Subcutaneous administration

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3D animation of a subcutaneous injection

Subcutaneous administration is the insertion of medications beneath the skin either by injection or infusion.

Contents

A subcutaneous injection is administered as a bolus into the subcutis, the layer of skin directly below the dermis and epidermis, collectively referred to as the cutis. The instruments are usually a hypodermic needle and a syringe. Subcutaneous injections are highly effective in administering medications such as insulin, morphine, diacetylmorphine and goserelin. Subcutaneous administration may be abbreviated as SC, SQ, subcu, sub-Q, SubQ, or subcut. Subcut is the preferred abbreviation to reduce the risk of misunderstanding and potential errors. [1]

Subcutaneous tissue has few blood vessels and so drugs injected into it are intended for slow, sustained rates of absorption, often with some amount of depot effect. Compared with other routes of administration, it is slower than intramuscular injections but still faster than intradermal injections. Subcutaneous infusion (as opposed to subcutaneous injection) is similar but involves a continuous drip from a bag and line, as opposed to injection with a syringe.

Medical uses

An insulin pump with a subcutaneous infusion site Insulin pump with infusion set.jpg
An insulin pump with a subcutaneous infusion site

A subcutaneous injection is administered into the fatty tissue of the subcutaneous tissue, located below the dermis and epidermis. [2] They are commonly used to administer medications, especially those which cannot be administered by mouth as they would not be absorbed from the gastrointestinal tract. A subcutaneous injection is absorbed slower than a substance injected intravenously or into a muscle, but faster than a medication administered by mouth. [3] : 721 

Medications

Medications commonly administered via subcutaneous injection or infusion include insulin, monoclonal antibodies, and heparin. These medications cannot be administered orally as the molecules are too large to be absorbed in the intestines. [4] Subcutaneous injections can also be used when the increased bioavailability and more rapid effects over oral administration are preferred. They are also the easiest form of parenteral administration of medication to perform by lay people, and are associated with less adverse effects such as pain or infection than other forms of injection. [4]

Insulin

Perhaps the most common medication administered subcutaneously is insulin. While attempts have been made since the 1920s to administer insulin orally, the large size of the molecule has made it difficult to create a formulation with absorption and predictability that comes close to subcutaneous injections of insulin. [5] People with type 1 diabetes almost all require insulin as part of their treatment regimens, and a smaller proportion of people with type 2 diabetes do as well — with tens of millions of prescriptions per year in the United States alone. [6]

Insulin historically was injected from a vial using a syringe and needle, but may also be administered subcutaneously using devices such as injector pens or insulin pumps. An insulin pump consists of a catheter which is inserted into the subcutaneous tissue, and then secured in place to allow insulin to be administered multiple times through the same injection site. [3] : 722 

Recreational drug use

Subcutaneous injection may also be used by people to (self-) administer recreational drugs. This can be referred to as skin popping. [7] In some cases, the administration of illicit drugs in this way is associated with unsafe practices leading to infections and other adverse effects. In rare cases, this results in serious side effects such as AA amyloidosis. [7] Recreational drugs reported to be administered subcutaneously have included cocaine, [8] mephedrone, [9] and amphetamine derivatives such as PMMA. [10]

Contraindications

Contraindications to subcutaneous injections primarily depend on the specific medication being administered. Doses which would require more than 2 mL to be injected at once are not administered subcutaneously. [11] Medications which may cause necrosis or otherwise be damaging or irritating to tissues should also not be administered subcutaneously. [12] An injection should not be given at a specific site if there is inflammation or skin damage in the area. [13] : 144 

Risks and complications

With normal doses of medicine (less than 2 mL in volume), complications or adverse effects are very rare. The most common adverse reactions after subcutaneous injections are administered are termed "injection site reactions". This term encompasses any combination of redness, swelling, itching, bruising, or other irritation that does not spread beyond the immediate vicinity of the injection. [14] Injection site reactions may be minimized if repeated injections are necessary by moving the injection site at least one inch from previous injections, or using a different injection location altogether. [14] There may also be specific complications associated with the specific medication being administered.

Medication-specific

Due to the frequency of injections required for the administration of insulin products via subcutaneous injection, insulin is associated with the development of lipohypertrophy and lipoatrophy. This can lead to slower or incomplete absorption from the injection site. Rotating the injection site is the primary method of preventing changes in tissue structure from insulin administration. [15] Heparin-based anticoagulants injected subcutaneously may cause hematoma and bruising around the injection site due to their anticoagulant effect. This includes heparin and low molecular weight heparin products such as enoxaparin. There is some low certainty evidence that administering the injection more slowly may decrease the pain from heparin injections, but not the risk of or extent of bruising. [16] Subcutaneous heparin-based anticoagulation may also lead to necrosis of the surrounding skin or lesions, most commonly when injected in the abdomen. [17]

Many medications have the potential to cause local lesions or swelling due to the irritating effect the medications have on the skin and subcutaneous tissues. This includes medications such as apomorphine [18] and hyaluronic acid injected as a filler, which may cause the area to appear bruised. Hyaluronic acid "bruising" may be treated using injections of hyaluronidase enzyme around the location. [19]

Other common medication-specific side effects include pain, burning or stinging, warmth, rash, flushing, or multiple of these reactions at the injection site, collectively termed "injection site reactions". This is seen with the subcutaneous injection of triptans for migraine headache, [20] medroxyprogesterone acetate for contraception, [21] as well as many monoclonal antibodies. In most cases, injection site reactions are self-limiting and resolve on their own after a short time without treatment, and do not require the medication to be discontinued. [21]

The administration of vaccines subcutaneously is also associated with injection site reactions. This includes the BCG vaccine which is associated with a specific scar appearance which can be used as evidence of prior vaccination. [22] Other subcutaneous vaccines, many of which are live vaccines including the MMR vaccine and the varicella vaccine, which may cause fever and rash, as well as a feeling of general malaise for a day or two following the vaccination. [23]

Technique

Comparison of angle of subcutaneous injection of a needle with other injection types. Needle-insertion-angles-1.png
Comparison of angle of subcutaneous injection of a needle with other injection types.

Subcutaneous injections are performed by cleaning the area to be injected followed by an injection, usually at a 45-degree angle to the skin when using a syringe and needle, or at a 90-degree angle (perpendicular) if using an injector pen. The appropriate injection angle is based on the length of needle used, and the depth of the subcutaneous fat in the skin of the specific person. A 90-degree angle is always used for medications such as heparin. If administered at an angle, the skin and underlying tissue may be pinched upwards prior to injection. The injection is administered slowly, lasting about 10 seconds per milliliter of fluid injected, and the needle may be left in place for 10 seconds following injection to ensure the medicine is fully injected. [3] : 724 

Equipment

The gauge of the needle used can range from 25 gauge to 27 gauge, while the length can vary between 1⁄2-inch to 5⁄8-inch for injections using a syringe and needle. [3] : 722  For subcutaneous injections delivered using devices such as injector pens, the needle used may be as thin as 34 gauge (commonly 30–32 gauge), and as short as 3.5 mm (commonly 3.5 mm to 5 mm). [24] Subcutaneous injections can also be delivered via a pump system which uses a cannula inserted under the skin. The specific needle size/length, as well as appropriateness of a device such as a pen or pump, is based on the characteristics of a person's skin layers. [3] : 722–724 

Locations

Subcutaneous injection sites Subcutaneous-injection-sites-274x300.png
Subcutaneous injection sites

Commonly used injection sites include: [3] : 723 

The choice of specific injection site is based on the medication being administered, with heparin almost always being administered in the abdomen, as well as preference. Injections administered frequently or repeatedly should be administered in a different location each time, either within the same general site or a different site, but at least one inch away from recent injections. [3] : 724 

Self-administration

As opposed to intramuscular or intravenous injections, subcutaneous injections can be easily performed by people with minor skill and training required. The injection sites for self-injection of medication are the same as for injection by a healthcare professional, and the skill can be taught to patients using pictures, videos, or models of the subcutaneous tissue for practice. People who are to self-inject medicine subcutaneously should be trained how to evaluate and rotate the injection site if complications or contraindications arise. Self-administration by subcutaneous injection generally does not require disinfection of the skin outside of a hospital setting as the risk of infection is extremely low, but instead it is recommended to ensure that the site and person's hands are simply clean prior to administration. [25]

Infusion

Subcutaneous infusion, also known as interstitial infusion or hypodermoclysis, is a form of subcutaneous (under the skin) administration of fluids to the body, often saline or glucose solutions. [26] It is the infusion counterpart of subcutaneous injection with a syringe.

Subcutaneous infusion can be used where a slow rate of fluid uptake is required compared to intravenous infusion. Typically, it is limited to 1 mL per minute, although it is possible to increase this by using two sites simultaneously. The chief advantages of subcutaneous infusion over intravenous infusion is that it is cheap and can be administered by non-medical personnel with minimal supervision. It is therefore particularly suitable for home care. The enzyme hyaluronidase can be added to the fluid to improve absorption during the infusion. [27]

Subcutaneous infusion can be speeded up by applying it to multiple sites simultaneously. The technique was pioneered by Evan O'Neill Kane in 1900. Kane was looking for a technique that was as fast as intravenous infusion but not so risky to use on trauma patients in unhygienic conditions in the field. [28]

See also

Related Research Articles

Intensive insulin therapy or flexible insulin therapy is a therapeutic regimen for diabetes mellitus treatment. This newer approach contrasts with conventional insulin therapy. Rather than minimize the number of insulin injections per day, the intensive approach favors flexible meal times with variable carbohydrate as well as flexible physical activities. The trade-off is the increase from 2 or 3 injections per day to 4 or more injections per day, which was considered "intensive" relative to the older approach. In North America in 2004, many endocrinologists prefer the term "flexible insulin therapy" (FIT) to "intensive therapy" and use it to refer to any method of replacing insulin that attempts to mimic the pattern of small continuous basal insulin secretion of a working pancreas combined with larger insulin secretions at mealtimes. The semantic distinction reflects changing treatment.

<span class="mw-page-title-main">Syringe</span> Medical injection device

A syringe is a simple reciprocating pump consisting of a plunger that fits tightly within a cylindrical tube called a barrel. The plunger can be linearly pulled and pushed along the inside of the tube, allowing the syringe to take in and expel liquid or gas through a discharge orifice at the front (open) end of the tube. The open end of the syringe may be fitted with a hypodermic needle, a nozzle or tubing to direct the flow into and out of the barrel. Syringes are frequently used in clinical medicine to administer injections, infuse intravenous therapy into the bloodstream, apply compounds such as glue or lubricant, and draw/measure liquids. There are also prefilled syringes.

<span class="mw-page-title-main">Intravenous therapy</span> Medication administered into a vein

Intravenous therapy is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrients for those who cannot, or will not—due to reduced mental states or otherwise—consume food or water by mouth. It may also be used to administer medications or other medical therapy such as blood products or electrolytes to correct electrolyte imbalances. Attempts at providing intravenous therapy have been recorded as early as the 1400s, but the practice did not become widespread until the 1900s after the development of techniques for safe, effective use.

<span class="mw-page-title-main">Autoinjector</span> Medical device designed to deliver a dose of a particular drug

An autoinjector is a medical device designed to deliver a dose of a particular drug. The injectors were initially designed to overcome the hesitation associated with self-administration of the needle-based drug delivery device.

<span class="mw-page-title-main">Hypodermic needle</span> Device to inject substances into the circulatory system

A hypodermic needle, one of a category of medical tools which enter the skin, called sharps, is a very thin, hollow tube with one sharp tip. It is commonly used with a syringe, a hand-operated device with a plunger, to inject substances into the body or extract fluids from the body. Large-bore hypodermic intervention is especially useful in catastrophic blood loss or treating shock.

<span class="mw-page-title-main">Route of administration</span> Path by which a drug, fluid, poison, or other substance is taken into the body

In pharmacology and toxicology, a route of administration is the way by which a drug, fluid, poison, or other substance is taken into the body.

<span class="mw-page-title-main">Intramuscular injection</span> Medical injection into a muscle

Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles have larger and more numerous blood vessels than subcutaneous tissue, leading to faster absorption than subcutaneous or intradermal injections. Medication administered via intramuscular injection is not subject to the first-pass metabolism effect which affects oral medications.

<span class="mw-page-title-main">Injection (medicine)</span> Method of medication administration

An injection is the act of administering a liquid, especially a drug, into a person's body using a needle and a syringe. An injection is considered a form of parenteral drug administration; it does not involve absorption in the digestive tract. This allows the medication to be absorbed more rapidly and avoid the first pass effect. There are many types of injection, which are generally named after the body tissue the injection is administered into. This includes common injections such as subcutaneous, intramuscular, and intravenous injections, as well as less common injections such as intraperitoneal, intraosseous, intracardiac, intraarticular, and intracavernous injections.

<span class="mw-page-title-main">Jet injector</span> Needle-free medical injection syringe

A jet injector is a type of medical injecting syringe device used for a method of drug delivery known as jet injection, in which a narrow, high-pressure stream of liquid penetrates the outermost layer of the skin to deliver medication to targeted underlying tissues of the epidermis or dermis, fat, or muscle.

<span class="mw-page-title-main">Intraosseous infusion</span> Medical procedure of injecting medications into bone marrow

Intraosseous infusion (IO) is the process of injecting medications, fluids, or blood products directly into the marrow of a bone; this provides a non-collapsible entry point into the systemic venous system. The intraosseous infusion technique is used to provide fluids and medication when intravenous access is not available or not feasible. Intraosseous infusions allow for the administered medications and fluids to go directly into the vascular system. The IO route of fluid and medication administration is an alternative to the preferred intravascular route when the latter cannot be established promptly in emergent situations. Intraosseous infusions are used when people have compromised intravenous access and need immediate delivery of life-saving fluids and medications.

<span class="mw-page-title-main">Infusion pump</span> Medical device

An infusion pump infuses fluids, medication or nutrients into a patient's circulatory system. It is generally used intravenously, although subcutaneous, arterial and epidural infusions are occasionally used.

<span class="mw-page-title-main">Drug injection</span> Method of introducing a drug

Drug injection is a method of introducing a drug into the bloodstream via a hollow hypodermic needle, which is pierced through the skin into the body. Intravenous therapy, a form of drug injection, is universally practiced in modernized medical care. As of 2004, there were 13.2 million people worldwide who self-administered injection drugs outside of medical supervision, of which 22% are from developed countries.

Dosage forms are pharmaceutical drug products in the form in which they are marketed for use, with a specific mixture of active ingredients and inactive components (excipients), in a particular configuration, and apportioned into a particular dose. For example, two products may both be amoxicillin, but one is in 500 mg capsules and another is in 250 mg chewable tablets. The term unit dose can also sometimes encompass non-reusable packaging as well, although the FDA distinguishes that by unit-dose "packaging" or "dispensing". Depending on the context, multi(ple) unit dose can refer to distinct drug products packaged together, or to a single drug product containing multiple drugs and/or doses. The term dosage form can also sometimes refer only to the pharmaceutical formulation of a drug product's constituent drug substance(s) and any blends involved, without considering matters beyond that. Because of the somewhat vague boundaries and unclear overlap of these terms and certain variants and qualifiers within the pharmaceutical industry, caution is often advisable when conversing with someone who may be unfamiliar with another person's use of the term.

In medicine, a bolus is the administration of a discrete amount of medication, drug, or other compound within a specific time, generally 1–30 minutes, to raise its concentration in blood to an effective level. The administration can be given by injection: intravenously, intramuscularly, intrathecally, subcutaneously, or by inhalation. The article on routes of administration provides more information, as the preceding list of ROAs is not exhaustive.

Skin popping is a route of administration of street drugs where they are injected or deposited under the skin. It is usually a depot injection, either subcutaneous or intradermal, and not an intramuscular injection. After deposition, the drug then diffuses slowly from the depot into the capillary networks, where it enters circulation. Skin popping is distinct from intravenous injection in that the latter deposits the drug directly into the bloodstream via a vein. Nonetheless, it is included with IV injection in the category of injection drug use because both involve injection, both are often done with the same drugs, and both carry many of the same risks. Higher-potency prescription opioids, such as morphine, fentanyl, or meperidine can be injected subcutaneously, as can cocaine. Skin popping increases the duration of the high one gets from drugs such as cocaine. The sites where skin popping with cocaine has been performed have an area of central pallor surrounded by bruising (ecchymosis). This pattern is due to the vasoconstrictive properties of cocaine acting locally at the injection site with hemorrhage occurring in the surrounding tissue. Skin popping puts one at risk for developing secondary amyloid associated (AA) amyloidosis. Tetanus has also been associated with skin-popping as has botulism.

<span class="mw-page-title-main">Infusion therapy</span>


In medicine, infusion therapy deals with all aspects of fluid and medication infusion, via intravenous or subcutaneous application. A special infusion pump can be used for this purpose.

<span class="mw-page-title-main">Injection port</span> Medical device

An injection port is a medical device used for the administration of insulin or other physician approved medicine into the subcutaneous tissue. The device is similar to infusion sets used by insulin pumps, except it is configured to receive a syringe instead of a tubing system. An injection port is usually a disposable device applied by the patient and worn for period of 3–5 days. When giving shots via an injection port, the needle stays above the surface of the skin. Medication is delivered via a short soft cannula. An injection port can be used in conjunction with multiple daily injections of insulin by people with diabetes. It can also be used for the subcutaneous administration of any other physician prescribed medication.

<span class="mw-page-title-main">Vitamin K reaction</span> Medical condition

Vitamin K reactions are adverse side effects that may occur after injection with vitamin K. The liver utilizes vitamin K to produce coagulation factors that help the body form blood clots which prevent excessive bleeding. Vitamin K injections are administered to newborns as a preventative measure to reduce the risk of hemorrhagic disease of the newborn (HDN).

<span class="mw-page-title-main">Intradermal injection</span> Medical injection into the dermis

Intradermal injection is a shallow or superficial injection of a substance into the dermis, which is located between the epidermis and the hypodermis. For certain substances, administration via an ID route can result in a faster systemic uptake compared with subcutaneous injections, leading to a stronger immune response to vaccinations, immunology and novel cancer treatments, and faster drug uptake. Additionally, since administration is closer to the surface of the skin, the body's reaction to substances is more easily visible. However, due to complexity of the procedure compared to subcutaneous injection and intramuscular injection, administration via ID is relatively rare, and is only used for tuberculosis and allergy tests, Monkeypox vaccination, and certain therapies.

<span class="mw-page-title-main">Injector pen</span> Drug storage and delivery device

An injector pen is a device used for injecting medication under the skin. First introduced in the 1980s, injector pens are designed to make injectable medication easier and more convenient to use, thus increasing patient adherence. The primary difference between injector pens and traditional vial and syringe administration is the easier use of an injector pen by people with low dexterity, poor vision, or who need portability to administer medicine on time. Injector pens also decrease the fear or adversity towards self-injection of medications, which increases the likelihood that a person takes the medication.

References

  1. ↑ "ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations" (PDF). www.ismp.org. 2013. Retrieved 13 May 2013.
  2. ↑ " subcutaneous injection " at Dorland's Medical Dictionary
  3. 1 2 3 4 5 6 7 Taylor C (2011). Fundamentals of nursing : the art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health and Lippincott Williams & Wilkins. ISBN   978-0781793834.
  4. 1 2 Usach I, Martinez R, Festini T, Peris JE (November 2019). "Subcutaneous Injection of Drugs: Literature Review of Factors Influencing Pain Sensation at the Injection Site". Advances in Therapy. 36 (11): 2986–2996. doi:10.1007/s12325-019-01101-6. PMC   6822791 . PMID   31587143.
  5. ↑ Gedawy A, Martinez J, Al-Salami H, Dass CR (February 2018). "Oral insulin delivery: existing barriers and current counter-strategies". The Journal of Pharmacy and Pharmacology. 70 (2): 197–213. doi: 10.1111/jphp.12852 . PMID   29193053. S2CID   12848146.
  6. ↑ "Insulin Human - Drug Usage Statistics". ClinCalc DrugStats Database.
  7. 1 2 Lejmi H, Jen KY, Olson JL, James SH, Sam R (April 2016). "Characteristics of AA amyloidosis patients in San Francisco". Nephrology. 21 (4): 308–313. doi:10.1111/nep.12616. PMID   26370715. S2CID   31760853.
  8. ↑ Khan F, Mukhtar S, Anjum F, Tripathi B, Sriprasad S, Dickinson IK, Madaan S (April 2013). "Fournier's gangrene associated with intradermal injection of cocaine". The Journal of Sexual Medicine. 10 (4): 1184–1186. doi:10.1111/jsm.12055. PMID   23347293.
  9. ↑ Meng H, Cao J, Kang J, Ying X, Ji J, Reynolds W, Rampe D (January 2012). "Mephedrone, a new designer drug of abuse, produces acute hemodynamic effects in the rat". Toxicology Letters. 208 (1): 62–68. doi:10.1016/j.toxlet.2011.10.010. PMID   22037396.
  10. ↑ Steele TD, Katz JL, Ricaurte GA (September 1992). "Evaluation of the neurotoxicity of N-methyl-1-(4-methoxyphenyl)-2-aminopropane (para-methoxymethamphetamine, PMMA)". Brain Research. 589 (2): 349–352. doi: 10.1016/0006-8993(92)91298-s . PMID   1382813. S2CID   232653.
  11. ↑ Mathaes R, Koulov A, Joerg S, Mahler HC (August 2016). "Subcutaneous Injection Volume of Biopharmaceuticals-Pushing the Boundaries". Journal of Pharmaceutical Sciences. 105 (8): 2255–2259. doi:10.1016/j.xphs.2016.05.029. PMID   27378678.
  12. ↑ Prettyman J (April 2005). "Subcutaneous or intramuscular? Confronting a parenteral administration dilemma". Medsurg Nursing. 14 (2): 93–8, quiz 99. PMID   15916264.
  13. ↑ Ballweg R, Brown DL, Vetrosky DT (2013). Physician assistant : a guide to clinical practice (5th ed.). Philadelphia, PA: Elsevier/Saunders. ISBN   9781455723102.
  14. 1 2 Thomaidou E, Ramot Y (March 2019). "Injection site reactions with the use of biological agents". Dermatologic Therapy. 32 (2): e12817. doi: 10.1111/dth.12817 . PMID   30637967. S2CID   58544258.
  15. ↑ Guo X, Wang W (June 2017). "Challenges and recent advances in the subcutaneous delivery of insulin". Expert Opinion on Drug Delivery. 14 (6): 727–734. doi:10.1080/17425247.2016.1232247. PMID   27626885. S2CID   19820269.
  16. ↑ Mohammady M, Radmehr M, Janani L (June 2021). "Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity". The Cochrane Database of Systematic Reviews. 2021 (6): CD008077. doi:10.1002/14651858.CD008077.pub6. PMC   8186522 . PMID   34101161.
  17. ↑ Bilen O, Teruya J (August 2012). "Complications of anticoagulation". Disease-a-Month. 58 (8): 440–447. doi:10.1016/j.disamonth.2012.04.002. PMID   22818558.
  18. ↑ Müller T (October 2020). "An evaluation of subcutaneous apomorphine for the treatment of Parkinson's disease". Expert Opinion on Pharmacotherapy. 21 (14): 1659–1665. doi:10.1080/14656566.2020.1787379. PMID   32640853. S2CID   220435665.
  19. ↑ DeLorenzi C (May 2013). "Complications of injectable fillers, part I". Aesthetic Surgery Journal. 33 (4): 561–575. doi: 10.1177/1090820X13484492 . PMID   23636629.
  20. ↑ Erlichson K, Waight J (July 2012). "Therapeutic applications for subcutaneous triptans in the acute treatment of migraine". Current Medical Research and Opinion. 28 (7): 1231–1238. doi:10.1185/03007995.2012.674501. PMID   22401601. S2CID   10487801.
  21. 1 2 Dragoman MV, Gaffield ME (September 2016). "The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review". Contraception. 94 (3): 202–215. doi: 10.1016/j.contraception.2016.02.003 . PMID   26874275.
  22. ↑ Grange JM (June 1998). "Complications of bacille Calmette-Guérin (BCG) vaccination and immunotherapy and their management". Communicable Disease and Public Health. 1 (2): 84–88. PMID   9644119.
  23. ↑ Ma SJ, Li X, Xiong YQ, Yao AL, Chen Q (November 2015). "Combination Measles-Mumps-Rubella-Varicella Vaccine in Healthy Children: A Systematic Review and Meta-analysis of Immunogenicity and Safety". Medicine. 94 (44): e1721. doi:10.1097/MD.0000000000001721. PMC   4915870 . PMID   26554769.
  24. ↑ Leonardi L, Viganò M, Nicolucci A (28 August 2019). "Penetration force and cannula sliding profiles of different pen needles: the PICASSO study". Medical Devices: Evidence and Research. 12: 311–317. doi: 10.2147/MDER.S218983 . PMC   6717876 . PMID   31695523.
  25. ↑ Frid AH, Kreugel G, Grassi G, Halimi S, Hicks D, Hirsch LJ, et al. (September 2016). "New Insulin Delivery Recommendations". Mayo Clinic Proceedings. 91 (9): 1231–1255. doi: 10.1016/j.mayocp.2016.06.010 . PMID   27594187.
  26. ↑ "hypodermoclysis", Merriam-Webster's medical dictionary online. Retrieved July 19, 2009.
  27. ↑ Menahem Sasson, Pesach Shvartzman, "Hypodermoclysis: an alternative infusion technique", American Family Physician, vol. 64, no. 9, pp. 1575-1579 (November 1, 2001).
  28. ↑ Edwin M. Hasbrouck, "An improved device for rapid hypodermoclysis", Journal of the American Medical Association, 34, p. 1273, 1900.
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