Effectiveness of Cold Application on Bruising at Subcutaneous Heparin Injection Sites: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Afaf Almabadi^1, , Atheer Almarri¹, Areej Almutairi¹, Mai Alharsan², Shaykhah Almasoud¹, Hanin Al-Harthiy³, Nourah Alzhrani¹, Rana Alsulami¹, Rawdhah alsulami¹, Elaf Alazmi⁴ and Ebtsam Abouhashish⁵

¹Nursing Student, College of Nursing, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia

²Khobar Health Network, Eastern Health Cluster, Saudi Arabia

³Nursing Student, College of Nursing, University of Taif, Taif, Saudi Arabia

⁴Nursing Student, College of Nursing, University of Princess Nourah, Riyadh, Saudi Arabi

⁵Associate Professor, College of Nursing, King Saud University for Health Sciences, Jeddah, Saudi Arabia

Cite this paper:
Afaf Almabadi, Atheer Almarri, Areej Almutairi, Mai Alharsan, Shaykhah Almasoud, Hanin Al-Harthiy, Nourah Alzhrani, Rana Alsulami, Rawdhah alsulami, Elaf Alazmi and Ebtsam Abouhashish. Effectiveness of Cold Application on Bruising at Subcutaneous Heparin Injection Sites: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. American Journal of Nursing Research. 2025; 13(2):51-58. doi: 10.12691/ajnr-13-2-6

Abstract

Introduction: Subcutaneous heparin administration commonly leads to injection site bruising (Chan, 2001). Previous studies indicate that cold therapy may decrease the size and severity of bruising caused by subcutaneous heparin injections. The primary aim of this study is to evaluate the effectiveness of cold therapy in reducing the size and severity of bruising at the injection site in patients receiving subcutaneous heparin injections. Method: This systematic review examined randomized controlled trials evaluating cold therapy to reduce subcutaneous heparin-induced bruising. The study design involved searching PubMed and Google Scholar databases for relevant keywords (e.g., cold application, cryotherapy, subcutaneous heparin, bruising). Eligible studies enrolled patients who received heparin injections, comparing cold application at the injection site to a control group. The primary outcomes were the incidence and size of injection-site bruising. Exclusion criteria included conditions affecting bruising beyond heparin, interventions beyond cold therapy, a lack of a control group, and failure to assess both bruising incidence and extent. Results: Based on the search criteria, 374 patients were found. We reviewed 581 patients for this systematic review from 10 full-text articles. The results from the six articles indicated a substantial decrease in the severity of bruising, with the experimental group performing better than the control group. However, there was considerable variation across the different studies. Individual research data varied substantially in terms of average bruise intensity. Conclusion: The results indicate that cold application effectively reduces the severity of bruising in patients receiving subcutaneous heparin injections. However, significant heterogeneity is observed across studies, attributable to differences in the language of publication, cold application interventions, and injection methods (e.g., site and needle size). Increased standardization of the cold therapy protocol and injection techniques in future research would help minimize these sources of variability and enable more robust comparative analysis.

Keywords:
Cold application cryotherapy ice subcutaneous heparin injection bruising ecchymosis or hematoma

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References:

[1]	Hughes, R. G.; Blegen, M. A. Medication Administration Safety. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses; Hughes, R. G., Ed.; Agency for Healthcare Research and Quality: Rockville, MD, 2008; pp 1-23.
[2]	Edwards, I. R.; Aronson, J. K. Adverse Drug Reactions: Definitions, Diagnosis, and Management. Lancet 2000, 356 (9237), 1255-1259.
[3]	Visvanathan, V. M. N.; CN, C.; CCRN, G. D.; GCert Research Methodologies. Slow vs. Fast Subcutaneous Heparin Injections for Prevention of Pain and Bruising. AJN Am. J. Nurs. 2015, 115 (12), 27.
[4]	Hiebert, L. M. Repeated Oral or Subcutaneous LMWH Has Similar Antithrombotic Activity in a Rat Venous Thrombosis Model: Antithrombotic Activity Correlates With Heparin on Endothelium When Orally Administered. J. Cardiovasc. Pharmacol. Ther. 2017, 22 (3), 264-272.
[5]	Chan, H. Effects of Injection Duration on Site-Pain Intensity and Bruising Associated with Subcutaneous Heparin. J. Adv. Nurs. 2001, 35 (6), 882-892.
[6]	De Campos, J. D. F.; da Silva, J. B.; Beck, A. R. M.; Secoli, S. R.; de Melo Lima, M. H. Subcutaneous Administration Technique of Low-Molecular-Weight Heparins: An Integrative Review. Clin. Nurs. Stud. 2013, 1, 36-44.
[7]	Algafly, A. A.; George, K. P. The Effect of Cryotherapy on Nerve Conduction Velocity, Pain Threshold and Pain Tolerance. Br. J. Sports Med. 2007, 41 (6), 365-369.
[8]	Quinlan, P.; Davis, J.; Fields, K.; Madamba, P.; Colman, L.; Tinca, D.; Cannon Drake, R. Effects of Localized Cold Therapy on Pain in Postoperative Spinal Fusion Patients: A Randomized Control Trial. Orthop. Nurs. 2017, 36 (5), 344-349.
[9]	Şendir, M.; Büyükyılmaz, F.; Çelik, Z.; Taşköprü, İ. Comparison of 3 Methods to Prevent Pain and Bruising After Subcutaneous Heparin Administration. Clin. Nurse Spec. 2015, 29 (3), 174-180. L.
[10]	Kuzu, N.; Ucar, H. The Effect of Cold on the Occurrence of Bruising, Haematoma and Pain at the Injection Site in Subcutaneous Low Molecular Weight Heparin. Int. J. Nurs. Stud. 2001, 38 (1), 51-59.
[11]	Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D. G.; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann. Intern. Med. 2009, 151 (4), 264-269.
[12]	Ouzzani, M.; Hammady, H.; Fedorowicz, Z.; Elmagarmid, A. Rayyan—A Web and Mobile App for Systematic Reviews. Syst. Rev. 2016, 5, 1-10.
[13]	Higgins, J. P.; Altman, D. G.; Gøtzsche, P. C.; Jüni, P.; Moher, D.; Oxman, A. D.; Savovic, J.; Schulz, K. F.; Weeks, L.; Sterne, J. A.; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration's Tool for Assessing Risk of Bias in Randomised Trials. BMJ 2011, 343, d5928.
[14]	Amaniyan, S.; Varaei, S.; Vaismoradi, M.; Haghani, H.; Sieloff, C. Effect of Local Cold and Hot Pack on the Bruising of Enoxaparin Sodium Injection Site: A Randomized Controlled Trial. Contemp. Nurse 2016, 52 (1), 30-41.
[15]	Kilic, E. K.; Midilli, T. S. Effects of Cold Application on Pain and Bruising Complications Associated with Subcutaneous Heparin in Intensive Care Patients. Int. J. Health Sci. Res. 2017, 7 (9), 173-183.
[16]	Simeon, I.; Thenmozhi, P. Dry Cold Application on Pain and Ecchymosis among Patients Receiving Low Molecular Weight Heparin. Res. J. Pharm. Tech. 2021, 14 (11), 5790-5796.
[17]	Cevheroğlu, S.; Büyükyilmaz, F. The Effect of 3 Different Local Cold Applications on Pain and Ecchymosis in Subcutaneous Heparin Injections. Arch. Health Sci. Res. 2023, 10 (3), 160-167.
[18]	Unal, N.; Tosun, B.; Aslan, Ö.; Tunay, S. Effects of Vapocoolant Spray Prior to SC LMWH Injection: An Experimental Study. Clin. Nurs. Res. 2021, 30 (2), 127-134.
[19]	Karadağ, S.; Aydinli, A.; Yilmaz, C.; Tutar, N. Effect of Cold Application and Compression on Pain and Bruising in Subcutaneous Heparin Injection. J. Vasc. Nurs. 2023, 41 (1), 22-26.
[20]	Mohammady, M.; Sadeghi, N. Effect of Cold Application on Bruising and Pain Following Heparin Subcutaneous Injection: A Systematic Review and Meta-Analysis. J. Nurs. Scholarsh. 2020, 52 (6), 634-642.