if you do end up bruising in this spot will hurt real bad too. The sensitive skin ones just peel off no problem.

If your injection site is sore, put the ice back on until it stops hurting and make a note to ice longer next time. Otherwise put the ice back in the freezer and you are all done. (I bought several because I tend to forget that step of putting ice back in freezer.) Depending on your local medical waste rules, push out the safety shield and dispose of the syringe. Here they ask we put them into metal cans such as coffee cans, duct tape the tops shut, and clearly mark them medical waste and then throw them into the regular trash. Other places have medical waste collection sites where you can get containers from them or maybe your local hospital will take yours.

Tamera

p.s. a note on the needles. If you are not allergic to the preservative in the multi use vials of Lovenox (I am) and find the shots painful or are giving them to a young child, ask your doctor for the multi use vials and coated smaller insulin needles and syringes. You can use a smaller needle than with the prefilled lovenox, it takes longer to inject but then I advocate slow injections anyway. They have made great advances in making insulin easier and less painful to inject, and you can use that technology with the multi use vials. I don't know why Adventis doesn't use this technology on their prefilled syringes, as it's not expensive to buy insulin needles. The coating makes them slippery so they go through skin easier, they are much sharper so easier to inject, and the smaller needle hurts less. I'm allergic to the preservative though, so I'm stuck with the prefilled syringes. The multi use vials would be harder to use, but worth it to get a better needle.