《中国糖尿病药物注射指南》--注射技术篇ppt课件

1、引见.目录第一章：医护人员的职责第二章：注射前的心思预备第三章：注射治疗的教育第四章：注射药物第五章：注射安装第六章：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：规范胰岛素注射规范步骤胰岛素笔第十章：注射部位规范检查3要素.中的引荐意见分级每条引荐意见后面均标有一个字母和一个数字如，A2对于引荐的强度，我们采用如下分级规范: 剧烈引荐 引荐 尚未决议的问题对于科学证据的支持程度，我们采用如下分级规范: 至少具备一项随机、对照临床研讨 至少具备一项非随机或非对照或流行病学临床研讨 以大量患者阅历为根底的专家共识.下面以“注射技术篇为例给大家讲解中所涉及到的一些问题！

2、. 注射技术篇.注射技术是糖尿病注射治疗的三大关键要素之一注射技术：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能否捏皮选择进针角度针头留置时间注射器材的废弃针头反复运用的危害.关于注射部位选择的引荐：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制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 A1Frid A, Gunnarsson R, Gntner P, Linde B. Effects of accidental intramuskulr injection o

3、n insulin absorption in IDDM. Diabetes Care 1988; 11: 41-45. Frid A & B Linde (1993) Clinically important differences in insulin absorption from the abdomen in IDDM. Diabetes Research and Clinical Practice: Vol 21. No 2-3. -141. Frid A, Lindn B. Intraregional differences in the absorption of unmodif

4、ied insulin from the abdominal wall. Diabet Med 1992;9:236-9.Annersten M, Willman A. Performing subcutaneous injections: a literature review. Worldviews Evid Based Nurs 2005; 2: 122-30.Zehrer C, Hansen R, Bantle J. Reducing blood glucose variability by use of abdominal insulin injection sites. Diabe

5、tes Educ 1985;16:474-7.Henriksen JE, Djurhuus MS, Vaag A, Thye-Ronn P, Knudsen D. Hother-Nielsen O, et al. Impact of injection sites for soluble insulin on glycaemic control in type 1 (insulin-dependent) diabetic patients treated with a multiple insulin injection regimen. Diabetologia 1993;36:752-8.

6、Sindelka G, Heinemann L, Berger M. Frenck W, Chantelau E. Effect of insulin concentration, subcutaneous fat thickness and skin temperature on subcutaneous insulin absorption in healthy subjects. Diabetologia 1994;37:377-40.Ahern J & ML Mazur (2001) Site rotation. Diabetes Forecast: Vol 54. No 4. 66-

7、68. Wood L, Wilbourne J, Kyne-Grzebalski D, et al. administration of insulin by injection. Practice Diabetes International 2002; 19(Suppl 2-1): S1-S2.Smith CP, Sargent MA, Wilson BP, Price DA. Subcutaneous or intramuscular insulin injections. Arch Dis Child 1991;66:879-82.腹部以肚脐为中心，半径2.5cm外的间隔。越接近腰部两

8、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/神经血管间隔/皮下组织情况：适宜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体偏瘦的患者，该部位的皮下组织依然丰富，最大限制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。引荐的注射部位 .注射部位还应思索胰岛素在不同部位的吸收差别腹部 87分钟 50%较快适宜短效胰岛素臀部 较慢适宜长效胰岛素 或中效胰岛素大腿 164分钟 50%中等至较慢手臂 141分钟 50%中等至较慢适宜长效胰岛素或中效

9、胰岛素不同注射部位胰岛素吸收不同分钟： 研讨显示，50%胰岛素吸收所需求的时间腹部最快，手臂中等，大腿和臀部较慢11.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标志去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*p上臂大腿Mudallar SR, et al. Diabetes Care 1999; 22: 1501-1506.关于注射部位轮换的引荐：一种曾经证明有效的注射部位轮换方案：将注射部位分为四个等分区域大腿或臀

10、部可等分为两个等分区域，每周运用一个等分区域并一直按顺时针方向进展轮换1,2 A3在任何一个等分区域内注射时，每次的注射点都应间隔至少1cm，以防止反复的组织损伤 A3从注射治疗一开场，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. Ti

11、ps 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

12、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间隔至少间隔1cm.关于注射部位检查和消毒的引荐：患者应于注射前检查注射部位1,2 A3一旦发现注射部位假设出现脂肪增生、炎症或感染，应改换注射部位3-10 A2注射时，应坚持注射部位的清洁11 A2当注射部位不干净，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 Organizati

13、on. 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 2021.Johansson U. Amsberg S, Hannerz L, Wredling R

14、, 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 subcut

15、aneous 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, Stee

16、l 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

17、 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 Metab2021;11:460-3.Frid A, Linden B. Computed tomography of injection sites in patients with

18、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

19、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 intens

20、ive 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. I

21、s 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;9

22、2:160(3O).关于捏皮的引荐：一切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，以防止将肌肉及皮下组织一同捏起最正确的注射步骤为：捏起皮肤构成皮褶 和皮褶外表呈90角进针后，缓慢推注胰岛素 当活塞完全推压究竟后，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.Clauson PG, Linde B. Absorption of rapid-acting insulin in obese and nonobese NIDDM patients. Diabetes Care

23、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 redu

24、ces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care. 2021 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 inje

25、ctions: Implications for needle length recommendations. Curr MedRes Opin 2021;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 2021;26:15

26、31-41.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 2021;58:A117.Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size

27、 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.Solv

28、ig 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

29、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

30、:1663-78.Frid A, Lindn B. Where do lean diabetics inject their insulin? A study using computed tomography. BMJ 1986; 292:1638.关于进针角度的引荐：运用较短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运用较长8mm的针头时，需求捏皮或45角以降低肌肉注射风险10,11 A1.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

31、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 (2021) S3-S18*A3.关于注射器材废弃的引荐医护人员和患者必需熟知国家有关医疗废弃物处置的相关规定1 A3一切医护人员从注射治疗的开场，就应教会患者如何正确废弃注射器材2 A3医护人员应向患者阐明能够发生于患者家人如刺伤儿童和效力人员如渣滓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渣滓桶或者渣滓场 A3Workman B. Safe

32、 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.注射器材的规范废弃胰岛素注射笔针头的废弃胰岛素公用注射器的废弃 废弃针头或者注射器的最正确方法是，将注射器或注射笔针头放入公用废弃容器内再丢弃。假设没有公用废弃容器，也可运用加盖的硬壳容器。.针头反复运用有危害注射笔针头应一次性运用1-7 A2Chantelau E, Lee DM, Hemmann DM, Zipfel

33、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

34、-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 2021.Schuler G, Pelz K, Kerp L. Is the reuse of needles for in

35、sulin 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.

36、 Pract Diabetes Int 2002;19:63.反复运用注射笔针头的常见缘由知识缺乏不了解反复运用针头的危害经济条件太贵了，不能接受个人阅历多次反复运用未感到风险风险教育教育者没有提过其他中华现代护理杂志 2021,16(14): 1631-1632.358例运用胰岛素注射笔的糖尿病患者，年龄1982岁，以问卷方式进展调查其胰岛素笔用针头平安运用情况。.反复运用注射笔针头具有多重风险之一：影响注射剂量的准确性注射漏液药液流失温度降低时胰岛素体积收缩导致空气进入笔芯，产生气泡导致注射时间的延伸产生漏液景象温度升高时胰岛素体积膨胀而从笔芯走漏浪费胰岛素改动混合胰岛素的浓度.反复运用注

37、射笔针头具有多重风险之二：针头断裂或针管堵塞.反复运用注射笔针头具有多重风险之三：疼痛添加新针头多次运用后的针头高倍电子显微镜下的针头外形 1.Bangstad H-J. ISPAD Clinical Practice Consensus Guidelines 2021 Compendium.Pediatric Diabetes 2021:10(Suppl.12):82-99.2.Chantelau E, et al. What makes insulin injections painful? British Medical Journal 1991;303: 26-27.反复运用注射笔针头

38、具有多重风险之四：导致皮下脂肪增生和硬结下腹部皮下脂肪增生上腹部皮下脂肪增生腹部两侧皮下脂肪增生Diabetes & Metabolism 36 (2021) S3-S18.注射相关问题皮下脂肪营养妨碍与其他并发症皮下脂肪营养妨碍疼痛出血和淤血胰岛素的储存胰岛素的混匀特殊人群的胰岛素注射儿童妊娠.皮下脂肪营养妨碍左侧：正常的部位捏起皮肤较薄右侧：发生皮下脂肪营养妨碍的部位，捏起皮肤较厚每次注射前都应检查注射部位，尤其是对曾经出现皮下脂肪增生的患者引荐方法：不仅需求视诊而且需求触诊。正常皮肤能被紧紧的捏在一同，而发生皮肤硬结的皮肤却不能判别并避开出现疼痛、皮肤凹陷、皮肤硬结、出血、瘀斑、感染的部

39、位如发现皮肤硬结，请确认出现硬结的部位及大小，避开硬结进展注射.关于皮下脂肪营养妨碍的引荐：一患者尤其是曾经出现皮下脂肪营养妨碍的患者每次就诊时，医护人员应对其注射部位进展检查。每个注射部位至少每年检查一次儿童患者最好每次就诊时都检查。医护人员应教会患者本人检查注射部位，并培训他们如何发现皮下脂肪增生1,2 A2用墨水笔在皮下脂肪营养妨碍部位的两端，即正常皮肤与“橡皮样病变的交界处做标志，丈量并记录病变的大小以便长期随访。假设病变部位肉眼可见，应同时拍照以便长期随访 A3Seyoum B, Abdulkadir J. Systematic inspection of insulin injec

40、tion sites for local complications related to incorrect injection technique. Trop Doct 1996;26:159-61.Teft G. Lipohypertrophy: patient awareness and implications for practice. J Diab Nursing 2002;6:20-3.关于皮下脂肪营养妨碍的引荐：二病变组织恢复正常通常需求数月至数年，在此之前，不得在此部位进展注射1,2 A2注射部位由病变组织转换至正常组织时，通常需求减少胰岛素的注射剂量。注射剂量的实践变化因

41、人而异，并在频繁血糖监测的指点下进展2,3 A2目前，预防和治疗皮下脂肪营养妨碍的战略包括：运用纯化的人胰岛素，每次注射时规范检查注射部位，选择注射部位时范围更广，不反复运用注射笔针头4-9 A2Hambridge K. The management of lipohypertrophy in diabetes care. Br J Nurs 2007;16:520-4.Jans M, Colungo C, Vidal M. Actualizacin sobre tcnicas y sistemas de administracin de la insulina (II). Update on

42、 insulin administration techniques and devices (II). Av Diabetol 2021;24:255-69.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.Teft G. Lipohypertrophy: patient awareness and impli

43、cations for practice. J Diab Nursing 2002;6:20-3.Nielsen BB, Musaeus L, Gde P. Attention to injection technique is associated with a lower frequency of lipohypertrophy in insulin treated type 2 diabetic patients. Diabetologia 1998;41(suppl1): A251 (Abstract 970).Vardar B, Kizilci S. Incidence of lip

44、ohypertrophy in diabetic patients and a study of influencing factors. Diabetes Res Clin Pract 2007;77: 231-6.Ampudia-Blasco J, Girbes J, Carmena R. A case of lipoatrophy with insulin glargine. Diabetes Care 2005;28: 2983.De Villiers FP. Lipohypertrophy -a complication of insulin injections. S Afr Me

45、d J 2005;95:858-9.Hauner H, Stockamp B, Haastert B. Prevalence of lipohypertrophy in insulin-treated diabetic patients and predisposing factors. Exp Clin Endocrinol Diabetes 1996;104:106-10.关于疼痛的引荐：减轻注射疼痛的方法包括：室温保管正在运用的胰岛素 假设运用酒精对注射部位进展消毒，应于酒精彻底挥发后进展注射 防止在体毛根部注射 选用直径较小、长度较短的注射笔针头 每次注射运用新针头1-5 A2Boha

46、nnon 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.Danish Nurses Organization. Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Di

47、abetes Mellitus, 2nd edition, December 2006.Association for Diabetescare Professionals (EADV). Guideline: The Administration of Insulin with the Insulin Pen. September 2021.Chantelau E, Lee DM, Hemmann DM, Zipfel U, Echterhoff S. What makes insulin injections painful? BMJ 1991;303: 26-7.注射过程多种情况引发疼痛

48、添加因注射疼痛导致的不愿进展胰岛素治疗的比例达50.8%温度较低的胰岛素诱发疼痛和不适感消毒皮肤的酒精未干会从针眼带到皮下引起疼痛体毛根部附近神经末梢丰富直径较小、长度较短的注射笔针头具有较好的平安性和耐受性注射笔针头反复运用后卷边反刺，针头外表光滑层发生零落，添加患者疼痛低温胰岛素消毒酒精未干注射在体毛根部针头的直径和长度针头反复运用.关于出血和淤血的引荐：应使患者放心，注射部位部分出血或淤血并不会给胰岛素的吸收或者糖尿病的整体管理带来不良的临床后果 A2有时注射时针头会触到血管，导致部分出血或淤血。改换注射笔针头的长度或者改动其他注射参数，似乎并不能改动出血或淤血的发生频率，虽然一项研讨提出5mm针头注射可减少出血或淤血的发生。Kahara T Kawara S. Shimizu A, Hisada A, Noto Y, Kida H. Subcutaneous hematoma due to frequent insulin injections in a single site. Intern Med 2004;43:148-9.Kreugel G, Beter HJM, Kerstens MN, Maaten ter JC, Sluiter WJ, Boot BS. Influence of needle size on meta