Small air bubble in fragmin/arixtra

[marty6001, EdD, EMT-P, APRN]

So we were having a discussion about this on the unit tonight and there was no clear answer. It is clear in the literature to keep the air bubble in the syringe prior to administration to ensure full dose of medication given. But it is not clear what to do with the bubble during administration. Some nurses push it in S/Q, some keep it in the syringe. I couldn't find anything in the literatire regarding this, so I'm here asking you all. What do you do with the air bubble during administration?

[sunnycalifRN]

I don't quite understand your question . . . the air bubble is purposely there to clear the needle of all medication, like you said. unless you're in outer space or you're administering the injection from underneath the patient, the air bubble will remain in the topmost part of the syringe until all the med is injected and then go into the bore of the needle, ensuring full med admininstration:confused:

[marty6001, EdD, EMT-P, APRN]

let me try again, as i am not in outer space or underneath the patient. when you are administering the medication, do you inject the air bubble into the s/q space of the patient, or is it as you said, that the amount of air is only enough to fill the needle? do you have literature to state that that is the amount of air, or is it just an anecdotal finding?

[fiveofpeep]

Ive heard for lovenox SQ and flu shots IM that the bubble is to prevent pain. I just leave it in...its an inconsequential amount.

[sunnycalifRN]

let me try again, as i am not in outer space or underneath the patient. when you are administering the medication, do you inject the air bubble into the s/q space of the patient, or is it as you said, that the amount of air is only enough to fill the needle? do you have literature to state that that is the amount of air, or is it just an anecdotal finding?

this is from the lovenox website:

to avoid the loss of drug when using the 30 mg and 40 mg prefilled syringes, do not expel the air bubble from the syringe before the injection.6

and

the technique used is a straight down (90 degree angle) deep sub-q injection . . . so the last thing going in is the air bubble . . . so yes, you do inject the bubble . . . this is what the manufacturer says.

[marty6001, EdD, EMT-P, APRN]

SunnycallifRN, I'm not sure what I've ever done to irritate you as I may have posted 20 times in all the time I've been a member here, but I apoligize for whatever it was. Your second answer is much clearer than your first, however, and I have read the reference you placed and don't see anywhere where it says to inject the air. In fact, this statement made me wonder, "Activation of the safety system may cause minimal splatter of fluid. For optimal safety activate the system while orienting it downwards away from yourself and others".

As far as I can tell by reading the Arixtra, Lovenox, and Fragmin sites (which I assure you I did prior to posting on here) they all say to keep the air bubble to prevent the loss of medication prior to administration. On none of these sites, nor on the 10-20 other places I looked does it say to inject the air into the S/Q space. I'm not sure where you got that the manufacturer said to inject the air, as I read the full prescribing information and all it says is the quote I posted above. Can you link that for me?

Again, not being a pest, this was a true conversation between myself and several ICU nurses. It is one of those things that we as nurses just "know" but never bothered to look up. Fiveofpeep's opinion is the same as many of the nurses on my unit, they do it just because they always have done it. I just thought it was an interesting topic to discuss and was hoping someone had some insight into it.

Seems another post had the same question, and there is a lack of literature there as well. I'm sure it's harmless, but I'm suprised that these companies have not thought to add in to do or not to do...

https://allnurses.com/general-nursing-discussion/prefilled-syringes-74183.html

[marty6001, EdD, EMT-P, APRN]

Got it finally. On one of the Arixtra prescribing information packets I found on this link: http://us.gsk.com/products/assets/us_arixtra.pdf

it says, "Push the plunger rod firmly with your thumb as far as it will go. This will ensure you have injected ALL THE CONTENTS of the syringe". Finally something that states to push everything, including the air.

[sunnycalifRN]

First off, I apologize for the silly tone in my first reply. You did nothing to offend me.

Now, my understanding from an inservice was that the air bubble in the Lovenox syringe was carefully measured to clear the medication from the needle bore, to insure full dose administration.

You are correct . . . nowhere does it say to inject air subQ. You are supposed to fully depress the syringe until it activates the safety mechanism, which will push the air bubble into the needle bore . . . maybe some air will go subQ, maybe not.

I don't know about Fragmin or Arixtra . . . I just found info about Lovenox.

[marty6001, EdD, EMT-P, APRN]

First off, I apologize for the silly tone in my first reply. You did nothing to offend me.

Now, my understanding from an inservice was that the air bubble in the Lovenox syringe was carefully measured to clear the medication from the needle bore, to insure full dose administration.

You are correct . . . nowhere does it say to inject air subQ. You are supposed to fully depress the syringe until it activates the safety mechanism, which will push the air bubble into the needle bore . . . maybe some air will go subQ, maybe not.

I don't know about Fragmin or Arixtra . . . I just found info about Lovenox.

No worries, it's probably me reading into it. I'm at work and its 2am here after a weekend with our 5 month old and have a 5 day stretch of working/teaching looming in front of me. The only reason I was even looking for an answer is a student was pushing me on why the air is there as only a student can and I wanted a detailed answer to give them. Thanks for taking the time to answer!!! Have a great week!!!