胰岛素注射指南介绍.ppt

中国糖尿病药物注射技术指南2011版介绍,糖尿病药物注射技术指南2011版目录,第一章：医护人员的职责,第二章：注射前的心理准备,第三章：注射治疗的教育,第四章：注射药物,第五章：注射装置,第六章：注射技术,第七章：皮下脂肪增生与其他并发症,第八章：胰岛素注射相关问题,第九章：规范胰岛素注射标准9步骤,第十章：注射部位规范检查3要素,本指南中对每一条推荐意见的推荐强度采用以下等级： 强烈推荐 推荐 尚未决定的问题 对于科学证据的支持程度采用以下标准： 至少具有一项随机、对照研究 至少具有一项非随机（或非对照或流行病学）研究 以大量患者经验为基础的专家共识 部分推荐意见缺乏临床试验证据，但是具有显著并令人信服的临床经验，则该部分被命名为“观察结果”，而未对这些推荐意见进行分级,糖尿病药物注射技术指南2011版推荐级别,中国糖尿病药物注射技术指南2011版注射药物篇,糖尿病注射药物发展史,1922年,胰岛素首次用于治疗糖尿病,1982年,第一个基因重组人胰岛素用于临床,1996年,超短效胰岛素类似物赖脯胰岛素问世,2001年,长效胰岛素类似物甘精胰岛素问世,2005年,GLP-1类似物 艾塞那肽 经FDA批准在 美国上市,超短效胰岛素类似物注射的相关推荐：,超短效胰岛素类似物在各注射部位的吸收不具有特异性，可以在任何注射部位给药1-5；A1 尽管有研究表明，超短效胰岛素类似物在脂肪组织和静息肌肉组织的吸收率相似，但仍不可以肌肉注射此类药物2,3,6；A2 目前，尚无关于超短效胰岛素类似物在运动状态肌肉中吸收率的研究2,3,6 。A2,Mudaliar SR, Lindberg FA, Joyce M, Beerdsen P, Strange P, Lin A, Henry RR. Insulin aspart (B28 asp-insulin): a fast-acting analog of human insulin: absorption kinetics and action profile compared with regular human insulin in healthy nondiabetic subjects. Diabetes Care 1999;22:1501-6. Rave K, Heise T, Weyer C, Herrnberger J, Bender R, Hirschberger S, et al. Intramuscular versus subcutaneous injection of soluble and lispro insulin: comparison of metabolic effects in healthy subjects. Diabet Med 1998;15:747-51. Frid A. Fat thickness and insulin administration, what do we know? Infusystems Int 2006;5:17-9. Guerci B, Sauvanet JP. Subcutaneous insulin: pharmacokinetic variability and glycemic variability. Diabetes Metab 2005;31:4S7-4S24. Braakter EW, Woodworth JR, Bianchi R. Cermele B. Erkelens DW. Thijssen JH, et al. Injection site effects on the pharmacokinetics and glucodynamics of insulin lispro and regular insulin. Diabetes Care 1996;19:1437-40. Lippert WC, Wall EJ. Optimal intramuscular needle-penetration depth. Pediatrics 2008;122:e556-63.,短效胰岛素注射的相关推荐：,胰岛素在腹部的吸收速度较快，因此短效胰岛素的注射部位首选腹部1-6；A1 短效胰岛素在老年糖尿病患者中的吸收速率可能减慢，因此对于老年糖尿病患者，当需要快速起效时不宜使用此类胰岛素7,8。B2,Frid A 18:986-91.,中效胰岛素注射的相关推荐：,为避免因快速吸收引发的严重低血糖反应，因此应避免肌肉注射NPH 1,2；A1 胰岛素在大腿和臀部的吸收速度较慢，因此当NPH作为基础胰岛素时，其首选注射部位是大腿和臀部 3,4；A1 为降低夜间低血糖发生风险，在可能的情况下，NPH应尽量在睡前给药，而避免在晚餐时给药 3,4。A1,Frid A, Ostman J, Linde B. Hypoglycemia risk during exercise after intramuscular injection of insulin in thigh in IDDM. Diabetes Care 1990;13:473-7. Vaag A, Handberg A, Lauritzen M, Henriksen JE, Pedersen KD, Beck-Nielsen H. Variation in absorption of NPH insulin due to intramuscular injection. Diabetes Care 1990;13:74-6. Bantle JP, Neal L, Frankamp LM. Effects of the anatomical region used for insulin injections on glycaemia in type 1 diabetes subjects. Diabetes Care 1993;16:1592-7. Henriksen JE, Vaag A, Hansen IR, Lauritzen M, Djurhuus MS, Beck-Nielsen H. Absorption of NPH (isophane) insulin in resting diabetic patients; evidence for subcutaneous injection in the thigh as preferred site. Diabet Med 1991;8:453-7.,长效胰岛素注射的相关推荐：,为防止严重的低血糖反应发生，严禁肌肉注射长效胰岛素和长效胰岛素类似物。对于接受长效胰岛素注射后进行体育运动的患者，必须给予低血糖警告1,2；A1 长效胰岛素类似物可在所有常规注射部位进行注射，但有待更深入的研究3,4。B2,Karges B, Boehm BO, Karges W. Early hypoglycaemia after accidental intramuscular injection of insulin glargine. Diabet Med 2005;22: 1444-5. Frid A. Personal Communication (Novo Nordisk, on file). Rassam AG, Zeise TM, Burge MR, Schade DS. Optimal Administration of Lispro Insulin in Hyperglycemic Type 1 Diabetes. Diabetes Care 1999;22:133-6. Owens DR, Coates PA, Luzio SD, Tinbergen JP, Kurzhals R. Pharmacokinetics of 125I-labeled insulin glargine (HOE 901) in healthy men: comparison with NPH insulin and the influence of different subcutaneous injection sites. Diabetes Care 2000;23:813-9.,预混胰岛素注射的相关推荐：,早餐前注射常规（短效）胰岛素 / NPH的预混胰岛素制剂时，首选注射部位是腹部，以加快常规（短效）胰岛素的吸收，便于控制早餐后的血糖波动1；A1 晚餐前注射任何含有NPH的预混胰岛素制剂时，首选注射部位是大腿或臀部，以延缓NPH的吸收，减少夜间低血糖的发生2,3。A1,Frid A, Gunnarsson R, Gntner P, Linde B. Effects of accidental intramuskulr injection on insulin absorption in IDDM. Diabetes Care 1988; 11: 41-45. Henriksen JE, Vaag A, Hansen IR, Lauritzen M, Djurhuus MS, Beck-Nielsen H. Absorption of NPH (isophane) insulin in resting diabetic patients; evidence for subcutaneous injection in the thigh as preferred site. Diabet Med 1991;8:453-7. Kendorf K, Bojsen J, Deckert T. Clinical factors influencing the absorption of 125 I-NPH insulin in diabetic patients. Horm Metab Res 1983;15:274-8.,GLP-1类似物注射的相关推荐：,GLP-1受体激动剂在各注射部位，其药代动力学未见部位特异性，因此可以在任何常规注射部位进行注射1；A2 关于GLP-1受体激动剂注射部位的轮换和针头长度的选择，目前应遵循现有的胰岛素注射推荐意见，但有待更深入的研究2。A1,Calara F, Taylor K, Han J, Zabala E, Carr EM, Wintle M, Fineman M. A randomized, open-label, crossover study examining the effect of injection site on bioavailability of exenatide (synthetic exendin-4). Clin Ther 2005;27:210-5. Byetta Pen User Manual. Eli Lilly and Company, 2007.,中国糖尿病药物注射技术指南2011版注射装置篇,注射装置篇内容摘要,临床可选用的胰岛素注射系统,传统注射器系统 （瓶装胰岛素+注射器）,耐用型注射系统 （胰岛素笔芯+注射笔）,预填充型注射系统 （胰岛素笔芯与 注射笔合二为一）,近年开发但尚未普及的一些注射/输注系统 （胰岛素泵、 无针注射器）,胰岛素专用注射器,40 IU 1mL,配合瓶装胰岛（400IU/10mL）使用，针筒上所标为胰岛素单位，一个刻度为一个胰岛素单位,优点： 有清晰的胰岛素刻度单位，避免因换算单位而导致的注射剂量的错误。固定针头的注射器减小死腔体积，能够提供较高的剂量精确度，需要时还可以用于胰岛素的混合。,缺点： 由于和某些胰岛素之间存在兼容性问题，因此目前没有针头长度小于8mm的注射器。,关于胰岛素专用注射器的推荐：,抽取胰岛素前，先用注射器吸入体积与胰岛素剂量相当的空气，然后将空气注入胰岛素瓶内，从而使胰岛素更易抽取；A3 若注射器内有气泡，可轻轻敲打注射器针筒使气泡积聚到注射器上部的药液表面，然后推动内塞排出气泡；A3 与胰岛素注射笔不同，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1-3；A3 注射器只能一次性使用4-10 。A2,Annersten M, Frid A. Insulin pens dribble from the tip of the needle after injection. Pract Diabetes Int 2000;17:109-11. Ginsberg BH. Parkes JL, Sparacino C. The kinetics of insulin administration by insulin pens. Horm Metab Res 1994;26:584-7. Broadway CA. Prevention of insulin leakage after subcutaneous injection, Diabetes Educ 1991;17:90. Chantelau E, Lee DM, Hemmann DM, Zipfel U, Echterhoff S. What makes insulin injections painful? British Medical Journal 1991; 303: 26-27. Strauss K, De Gols H, Letondeur C, Matyjaszczyk M, Frid A. The second injection technique event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int 2002; 19: 17-21. Danish 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. 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. Maljaars C. Scherpe studie naalden voor eenmalig gebruik Sharp study needles for single use; Diabetes and Levery 2002;4:36-7. Torrance T. An unexpected hazard of insulin injection. Pract Diabetes Int 2002;19:63.,胰岛素注射笔,笔芯可更换胰岛素注射笔由注射笔和胰岛素笔芯构成，笔芯中的胰岛素一旦用完，需要更换新的笔芯，而注射笔可重复使用。,优点： 胰岛素注射笔上标有刻度，其使用的注射针头非常细小，因此能减少注射时的痛苦和患者的精神负担。此外，胰岛素注射笔使用方便，便于携带，十分适合用于一日多次的胰岛素治疗方案。,缺点： 不同的胰岛素不能被混用，因此当使用不同类型的胰岛素时，不能自由配比，除非使用预混胰岛素，否则需要分别进行两次注射，具有一定的局限性。,胰岛素特充注射笔,胰岛素特充注射笔是一种预充3ml（含300U）胰岛素的一次性注射装置，无需更换笔芯，用完后直接丢弃。在具有普通胰岛素注射笔的优点的同时，提高了安全性，避免了更换笔芯可能带来的剂型或者剂量发生错误的可能。对于复杂的胰岛素治疗方案，混淆的可能性也比较低。其缺点是价格较高。,关于胰岛素注射笔的推荐：,注射前，为保证药液通畅并消除针头死腔，可按厂家说明书推按注射笔按钮，确保至少一滴药液挂在针尖上 1,2；A3 每套注射笔和笔芯只能用于同一个患者，绝对不能在患者之间共用3,4；A2 为防止空气或其他污染物进入笔芯和药液渗漏，注射笔的针头在使用后应立即除下，不得留在注射笔上5-9；A2,Bohannon NJ. Insulin delivery using pen devices. Simple-to-use tools may help young and old alike. Postgrad Med 1999;106:57-8. Dejgaard A, Murmann C. Air bubbles in insulin pens. Lancet 1989;334:871. Bartsch U, Comtesse C, Wetekam B. Insulin pens for treatment of diabetes (article in German). Ther Umsch 2006;63:398-404. 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. Byetta Pen User Manual. Eli Lilly and Company, 2007. Annersten M, Frid A. Insulin pens dribble from the tip of the needle after injection. Pract Diabetes Int 2000;17:109-11. Bartsch U, Comtesse C, Wetekam B. Insulin pens for treatment of diabetes. Ther Umsch 2006;63:398-404. 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. Chantelau E. Heinemann L, Ross D. Air Bubbles in insulin pens. Lancet 1989; 334: 387-8.,关于胰岛素注射笔的推荐：,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1-6；A1,Annersten M, Frid A. Insulin pens dribble from the tip of the needle after injection. Pract Diabetes Int 2000;17:109-11. 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. King L. Subcutaneous insulin injection technique. Nurs Stand. 2003;17:45-52. Ginsberg BH. Parkes JL, Sparacino C. The kinetics of insulin administration by insulin pens. Horm Metab Res 1994;26:584-7. Rissler J, Jrgensen C, Rye Hansen M, Hansen NA. Evaluation of the injection force dynamics of a modified prefilled insulin pen. Expert Opin Pharmacother 2008; 9: 2217-22. Broadway CA. Prevention of insulin leakage after subcutaneous injection, Diabetes Educ 1991;17:90.,注射装置篇内容摘要,针头的发展历程：更短、更细,皮肤的结构,上皮层,真皮层,皮下脂肪组织,肌肉组织,皮肤,皮肤的平均厚度在1.9-2.4mm之间,不同部位皮肤的厚度（mm）,用超声对388例美国糖尿病患者的皮肤厚度和皮下脂肪厚度进行评估。388例患者中BMI19.4-64.5kg/m2，年龄18-85岁，40%为高加索人种，25%为亚洲人种，16%为黑色人种，14%为西班牙人种，其中28%为1型糖尿病。,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.,即使消瘦患者，绝大多数皮肤表面至肌肉厚度超过6mm,67.9% 6mm,84.9% 6mm,皮肤表面至肌肉层厚度： 所有患者中67.9%超过6mm，成年患者中无人小于4mm,皮肤表面至肌肉层厚度： 所有患者中84.9%超过6mm，所有患者中无人小于4mm,研究纳入21例体型消瘦的儿童糖尿病患者（16例男性）和32例体形消瘦的成年糖尿病患者（23例男性），BMI-Z评分0，利用超声评估不同部位皮肤表面至肌肉厚度。,Birkebaek NH, Solvig J, et al. A 4-mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. .Diabetes Care. 2008 Sep;31(9):e65.,即使消瘦患者能够安全使用4mm针头,Birkebaek NH, Solvig J, et al. A 4-mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. .Diabetes Care. 2008 Sep;31(9):e65.,成人糖尿病患者使用较长针头极易注射到肌肉层,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.,BMI=25.2kg/m2 不同长度的针头垂直注射,关于注射针头的推荐：成年（1）,4mm、5mm和6mm针头适用于所有成人患者，包括肥胖患者，并且在注射时通常无需捏起皮肤，特别是4mm针头1-8；A1 成人患者采用较短针头（4mm、5mm）注射时，应使针头与皮肤表面呈90角进针1-9；A1,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 mm32G 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).,关于注射针头的推荐：成年（2）,在四肢或脂肪较少的腹部进行注射时，为防止肌肉注射，甚至在使用4mm和5mm针头时，可捏皮注射。使用6mm针头时，可以采用捏皮或45角注射 1-4；A2 在成人中，没有任何医学证据推荐使用长度超过8mm的针头。初始注射治疗应采用较短的针头3,5,6；A2 使用长度8mm针头的患者，为避免肌肉注射，应捏皮注射或以45角注射3,4。A2,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. 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. 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, Lindn B. Where do lean diabetics inject their insulin? A study using computed tomography. BMJ 1986; 292:1638. Ross SA, Jamal R, Leiter LA, Josse RG, Parkes JL, Qu S, et al. Evaluation of 8 mm insulin pen needles in people with type 1 and type 2 diabetes. Pract Diabetes Int 1999;16:145-8. Frid A, Lindn B. CT scanning of injections sites in 24 diabetic patients after injection of contrast medium using 8 mm needles. Diabetes 1996;45: A444.,中国糖尿病药物注射技术指南2011版注射技术篇,注射技术是糖尿病注射治疗的三大关键因素之一,注射技术： 注射部位的选择 注射部位的轮换 注射部位的检查和消毒 选择是否捏皮 选择进针角度 拔针时间 注射器材的废弃 关于针头重复使用的建议,关于注射部位选择的推荐：,注射餐时胰岛素等短效胰岛素，最好选择腹部1-7；A1 希望胰岛素的吸收速度较缓时，可以选择臀部。臀部注射可以最大限度地降低注射至肌肉层的风险8,9；A1 给少儿患者注射中效或者长效胰岛素时，最好选择臀部或者大腿10。A1,Frid A, Gunnarsson R, Gntner P, Linde B. Effects of accidental intramuskulr injection on insulin absorption in IDDM. Diabetes Care 1988; 11: 41-45. Frid A 66:879-82.,腹部 以肚脐为中心，半径2.5cm外的距离。越靠近腰部两侧（即使是肥胖患者），皮下组织的厚度也会变薄，因此容易导致肌肉注射。,根据可操作性/神经血管距离/皮下组织状况：适合注射的部位,上臂 上臂侧面或者后侧部位；皮下组织较厚，导致肌肉注射的概率较低。,臀部 臀部上端外侧部位；即使是少儿患者还是身材偏瘦的患者，该部位的皮下组织仍然丰富，最大限度降低肌肉注射的危险性。,大腿 大腿外侧；皮下组织较厚，离大腿血管和坐骨神经较远，针头导致外伤的概率较低。,推荐的注射部位,注射部位还应考虑胰岛素在不同部位的吸收差异,不同注射部位胰岛素吸收不同（分钟）： 研究显示，50%胰岛素吸收所需要的时间腹部最快，手臂中等，大腿和臀部较慢1,1.The American Journal of Nursing, Vol. 98, No.7, pp. 55+57,不同注射部位吸收胰岛素速度快慢不一,125I标记清除占初始剂量的百分比（%）,时间（分钟）,时间（分钟）,*p0.05 ，大腿 vs 上臂 *p0.05 ，上臂 vs. 腹部 *p0.005，腹部vs. 大腿,注射胰岛素后餐后血糖水平（mg/dl）,吸收速度：腹部上臂大腿,Mudallar SR, et al. Diabetes Care 1999; 22: 1501-1506.,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。A3,Diagrams 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.,注射部位的轮换：不同注射部位之间的轮换,午餐前,晚餐前,不同注射部位之间的轮换： “每天同一时间注射同一部位，每天不同时间注射不同部位”,早餐前,午餐前,晚餐前,早餐前,睡前,一天注射三次：,一天注射四次：,注射部位的轮换：左右轮换,注射部位左右轮换： 左边一周，右边一周，部位对称轮换 左边一次，右边一次，部位对称轮换,注射部位的轮换：同一注射部位内的轮换,同一注射部位内的轮换： 每次注射时离上次注射点之间距离至少1cm的距离,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。A3,Danish 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 92:160(3O).,关于捏皮的推荐：,所有患者在起始胰岛素治疗时就应掌握捏皮的正确方法；A3 捏皮时力度不得过大导致皮肤发白或疼痛；A3 不能用整只手来提捏皮肤，以避免将肌肉及皮下组织一同捏起； 最佳的注射步骤为： 捏起皮肤形成皮褶； 和皮褶表面呈90角进针后，缓慢推注胰岛素； 当活塞完全推压到底后，针头在皮肤内停留10秒钟（采用胰岛素笔注射）； 拔出针头； 松开皮褶。A3,正确的捏皮手法,错误的捏皮手法,捏皮使注射部位皮下组织深度变深,SC thickness (mm),Diabetes Care. 19(12):1434-6, 1996 Dec.,64例连续手诊住院的儿童糖尿病患者，糖尿病病程3个月。根据注射情况分为肌肉注射组（IM group，n=18）和皮下注射组（SC group，n=41），分别对捏皮和不捏皮情况下的皮肤至肌肉层的厚度（即皮下组织深度）进行测量。,捏皮降低肌肉注射发生风险,儿童 糖尿病患者,青少年 糖尿病患者,成年 糖尿病患者,肌肉注射风险,Diabetes care.2010-09;33(9):1940-4.,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 mm32G 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, Lindn 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,进针角度,90注射,45注射,为保证将胰岛素注射至皮下组织，在不捏皮的情况下可以45角进行注射，以增加皮下组织的厚度，降低胰岛素注射至肌肉层的危险。,针头留置时间,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 13:47-53. Bain A, Graham A. How do patients dispose of syringes? Pract Diabetes Int 1998; 15: 19-21.,注射器材的规范废弃,胰岛素注射笔针头的废弃,胰岛素专用注射器的废弃,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。,关于针头重复使用的建议,注射笔针头应一次性使用1-7。A2,Chantelau E, Lee DM, Hemmann DM, Zipfel U, Echterhoff S. What makes insulin injections painful? British Medical Journal 1991; 303: 26-27. Strauss K, De Gols H, Letondeur C, Matyjaszczyk M, Frid A. The second injection technique event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int 2002; 19: 17-21. Danish 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. Schuler G, Pelz K, Kerp