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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Slow versus fast heparin injections, Outcome 1 Intensity of injection pain.
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Analysis 1.1

Comparison 1 Slow versus fast heparin injections, Outcome 1 Intensity of injection pain.

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Comparison 1 Slow versus fast heparin injections, Outcome 2 Bruise size 48 hours after injection.
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Analysis 1.2

Comparison 1 Slow versus fast heparin injections, Outcome 2 Bruise size 48 hours after injection.

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Comparison 1 Slow versus fast heparin injections, Outcome 3 Bruise size.
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Analysis 1.3

Comparison 1 Slow versus fast heparin injections, Outcome 3 Bruise size.

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Summary of findings for the main comparison. Slow versus fast subcutaneous heparin injection for prevention of bruising and site pain intensity

Slow vs fast subcutaneous heparin injection for prevention of bruising and site pain intensity

Patient or population: patients treated with subcutaneous heparin injections

Settings: hospital outpatient and inpatient units

Intervention: slow injection (injection speed of 20 or more seconds)

Comparison: fast injection (injection speed of less than 20 seconds)

Outcomes

Illustrative comparative risks* (95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk with fast injection

Corresponding risk with slow injection

Intensity of injection pain

immediately after injection

(VAS 0 to 10 cm)

0 (no pain) to 10 (worst possible pain)

Mean pain intensity reported by the 2 studies ranged across fast injection groups from 2 to 5.

Mean pain intensity in the slow injection group was 1.52 points less than in the fast group (3.56 lower to 0.53 higher; P = 0.15).

140
(2 RCTs)

⊕⊕⊝⊝a
low

Intensity of injection pain

48 hours after injection

(VAS 0 to 10 cm)

0 (no pain) to 10 (worst possible pain)

Mean pain intensity ranged across fast injection groups from 2.1 to 2.8.

Mean pain intensity in the slow injection group was 1.68 points less than in the fast group (2.91 lower to 0.45 lower; P = 0.007).

59
(2 RCTs)

⊕⊕⊝⊝b
low

Bruise size

48 hours after injection

(mm/mm2)

See comment.

Mean bruising size in the slow injection group was 0.6 SD lower than in the fast injection group (1.24 lower to 0.04 higher; P = 0.07).

459
(4 RCTs)

⊕⊕⊝⊝c
low

Bruise size was measured on different scales; therefore we used the SMD to pool data.

Haematoma at injection site

See comment.

No studies measured this outcome.

*The basis for the assumed risk (e.g. median control group risk across studies) for pain intensity was the range of mean pain score reported following fast injection by the 2 studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the mean difference of the intervention (and its 95% CI).
CI: confidence interval; cm: centimetre; mm: millimetre; RCTs: randomised controlled trials; SD: standard deviation; SMD: standardised mean difference; VAS: visual analogue scale.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aWe downgraded the quality of evidence by two steps owing to study limitations, as we identified few studies with small numbers of participants (imprecision) and high heterogeneity (I2 = 73%) (inconsistency).
bWe downgraded the quality of evidence by two steps owing to study limitations, as we identified few studies with small numbers of participants (imprecision) and high heterogeneity (I2 = 72%) (inconsistency).
cWe downgraded the quality of evidence by two steps owing to study limitations, as we identified few studies with small numbers of participants (imprecision) and high heterogeneity (I2 = 85%) across studies (inconsistency).

Figuras y tablas -
Summary of findings for the main comparison. Slow versus fast subcutaneous heparin injection for prevention of bruising and site pain intensity
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Comparison 1. Slow versus fast heparin injections

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Intensity of injection pain Show forest plot

3

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Immediately after each injection

2

140

Mean Difference (IV, Random, 95% CI)

‐1.52 [‐3.56, 0.53]

1.2 48 hours after injection

2

59

Mean Difference (IV, Random, 95% CI)

‐1.68 [‐2.91, ‐0.45]

1.3 60 hours after injection

1

40

Mean Difference (IV, Random, 95% CI)

‐1.0 [‐2.15, 0.15]

1.4 72 hours after injection

1

40

Mean Difference (IV, Random, 95% CI)

‐0.8 [‐1.70, 0.10]

2 Bruise size 48 hours after injection Show forest plot

4

459

Std. Mean Difference (IV, Random, 95% CI)

‐0.60 [‐1.24, 0.04]

2.1 Bruise size (mm2)

2

140

Std. Mean Difference (IV, Random, 95% CI)

‐0.30 [‐0.64, 0.03]

2.2 Bruise size (mm)

2

319

Std. Mean Difference (IV, Random, 95% CI)

‐1.69 [‐5.07, 1.70]

3 Bruise size Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 60 hours after injection (mm2)

1

40

Mean Difference (IV, Fixed, 95% CI)

‐3.85 [‐8.99, 1.29]

3.2 72 hours after injection (mm2)

2

140

Mean Difference (IV, Fixed, 95% CI)

‐2.29 [‐6.57, 1.99]
Figuras y tablas -
Comparison 1. Slow versus fast heparin injections
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