15. 不同胰岛素注射部位的选择 胰岛素类型注射部位短效人胰岛素腹部速效胰岛素类似物任一部位中效人胰岛素或长效胰岛素类似物大腿或臀部预混人胰岛素或预混胰岛素类似物早晨 腹部 傍晚 大腿或臀部Birtha Hansen,et al. 2006.2nd edition,page52;
A.Frid,et al. New injection recommendations for patients with diabetes. Diabetes & Metabolism 36(2010)S3-S18
16. 关于注射部位轮换的推荐:一种已经证实有效的注射部位轮换方案:将注射部位分为四个象限(大腿或臀部可等分为两个等分区域),每周使用一个象限并始终按顺时针方向进行轮换[1,2];A3
在任何一个象限或等分区域内注射时,每次的注射点都应间隔至少1cm,以避免重复的组织损伤;A3
从注射治疗一开始,就应教会患者掌握一套简单易行的注射部位轮换方案[3];A2
每次患者就诊时,医护人员都应检查患者轮换方案的执行情况。A3Diagrams courtesy of Lourdes Saez-de Ibarra and Ruth Gaspar, Diabetes Nurses and Specialist Educators from La Paz Hospital, Madrid, Spain.
Lumber T. Tips for site rotation. When it comes to insulin. where you inject is just as important as how much and when. Diabetes Forecast 2004;57:68-70.
Thatcher G. Insulin injections. The case against random rotation. Am J Nurs 1985; 85: 690-2.
17. 关于注射部位检查和消毒的推荐:患者应于注射前检查注射部位[1,2];A3
一旦发现注射部位若出现脂肪增生、炎症或感染,应更换注射部位[3-10];A2
注射时,应保持注射部位的清洁[11];A2
当注射部位不洁净,或者患者处于感染已于传播的环境(如:医院或疗养院),注射前应消毒注射部位[2,12,16-18]。A3Danish Nurses Organization. Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus, 2nd edition, December 2006.
Association for Diabetescare Professionals (EADV). Guideline: The Administration of Insulin with the Insulin Pen. September 2008.
Johansson U. Amsberg S, Hannerz L, Wredling R, Adamson U, Arnqvist HJ & P Lins (2005) Impaired Absorption of insulin Aspart from Lipohypertrophic Injection Sites. Diabetes Care: Vol 28, No 8, 2025-2027.
Ariza-Andraca CR, Altamirano-Bustamante E, Frati-Munari AC, Altamirano-Bustamante P, Graef-Sanchez A. Delayed insulin absorption due to subcutaneous edema. Arch Invest Med 1991;22:229-33.
Saez-de Ibarra L, Gallego F. Factors related to lipohypertrophy in insulin-treated diabetic patients; role of educational intervention. Pract Diabetes Int 1998;15:9-11.
Young RJ, Hannan WJ, Frier BM, Steel JM, Duncan LJ. Young RJ, Hannan WJ, Frier BM, Steel JM Diabetic lipohypertrophy delays insulin absorption. Diabetes Care 1984;7:479-80.
Chowdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ 2003;327:383-4.
Johansson UB. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care 2005;28:2025-7.
Overland J, Molyneaux L, Tewari S., Fatouros R, Melville P, Foote D, et al. Lipohypertrophy: Does it matter in daily life? A study using a continuous glucose monitoring system. Diabetes Obes Metab2009;11:460-3.
Frid A, Linden B. Computed tomography of injection sites in patients with diabetes mellitus. Injection and Absorption of Insulin. Stockholm: Thesis, 1992.
Gorman KC. Good hygiene versus alcohol swabs before insulin injections (Letter). Diabetes Care 1993;16:960-1.
Schuler G, Pelz K, Kerp L. Is the reuse of needles for insulin injection systems associated with a higher risk of cutaneous complications? Diabetes Res Clin Pract 1992;16:209-12.
Workman B. Safe injection techniques. Nurs Stand 1999;13:47-53.
Bain A, Graham A. How do patients dispose of syringes? Pract Diabetes Int 1998; 15: 19-21.
Chantelau E, Schiffers T, Schutze J, Hansen B. Effect of patient-selected intensive insulin therapy on quality of life. Patient Educ Couns 1997 Feb; 30(2): 167-73.
Le Floch JP, Herbreteau C, Lange F, Perlemuter L. Biologic material in needles and cartridges after insulin injection with a pen in diabetic patients. Diabetes Care 1998;21:1502-4.
McCarthy JA, Covarrubias B, Sink P. Is the traditional alcohol wipe necessary before an insulin injection? Dogma disputed (Letter). Diabetes Care 1993;16:402.
Swahn A. Erfarenheter av 94000 osterilt givna insulininjektioner (Experiences from 94000 insulin injections given without skin swab). Sv Lakaresallskapets Handlingar Hygiea 1982;92:160(3O).
19. Clauson PG, Linde B. Absorption of rapid-acting insulin in obese and nonobese NIDDM patients. Diabetes Care 1995;18:986-91.
Jamal R, Ross SA, Parkes JL, Pardo S, Ginsberg BH. Role of injection technique in use of insulin pens: prospective evaluation of a 31-gauge, 8mm insulin pen needle. Endocr Pract 1999;5:245-50.
Birkebaek N, Solvig J, Hansen B, Jorgensen C, Smedegaard J, Christiansen J. A 4mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care. 2008 Sep;22(9): e65.
Gibney MA, Arce CH, Byron KJ, Hirsch LJ. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: Implications for needle length recommendations. Curr MedRes Opin 2010;26:1519-30.
Hirsch L, Klaff L, Bailey T, Gibney M, Albanese J, Qu S, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm\32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41.
Kreugel G, Keers JC, Jongbloed A, Verweij-Gjaltema AH, Wolffenbuttel BHR. The influence of needle length on glycemic control and patient preference in obese diabetic patients. Diabetes 2009;58:A117.
Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size for SC insulin administration on metabolic control and patient acceptance. Europ Diab Nursing 2007;4:1-5.
Van Doorn LG, Alberda A, Lytzen L. Insulin leakage and pain perception with NovoFine 6 mm and NovoFine 12 mm needle lengths in patients with type 1 or type 2 diabetes. Diabet Med 1998;1:S50.
Solvig J, Christiansen JS, Hansen B, Lytzen L. Localisation of potential insulin deposition in normal weight and obese patients with diabetes using Novofine 6 mm and Novofine 12 mm needles. Meeting Federation European Nurses in Diabetes, Jerusalem, Israel, 2000 (Abstract).
Schwartz S, Hassman D, Shelmet J, Sievers R, Weinstein R, Liang J, Lyness W. A multicenter, open-label, randomized, two-period crossover trial comparing glycemic control, satisfaction, and preference achieved with a 31 gauge x 6mm needle versus a 29 gauge x 12.7mm needle in obese patients with diabetes mellitus. Clin Ther 2004;26:1663-78.
Frid A, Lindén B. Where do lean diabetics inject their insulin? A study using computed tomography. BMJ 1986; 292:1638.关于进针角度的推荐:使用较短(4mm或5mm)的针头时,大部分患者无需捏起皮肤,并可90°
进针[1-9];A1
使用较长(≥ 8mm)的针头时,需要捏皮或45°角以降低肌肉注射风险[10,11]。A1
20. 针头留置时间使用胰岛素注射笔:在完全按下拇指摁钮后,应在拔出针头前至少停留10秒,从而确保药物剂量全部被注入体内,同时防止药液渗漏。药物剂量较大时,有必要超过10秒使用胰岛素专用注射器:当注射器内塞推压到位后,注射器针头无需在皮下停留10秒即可拔出药液的流速还与注射笔针头的内径有关,注射笔针头的内径越大,其药液流速更快。目前,临床上有采用 “薄壁”设计的针头,在同等外径的情况下内径更大,在降低注射引起不适感的同时保证胰岛素的流速,更利于机体对胰岛素的吸收* Frid A. New injection recommendations for patients with diabetes.Diabetes & Metabolism 36 (2010) S3-S18*A3
21. 关于注射器材废弃的推荐医护人员和患者必须熟知国家有关医疗废弃物处理的相关规定[1];A3
所有医护人员从注射治疗的开始,就应教会患者如何正确废弃注射器材[2];A3
医护人员应向患者说明可能发生于患者家人(如刺伤儿童)和服务人员(如垃圾收运工和清洁工)的不良事件;A3
任何情况下都不能将注射器材丢入公共垃圾桶或者垃圾场。A3Workman B. Safe injection techniques. Nurs Stand 1999;13:47-53.
Bain A, Graham A. How do patients dispose of syringes? Pract Diabetes Int 1998; 15: 19-21.注射笔针头的废弃专用注射器的废弃废弃针头或者注射器的最佳方法是,将注射器或注射笔针头放入专用废弃容器内再丢弃。如果没有专用废弃容器,也可使用加盖的硬壳容器。