Introduction

A medication administered into subcutaneous tissues is known as a subcutaneous (SC) injection. SC administration is the preferred route for medications requiring slow, steady absorption (given reduced blood supply to adipose tissue).

SC medication administration is a common route of administration of medications in both the hospital and community settings. SC infusion of medications is used widely in palliative care to optimise the delivery of medications and provide appropriate symptom management, in those patients who have poor gut absorption, nausea, and vomiting. Other patients with acute symptomology could benefit from the SC route of medication administration. Indwelling subcutaneous catheter devices may assist in medication delivery and decrease trauma, distress, and discomfort for the patient.

Aim

1. Facilitate the administration of subcutaneous injections and insertion.
2. Manage and remove subcutaneous devices to maximise the therapeutic effect while reducing potential complications and patient discomfort.

Definition of terms

• Subcutaneous: Between the skin and muscle, the skin, the innermost (deepest) layer of skin.
  
• Continuous infusion: A background infusion of medications that is given over a specific period, for example over 24 hours.
  
• Bolus/breakthrough dose: A regular or PRN medication that is administered to reduce symptoms. If the patient has a continuous subcutaneous infusion via a BD Saf-T-Intima™, breakthrough subcutaneous medications should be administered via a second BD Saf-T-Intima™.
  
• BD Saf-T-Intima™: a SC device used to administer medications in the SC tissue commonly used in patients receiving palliative care

Assessment

Clinical judgement is required when selecting an injection site and needle length. The indwelling subcutaneous catheter device must be inserted into an area where there is adequate subcutaneous tissue.

Site selection and land marking

Anterior abdominal wall

The anterior abdominal wall is the preferred SC site for children above 2 years old. The recommended volume is 1.5mLs, however larger volumes of 3mLs are well tolerated when injected into the abdominal wall. These areas have a large surface area that allow rotation for SC injections within the same site for example when administrating clexane™. This site can also be used to insert an indwelling device.

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To landmark the anterior abdominal wall, position the patient lying down or being held by a parent (Procedure Management Guideline). From below the costal margin to the iliac crest and more than 5cms from the umbilicus. Gently grasp the area to make sure you can pinch 2-5cm of skin. 

Anterior upper arm

For children 12 months and older. Use the adipose tissue over the back part of the upper arm. The recommended maximum volume for single injection is 1.5mLs, larger volumes can be associated with pain in this area.

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To landmark this site, the patient should be sitting comfortably, in young children they can be hugging their parent with the back of their upper arm visible. The injection should be given in the outer lateral aspect of the upper arm at least 8cm below the shoulder and 8cm above the elbow. Gently grasp the area to make sure you can pinch 2-5cm of skin.   

Anterior upper thigh

The anterior upper thigh is the preferred SC site for children below 2 years old. The recommended volume is 1.5mLs. This area can have an increased association of pain. Use the front, outer top of the thigh and locate the middle where there is a lot of adipose tissue. Do not use the inner or back of the thigh. This site can also be used to insert an indwelling device in each thigh if required to rotate medications.

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To landmark this site, the patient should be positioned either laying on their back or held by a parent in a semi-reclined/ relaxed seated position. The injection should be given halfway between the knee and hip slightly to the side. Gently grasp the area to make sure you can pinch 1-2 inches of skin. 

Areas to avoid

1. Skin folds or areas where clothing may rub or constrict the flow of medication (particularly in the indwelling subcutaneous device).
2. Skin that is edematous, bruised, hard, red, broken or where there is infection.
3. Directly over a tumor or areas that have recently been irritated or irradiated.
4. Over a bony area or joint.
   

Special considerations

• The age/developmental needs of the child: for example, do not insert the device in the lower abdomen if the child is in nappies.
• The person who will administer the medication: for example, if the patient is to self-administer, position the hub of the Insuflon™, BD Saf-T-Intima™ or Neria™ Soft device for ease of access for the patient.
• Patient and/or caregiver preference.
• For neonates receiving anticoagulant medications consideration should be given to the appropriateness of using an indwelling device versus rotating injection sites: for example, the administration of Clexane™. In some cases, two indwelling devices may need to be inserted.

Subcutaneous injection

Needle size

A hypodermic needle is used to administer SC injections.

Needle sizes most commonly used at RCH include:

• 25g x 16mm ORANGE
• 27g x 13mm GREY

Equipment

• Appropriate size needle or device for administration
• Drawing up needle and syringe (if medication not pre-filled)
• Sharps container
• Alcohol impregnated swab (if area visibly soiled)
• Cotton ball
• Band-Aid/small dressing (check for allergies)
• Personal Protective Equipment (PPE) such as gloves for hazardous medications

Procedure

1. Prepare patient and obtain consent.
2. Perform hand hygiene.
3. Prepare equipment as per Aseptic Technique. Open procedure pack or tray or field protecting all key parts.
4. Complete the six rights of medication administration.
5. Perform hand hygiene. Don PPE if required (particularly for hazardous medications)
6. Draw up or prime medication as per Paediatric Injectable Guidelines
7. Position patient in a safe and comfortable position Procedure Management Guideline
8. Consider the use of comfort techniques such as local anesthetic cream and transparent occlusive dressing, cool sense pain numbing applicator, distraction, buzzy bee, ice, or a countdown.
9. Landmark injection site (see above)
10. Clean site with an alcohol swab (if required)
11. Gently grasp the skin to make sure you can pinch 1-2 inches with the non-dominant hand.
12. Inject at a 45° angle.
13. Release the skin.
14. Inject the medication at a slow and steady pace.
15. Wait 10 seconds before removing the needle.
16. Remove the needle and apply a cotton ball. Remove gloves if worn and perform hand hygiene.
17. Place the needle in a sharp container.
18. Apply Band-Aid/small dressing if required.
19. Perform hand hygiene.
20. Clean surfaces, dispose of waste and perform hand hygiene.
21. Document procedure on EMR as relevant.

Deep Subcutaneous

Some medications require administration into the deep subcutaneous tissue as per manufacture instructions. In most cases, these medications come in pre-filled syringes. As with SC injections, positioning and analgesia should be considered prior to use. Deep SC injections can either be given in the abdomen or upper buttock. In children, the upper buttock is the preferred site as children can be positioned lying on their stomach for comfort and safety. The medication is delivered into deeper tissue and can be more painful for the child. An order for local anaesthetic such as Lignocaine 1%, can be considered prior to deep SC administration for patient comfort.

Procedure

1. Steps 1-11 of procedure (as above)
2. Inject the needle halfway at a 45-degree angle.
3. Then lower the needle so that it is flat against the skin (180-degree angle) and insert the needle fully so that the hub is against the skin.
4. Inject the medication at a slower and steady pace. With some pre-filled medications (e.g., Zoladex™) you will hear the device click and the needle with automatically retract. 
5. Steps 15-19 of procedure (as above)
   

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Subcutaneous Device Injection Procedure

Device selection

Indwelling devices: Devices commonly used at RCH include:

Insuflon™	BD Saf-T-Intima™	Neria ™Soft
Photo taken by RCH staff member	Photo taken by RCH staff member	Photo taken by RCH staff member
The catheter system requires a needle and syringe to administer the medication through the device.  Medications used commonly for daily, or BD dosing include anti-coagulant therapy, chemotherapy an granulocyte colony stimulating factor (GCSF).	Used mostly in palliative care patients. Needless closed indwelling subcutaneous catheter system, which is used for SC administration of medications, either as a continuous infusion or for breakthrough/ bolus doses. Medications commonly administered via a BD Saf-T-Intima™ can include opioids, benzodiazepines, and anti-emetics. This device can be attached to a Niki T 34™ syringe driver either on Alaris Asena GH MK III™ for inpatient use, or a Niki T 34™ infusion pump, either for inpatient or outpatient use.	Indwelling subcutaneous catheter system which is used for SC administration of medications as an infusion. Medications administered via a Neria™Soft can include immunoglobin and desferrioxamine (Desderal™). These devices are used in day medical unit by haematology and immunology. The device features a disconnection option where the indwelling device can remain in situ and the infusion set is attached as required for medication administration. The device is often used for subcutaneous infusions of short duration and attached to a syringe driver such as a Niki T 34™ infusion pump or a Springfusor™ syringe infusion pump.

Equipment

• SC device and supplied dressing or transparent occlusive dressing if required.
• Red caps (if required)
• Alcohol wipes
• Sharps container

Procedure

Follow steps 1-13 of SC procedure (as above)

• Dispose of needle in a sharp’s container.
• Write date of insertion on the dressing.
• Insertion of the indwelling SC catheter device and site should be clearly documented in the EMR. The insertion should be recorded in the LDA (Lines, Drains, Airways) flowsheet and the avatar.

Subcutaneous Device Management

• Observe the SC device and insertion site once daily and prior to medication administration including bolus/breakthrough doses.
  • Devices which are being used to administer continuous infusions should be observed at least four hourly as well as prior to bolus/breakthrough doses of medication
• S/C devices need to be changed at regular intervals, please see the table below for recommendations on commonly used devices at RCH. Please note this table is a guide only and devices may need to be changed more frequently due to the use of some medications* or if complications occur.

Management of complications

Poor technique and incorrect site selection of the injection site can lead to site reactions, sub-optimal medication absorption and adverse events.

Potential complications:

• Infection
• Discomfort
• Difficulty injecting medication
• Blockage
• Redness
• Inflammation
• Exudates
• Bruising and bleeding
• Pain
• Leakage

Management 

• Do not reinsert the needle if the catheter is dislodged/ withdrawn, instead repeat insertion with a new SC device.
• Never reinsert the needle into the catheter as this could shear the catheter.
• Do not bend the needle prior to insertion.
• Complications should be documented in the LDA or Progress Notes
• Consider need to notify the medical team of complications i.e., Excessive bruising/bleeding when Clexane™ is being administered
• In patients who have a BD Saf-T-Intima™ insitu, consider dexamethasone addition to preserve sites ongoing. Discuss with VPPCP (Victorian Paediatric Palliative Care Program).

Administration of medication via a subcutaneous device

Ensure all medications given are recommended for subcutaneous use. Medications are ordered on the MAR and administered as per the Medication Management Procedure

Equipment

• Appropriately sized syringe
• Drawing up needle
• Luer lock syringe
• Red caps
• 75 cm minimum volume extension set (if using for continuous infusion)
• Alcohol swab
• Sharps container

Drug Compatibility Guidelines

Please follow the link below for a comprehensive list of drug compatibility used in a subcutaneous infusion.

https://www.safercare.vic.gov.au/sites/default/files/2021-02/GUIDANCE_Syringe%20driver%20compatability%20FINAL_0.pdf

Removal of a subcutaneous device

Equipment

• Band-Aid or transparent occlusive dressing
• Gauze/ cottonwool

Procedure

1. Perform the five moments of hand hygiene.
2. Explain the procedure to the child (if appropriate) and parents/ caregivers.
3. Utilise standard aseptic technique Aseptic Technique
4. Remove the dressing from the skin, it may be helpful to place a small amount of pressure on the device/ wings of the S/C device as you remove the dressing.
5. Withdraw the S/C device from the insertion site in one quick, smooth movement.
6. Apply gauze over the insertion site (if required) 
7. Apply a transparent occlusive dressing. If there is an increased amount of exudate from the site, an absorbent dressing can be used.
8. Dispose of any waste in the appropriate bins
9. Perform hand hygiene.
10. Complete appropriate documentation. Removal of the device should be documented in the LDA flowsheet and the avatar.

Companion Documents

• Procedure Management Guideline
• Medication Management Procedure
• Hazardous Medicines- Safe handling of

Please remember to read the disclaimer.

The revision of this nursing guideline was coordinated by Natalie Tingate, RN, Kookaburra, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2024.