Preparation before insulin injection
1.For each person insulin pen and the corresponding injectable drug requirements are very strict.
2.Choose clean and dry skin for injection. There is no need to sterilize the skin and the corresponding apparatus.
3.Insulin should be injected preferably at room temperature.
4.Mix the premixed insulin well by shaking it back and forth at least 10 times until a uniform white emulsion appears.
5.When the amount of premixed insulin is less than 12 IU, it is necessary to replace the insulin refill with a new one.
6.Before each injection, repeatedly expel air upward until insulin liquid overflows from the needle.
7.When the insulin dosage exceeds 50 IU at one time, the insulin doses should be injected separately and separated as early as possible if necessary.
Preferred injection sites and tissues
1.Inject insulin in subcutaneous tissue
2. Fast-acting insulin should preferably be injected in the abdomen, and slow-acting insulin should preferably be injected in the outer thigh and/or buttocks, while the upper arm is not a recommended injection site. There is no difference between different types of insulin in the above recommended injection sites.
3.Select undamaged skin for injection.
4. The injection sites must be rotated to prevent skin damage.
5.Check for skin damage at least once a year. When there is skin damage, it is necessary to check the injection site more frequently and educate about the possibility of other injection sites, rotation of injection sites, disposable use of needles, and reduction of insulin requirements.
Characteristics of injection needles
1. The length of the needle must be individualized according to the different injection sites combined with the injection technique. Usually needles <8 mm, especially 5 or 6 mm needles, are used for subcutaneous insulin injections.
Each needle can only be used once and should be discarded immediately after insulin injection, unless the insulin dose must be divided into two or more injections.
3. Insulin pens must be prepared in advance, while referring to the manufacturer’s instructions or seeking the appropriate manufacturer’s guidance.
Injection Technique
1.There are different recommendations on injection technique, combining the injection site and the length of the needle.
When there are no skin folds vertically, a short needle (5 or 6 mm) is preferred. When the needle is >8 mm pinch the skin folds with the thumb and index finger instead of pinching the subcutaneous muscle tissue. There is no uniform rule regarding the time to release the skin folds.
2.Injection through clothing is not recommended.
3. The speed of needle insertion and extraction is determined by the patient. Once the needle is inserted into the skin, the injection angle of the needle cannot be changed during the injection.
4.Insulin must be injected slowly.
5.When the insulin has been injected, the needle must be left under the skin for 10s.
6.Do not massage the skin after the injection.
Tasks of health care workers
1.There are three major types of injectable drugs available for the treatment of diabetes: insulin, GLP-1 factor and pancreatin.
2.The primary task of the diabetes educator is to teach the patient how to inject these drugs correctly.
3.Before educating the patient on the ideal injection technique, it is necessary to first have some understanding of the anatomy of the injection site.
4. It is necessary to recognize that there are differences in the absorption of different factors by different tissues and sites.
5. The main purpose of education on proper injection technique is to avoid intramuscular injections.
6.Another major task of health care workers is to help patients overcome the many psychological barriers that may arise during injection, especially in the early stages of implementing insulin injection therapy.
Psychological challenges of insulin injection therapy
Children
1. The fear that most children have when starting injection therapy usually stems from early immunization injection experiences and negative social messages about injections.
2. Health care workers and parents fearing harm to the child usually tend to transmit this fear to the child.
3. Parents who are well prepared in advance can reduce the corresponding anxiety, and their calm and affirmative performance is the most effective support for the fearful child.
4, The child’s anticipated fear is often worse than the actual fear at the time of injection.
5. A health care worker who smiles while injecting a child may be misinterpreted as enjoying harming the child. It is most appropriate at this time to not have any expression.
6.Distraction methods can be used for young children during injection (as long as deception is not used), while cognitive-behavioral therapy is more appropriate for older children.
7. Cognitive-behavioral therapy includes relaxation training, guided thinking, hierarchical contact, positive movement demonstration and reinforcement training.
Adolescents
Health care providers need to be aware that many adolescents are reluctant to inject insulin in front of their peers.
2. There is a greater tendency among adolescents to neglect injections, mostly due to simple forgetfulness, although in some cases it may be due to peer pressure or their own emotional resistance, etc.
3. If there is a risky behavior of considering insulin dose reduction as a method of weight control, neglecting injections may become a habit.
4. Among young women, there is more intentional reduction of insulin dose, and whenever there is a difference between the effect of recommended dose treatment and HbA1C, it is necessary to find out the reason.
5. Teenagers should be given the benefit of the doubt: no one can manage diabetes perfectly all the time, and occasional lapses, as long as they are not habit-forming, are not considered failures; they have only small, non-long-term consequences.
6. Any measures to strengthen their management awareness can have a positive impact on adolescents (e.g. flexible injection planning for weekends or holidays).
7. All parents, and especially teens themselves, should be encouraged to talk about their feelings about injecting, especially the frustrations they encounter and their own efforts.
Adults
1. Although only a minority of adults have needle phobia, there are still many who have anxiety about injections, especially in the early stages of starting treatment.
2. Even experienced parents may have some rejection or aversion to injections.
3, At the beginning of treatment, health care workers take self-injection insulin demonstration can reduce the patient’s fear.
4.If the patient’s parents had experience of self-injecting insulin after the previous diagnosis of diabetes, it can significantly reduce the patient’s fear of injection.
5. Insulin itself is also an aspect of the patient’s cause for concern. Health care workers can prepare newly diagnosed type 2 diabetes patients for future implementation of insulin therapy by explaining that the natural, progressive nature of the disease substantially includes insulin therapy and that the use of insulin therapy does not imply a failure of treatment.
6. The benefits of good glycemic control in the short and long term need to be emphasized.
7. The goal of treatment should be to identify early appropriate combination therapy for glycemic control rather than minimizing the types of therapeutic drugs used.
8. Health care workers should think carefully about their own understanding of insulin therapy and avoid using any terminology that implies that insulin therapy is a failure, a form of punishment or threat.
9. Health care workers should demonstrate how insulin injection therapy can prolong life and improve quality of life from a human-cultural perspective, through appropriate metaphors, pictures and stories.
Education
1. Decisions about injections should be made in a discussion setting where the patient is a participant and the health care worker is responsible for providing relevant experience and advice.
Health care workers should take time to explore patients’ fears about the injection process and insulin itself.
3. At the beginning of injection therapy (and at least annually thereafter), health care workers should discuss the following topics.
Methods of injecting
Selection and management of instruments to be used
Protection and self-examination of the injection site
Proper injection technique including rotation of injection sites, angle of injection, and use of skin folds
Optimal needle length for injections
Reasonable appliance handling protocols
4. Health care workers should ensure that patients properly understand and accept this information.
5. If possible, the patient should be asked about and observed for current injection behavior, and the injection site should be examined and palpated at each visit; or at least once a year.
6. Patients (or parents of children with diabetes) should be taught how to visualize/palpate the injection site for early detection of fatty hypertrophy.
7. When educating groups, there is evidence that only the use of formally trained educators can produce improved knowledge and improved metabolic control.
Insulin needle length
The goal of treatment with insulin/exenatide/glucagon is to ensure that the drug is released into the subcutaneous tissue without spillage and to reduce pain or discomfort.
Children
1. Childhood is defined as the period between birth and adolescence.
2. Needle fear is very common in children, especially in the early stages of treatment, and should be carefully presented to children and their parents.
3, Appropriate needle length is critical for children to avoid intramuscular injections that produce pain, worsen diabetes treatment, and sometimes even appear dangerous.
4. The pattern of subcutaneous tissue is essentially the same in both sexes before puberty, and girls have to acquire relatively more fat accumulation than boys after puberty, so there may be a higher long-term risk of intramuscular injections in boys.
5, Children should use 4, 5 or 6mm needles and should pinch up the skin crease with each injection.
6, There is no medical basis for recommending needles larger than 6mm for children.
7. When only an 8mm needle is available for injection, the child’s skin needs to be pinched up and injected at a 45° angle. Another option is to use a needle shortener.
8, Avoid pressing or moving the skin during the injection because the needle may enter deeper than expected.
9.Injections in the arm should only be chosen if someone else is injecting and pinching up the skin.
10.Self-injection in the arm is not recommended because it is not easily achieved by pinching up the skin and injecting at the same time.
11.Patients and/or their parents should demonstrate their injection technique to the health care worker.
Adolescents and adults
1. Finding the appropriate needle length for each of the different patients is critical to ensure subcutaneous injections and avoid intramuscular injections.
2. Any patient, including obese individuals, can use 4,5 and 6mm needles, and there is no difference between them and 8mm and 12.7mm needles in terms of glycemic control.
3. Patients should realize that there are always longer needles available, so they should start with shorter needles in the early stages of treatment.
4, To date, there is no evidence that the use of short needles (≤6mm) produces severe insulin spillage, increased pain, worsening of diabetes treatment or some other complications.
5. Injections with these needles require a 90° perpendicular skin surface approach, although there is some evidence that the use of 6mm needles may also be effective when injected at a 45° angle.
6, There is no medical basis for recommending the use of needles >8mm.
7, Pinching up the skin is especially important when injecting the extremities or abdomen of patients who are thin or normal weight, especially when using >8mm needles.
8, When patients have poor glycemic control, the length of the needle and the patient’s injection technique need to be evaluated annually.
Skin folds
1. Pinching up the skin fold is especially important when the distance from the skin surface to the muscle is less than the length of the needle.
2. Pinching up the skin fold is a simple and effective method to ensure subcutaneous injection.
3. All patients should be taught the correct way to pinch the skin crease from the beginning of insulin therapy.
4. Pinch the appropriate skin fold with the thumb and index finger (sometimes with the middle finger).
5. Pinching up the skin with the entire hand may pinch up the subcutaneous tissue along with the muscle, resulting in intramuscular injection.
6, Pinching up the skin of the abdomen and thighs is easy, but the buttocks (which are rarely used) are much more difficult, and when self-injecting, this is simply not possible in the arms.
Injection site care
1. You should use clean hands to inject on clean areas.
2.It is usually not necessary to sterilize the injection site outside the hospital.
3.Inspection of the injection site should be done prior to injection.
4.Injecting through clothing does not necessarily have serious consequences, but common sense and the fact that the patient will not be able to see the injection site is not a desirable option.
5. If there are signs of fat pads, inflammation or infection, the injection site needs to be replaced.
Storage and activation
1. Store insulin at room temperature (up to one month within the expiration date) in the container currently used with it (pen, cartridge or glass bottle).
2.Mixed insulins (e.g. NPH and premixed insulin) must be slowly shaken and/or tilted for at least 20 turns until the crystals turn into a suspension (the solution turns milky white).
3. Prepare the insulin pen (visible insulin droplets hanging from the needle tip) before injection to ensure fluid flow and no obstruction during injection.
Injection
1.Inject slowly to ensure complete downward pressure on the syringe plunger or the thumb button of the insulin pen.
2.When the injection is finished then wait 10s to pull out the needle to avoid spillage, to ensure that the injected dose is completely released and absorbed.
3.Insulin needs to be injected at room temperature because some insulins will be denatured when injected at low temperature.
4. It is usually not recommended to massage the injection site after injection, as it will accelerate the absorption of insulin.
Pens
1.Injection pens and refills can only be used for the same patient and should never be shared between patients.
2.After the injection, the needle should be discarded immediately instead of leaving it on the pen, which can prevent air or other contaminants from entering the refill and insulin spillage.
3. After fully depressing the thumb button, the patient should slowly count to 10 before pulling out the refill to obtain an adequate dose and prevent insulin spillage.
4. It is necessary to count to more than 10 for larger doses.
Syringes
1. Many patients around the world still use syringes as their primary injection device.
2.There is no syringe with a needle length <8mm.
3. Unlike insulin pens, there is no evidence that the syringe needle must remain subcutaneously for 10s when the plunger is fully depressed.
4. There is no medical basis for the use of syringes with removable needles for insulin injection. Syringes with fixed needles provide more accurate dosing and reduce ineffective cavities, and allow mixing of insulin when needed.
Insulin analogues (rapid-acting)
1.Quick-acting insulin analogues can be injected at any injection site because there is no difference in their absorption rate at different injection sites.
2. Fast-acting insulin analogs cannot be injected intramuscularly, although some studies have shown that their absorption rates are similar in adipose tissue and in muscle at rest. There is no study on the absorption rate of muscle under working condition.
3.Injecting 15min before meal can ensure that the insulin analogues can play their active role better with the absorption of sugar.
Insulin analogues (slow-acting)
1. Intramuscular injection of long-acting insulin analogues must be avoided to prevent the risk of severe hypoglycemia.
2.Dietary insulin is absorbed more quickly when injected in the abdomen than in the thigh.
3.With further research, patients can inject slow-acting insulin analogues at any regular injection site.
4. The absorption pattern of dett insulin is dose-dependent and tends to show significant peaks when large doses are given, at which point it is best to split the large dose into two injections.
5.There is no unified regulation on the range of insulin dose separate injections, which is usually considered to be 40-50 IU.
6. Patients who take part in sports after injecting glargine insulin or detergent insulin need to beware of the occurrence of hypoglycemia.
Human and premixed insulin
1, NPH insulin is absorbed more slowly when injected in the thigh or buttocks. These areas are more suitable for using NPH insulin as basal insulin.
2.Soluble human insulin (regular insulin injection, regular lysergic insulin injection) is generally absorbed more slowly than the fast-acting analogues.
3. Soluble human insulin is absorbed fastest at the preferred site of injection – abdomen.
4. Soluble human insulin is absorbed very slowly in the elderly, and this type of insulin should not be used when fast-acting effects are needed.
5. Premixed insulin is recommended to be injected in the abdomen in the morning and in the thighs or buttocks in the evening. If NPH insulin is absorbed too fast at night, we should be careful about the occurrence of nighttime hypoglycemia.
GLP-1 factor
1. GLP-1 factor should be injected according to the guidelines that have been established regarding insulin injection (e.g. needle length, skin folds and site rotation).
2.GLP-1 factor can be injected at any injection site, because there is no difference in the pharmacokinetics of different injection sites.
3. The needle for injecting GLP-1 factor can only be used once.
Fatty hypertrophy (fat pad)
1. Fat pad is a thickened, rubber-like injury that can appear in the subcutaneous tissue at the injection site in half of insulin-injected patients (up to 70% in children).
2. Detection of fat pads requires both visualization and palpation of the injection site, as some injuries are more easily felt than visualized.
3. Patients should not be injected at the fat pad site because its insulin absorption may be delayed or unstable, which could potentially worsen the treatment of diabetes.
4, In addition, patients should be informed of the benefits of eliminating fat pads: less fluctuation in blood glucose, better control of HbA1C, less occurrence of hypoglycemia, and better aesthetics.
5.No relevant randomized, prospective studies have been published to confirm the predisposing factors of fat pads.
6, The literature confirms a strong relationship between the formation of fat pads and not rotating injection sites, injecting in small areas, repeatedly injecting in the same area, and repeated use of needles.
7, (When injecting repeatedly at the same site) insulin pens and syringes can cause fat hypertrophy as can insulin pumps, and all types of needles can cause these injuries.
8, Health care workers should check patients’ injection sites at each visit, especially for patients who have developed fat pads, and injection sites should be checked at least once a year.
9. Patients should be taught to examine their own injection sites and how to identify fat pads.
10. The use of “fat models” (where the patient can feel the typical injury) can make it easier for the patient to grasp.
11. It is also helpful to use group sessions for patients to share their knowledge about fat pads with each other.
12.Mark the corresponding edges of the fat pad with ink (at the junction of normal and rubbery tissue) to facilitate measurement of the injury and long-term follow-up.
13, If the fat pad is already visible, it can also be photographed with a camera for measurement and follow-up.
14.Injections in the hypertrophic area should be avoided until the abnormal tissue returns to normal (which takes about several months to several years).
15.When replacing from fat pad to normal tissue for injection, it is often necessary to reduce the corresponding insulin injection dose. The dose of insulin that needs to be reduced varies from person to person, depending on the rapid blood glucose value.
16.The use of monitoring systems (such as diabetes management software) can help patients directly see the metabolic advantages of not injecting in fatty hypertrophy areas, resulting in better patient compliance.
17. The best current strategies for treating and preventing lipohypertrophy include changing injection sites with each injection, using a larger injection area and not reusing needles.
Rotation of injection sites
1. Many studies have shown that in order to protect normal tissues, patients must keep changing injection sites appropriately.
2. Patients should be taught a simple, easy-to-follow replacement protocol from the start of insulin therapy.
A protocol that has been shown to be effective is to divide the injection site into four quadrants (two halves when injecting the thigh), using one quadrant per week and rotating it clockwise.
4. When injecting in any quadrant, the injection sites should be separated by at least 1 cm each time to avoid repeated tissue damage.
5. The health care worker should verify patient compliance with the rotation schedule at each visit and provide appropriate assistance and advice when needed.
Bleeding and bruising
1. When injecting, the syringe can sometimes injure a blood vessel, resulting in bleeding or bruising.
2. Changing the length of the injection needle or other injection parameters does not change the frequency of bleeding or bruising.
3. Bleeding or bruising has not been shown to have serious clinical consequences for insulin uptake or the overall treatment of diabetes.
Pregnancy
More studies are needed to elucidate the issue of insulin injections during pregnancy. Due to the lack of these studies, the following are reasonable recommendations at this time: 1. Patients with gestational diabetes (regardless of type) should be injected with the skin raised and pinched up if they are to continue to be injected in the abdomen.
2. The use of routine fetal ultrasound gives health care workers the opportunity to assess abdominal subcutaneous fat and develop relevant injection guidelines based on the data.
3. Injections around the umbilicus should be avoided in the second trimester of pregnancy. When injecting in the ribbed abdomen, pinching is required to raise the skin flab.
Intradermal injection
1, The thickness of the epidermis at all injection sites is 1.5-3.0 mm, so reasonable use of 4, 5 and 6 mm needles will not incur the risk of injection into the dermis.
2, In the future, the space within the dermis may also become a target area for injection, but until further studies confirm this, it is still not recommended to inject in this area.
Safe needles
1, Needle stab injuries occur frequently among health care workers, and there are many studies showing serious underreporting for various reasons.
2, Safety needles can be effective in preventing such injuries and should be recommended whenever there is a risk of injury from contaminated needles (e.g., in hospitals).
3, a great deal of education and training is needed to ensure the correct and effective use of currently available safety needles.
4, The safety performance of these needles needs to be as intuitive as possible, and their mechanism should be able to be automatically combined into the daily use of syringe instruments.
5, In hospitals, penetrating needle puncture injuries often occur when health care workers pinch up the skin to give injections to patients.
6. Most safety mechanisms do not prevent this type of injury, so it would make more sense to use short needles and not pinch up the skin for injections.
Handling of injection equipment
1. Patients should be educated from the beginning of injection treatment and reinforced from the beginning to the end about the proper handling of injection equipment.
2. There is a need to communicate with each other from center to center, as there are significant differences in existing protocols in different regions.
3. Each center and region should have an effective protective needle handling system, which needs to be clearly explained to patients and implemented by medical staff and other management.
4, Wherever available, needle cut-off handling equipment should be used.
5. Under no circumstances should unprotected sharp instruments be disposed of into the normal (public) waste or garbage disposal system.
6.Current state/local laws or guidelines that exist should be explained to local patients.
7. The legal and social consequences of not implementing reasonable disposal should be re-examined.
8. Potential adverse events should be explained to patients’ families (e.g., children with needle-stick injuries) and service personnel (e.g., garbage collectors).
9. All relevant personnel (patients, health care workers, community workers and manufacturers) share responsibility for ensuring the reasonable handling of used sharps.