胰岛素注射知识

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《2011版中国糖尿病药物注射技术指南》介绍 《2011版糖尿病药物注射技术指南》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0步骤（胰岛素笔）第十章：注射部位规范检查3要素 《2011版中国糖尿病药物注射技术指南》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针头留置时间注射器材的废弃针头重复使用的危害 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]A1FridA,GunnarssonR,GüntnerP,LindeB.EffectsofaccidentalintramuskulærinjectiononinsulinabsorptioninIDDM.DiabetesCare1988;11:41-45.FridA&BLinde(1993)ClinicallyimportantdifferencesininsulinabsorptionfromtheabdomeninIDDM.DiabetesResearchandClinicalPractice:Vol21.No2-3.137-141.FridA,LindénB.Intraregionaldifferencesintheabsorptionofunmodifiedinsulinfromtheabdominalwall.DiabetMed1992;9:236-9.AnnerstenM,WillmanA.Performingsubcutaneousinjections:aliteraturereview.WorldviewsEvidBasedNurs2005;2:122-30.ZehrerC,HansenR,BantleJ.Reducingbloodglucosevariabilitybyuseofabdominalinsulininjectionsites.DiabetesEduc1985;16:474-7.HenriksenJE,DjurhuusMS,VaagA,Thye-RonnP,KnudsenD.Hother-NielsenO,etal.Impactofinjectionsitesforsolubleinsulinonglycaemiccontrolintype1(insulin-dependent)diabeticpatientstreatedwithamultipleinsulininjectionregimen.Diabetologia1993;36:752-8.SindelkaG,HeinemannL,BergerM.FrenckW,ChantelauE.Effectofinsulinconcentration,subcutaneousfatthicknessandskintemperatureonsubcutaneousinsulinabsorptioninhealthysubjects.Diabetologia1994;37:377-40.AhernJ&MLMazur(2001)Siterotation.DiabetesForecast:Vol54.No4.66-68.WoodL,WilbourneJ,Kyne-GrzebalskiD,etal.administrationofinsulinbyinjection.PracticeDiabetesInternational2002;19(Suppl2-1):S1-S2.SmithCP,SargentMA,WilsonBP,PriceDA.Subcutaneousorintramuscularinsulininjections.ArchDisChild1991;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腹部87分钟50%较快适合短效胰岛素臀部较慢适合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%中等至较慢适合长效胰岛素或中效胰岛素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11.TheAmericanJournalofNursing,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）*p<0.05，大腿vs上臂**p<0.05，上臂vs.腹部***p<0.005，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MudallarSR,etal.DiabetesCare1999;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等分区域（大腿或臀部可等分为两个等分区域），每周使用一个等分区域并始终按顺时针方向进行轮换[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A3DiagramscourtesyofLourdesSaez-deIbarraandRuthGaspar,DiabetesNursesandSpecialistEducatorsfromLaPazHospital,Madrid,Spain.LumberT.Tipsforsiterotation.Whenitcomestoinsulin.whereyouinjectisjustasimportantashowmuchandwhen.DiabetesForecast2004;57:68-70.ThatcherG.Insulininjections.Thecaseagainstrandomrotation.AmJNurs1985;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间隔1cm 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]A3DanishNursesOrganization.Evidence-basedClinicalGuidelinesforInjectionofInsulinforAdultswithDiabetesMellitus,2ndedition,December2006.AssociationforDiabetescareProfessionals(EADV).Guideline:TheAdministrationofInsulinwiththeInsulinPen.September2008.JohanssonU.AmsbergS,HannerzL,WredlingR,AdamsonU,ArnqvistHJ&PLins(2005)ImpairedAbsorptionofinsulinAspartfromLipohypertrophicInjectionSites.DiabetesCare:Vol28,No8,2025-2027.Ariza-AndracaCR,Altamirano-BustamanteE,Frati-MunariAC,Altamirano-BustamanteP,Graef-SanchezA.Delayedinsulinabsorptionduetosubcutaneousedema.ArchInvestMed1991;22:229-33.Saez-deIbarraL,GallegoF.Factorsrelatedtolipohypertrophyininsulin-treateddiabeticpatients;roleofeducationalintervention.PractDiabetesInt1998;15:9-11.YoungRJ,HannanWJ,FrierBM,SteelJM,DuncanLJ.YoungRJ,HannanWJ,FrierBM,SteelJMDiabeticlipohypertrophydelaysinsulinabsorption.DiabetesCare1984;7:479-80.ChowdhuryTA,EscudierV.Poorglycaemiccontrolcausedbyinsulininducedlipohypertrophy.BMJ2003;327:383-4.JohanssonUB.Impairedabsorptionofinsulinaspartfromlipohypertrophicinjectionsites.DiabetesCare2005;28:2025-7.OverlandJ,MolyneauxL,TewariS.,FatourosR,MelvilleP,FooteD,etal.Lipohypertrophy:Doesitmatterindailylife?Astudyusingacontinuousglucosemonitoringsystem.DiabetesObesMetab2009;11:460-3.FridA,LindenB.Computedtomographyofinjectionsitesinpatientswithdiabetesmellitus.InjectionandAbsorptionofInsulin.Stockholm:Thesis,1992.GormanKC.Goodhygieneversusalcoholswabsbeforeinsulininjections(Letter).DiabetesCare1993;16:960-1.SchulerG,PelzK,KerpL.Isthereuseofneedlesforinsulininjectionsystemsassociatedwithahigherriskofcutaneouscomplications?DiabetesResClinPract1992;16:209-12.WorkmanB.Safeinjectiontechniques.NursStand1999;13:47-53.BainA,GrahamA.Howdopatientsdisposeofsyringes?PractDiabetesInt1998;15:19-21.ChantelauE,SchiffersT,SchutzeJ,HansenB.Effectofpatient-selectedintensiveinsulintherapyonqualityoflife.PatientEducCouns1997Feb;30(2):167-73.LeFlochJP,HerbreteauC,LangeF,PerlemuterL.Biologicmaterialinneedlesandcartridgesafterinsulininjectionwithapenindiabeticpatients.DiabetesCare1998;21:1502-4.McCarthyJA,CovarrubiasB,SinkP.Isthetraditionalalcoholwipenecessarybeforeaninsulininjection?Dogmadisputed(Letter).DiabetesCare1993;16:402.SwahnA.Erfarenheterav94000osteriltgivnainsulininjektioner(Experiencesfrom94000insulininjectionsgivenwithoutskinswab).SvLakaresallskapetsHandlingarHygiea1982;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 ClausonPG,LindeB.Absorptionofrapid-actinginsulininobeseandnonobeseNIDDMpatients.DiabetesCare1995;18:986-91.JamalR,RossSA,ParkesJL,PardoS,GinsbergBH.Roleofinjectiontechniqueinuseofinsulinpens:prospectiveevaluationofa31-gauge,8mminsulinpenneedle.EndocrPract1999;5:245-50.BirkebaekN,SolvigJ,HansenB,JorgensenC,SmedegaardJ,ChristiansenJ.A4mmneedlereducestheriskofintramuscularinjectionswithoutincreasingbackflowtoskinsurfaceinleandiabeticchildrenandadults.DiabetesCare.2008Sep;22(9):e65.GibneyMA,ArceCH,ByronKJ,HirschLJ.Skinandsubcutaneousadiposelayerthicknessinadultswithdiabetesatsitesusedforinsulininjections:Implicationsforneedlelengthrecommendations.CurrMedResOpin2010;26:1519-30.HirschL,KlaffL,BaileyT,GibneyM,AlbaneseJ,QuS,etal.Comparativeglycemiccontrol,safetyandpatientratingsforanew4mm32Ginsulinpenneedleinadultswithdiabetes.CurrMedResOpin2010;26:1531-41.KreugelG,KeersJC,JongbloedA,Verweij-GjaltemaAH,WolffenbuttelBHR.Theinfluenceofneedlelengthonglycemiccontrolandpatientpreferenceinobesediabeticpatients.Diabetes2009;58:A117.KreugelG,BeijerHJM,KerstensMN,terMaatenJC,SluiterWJ,BootBS.InfluenceofneedlesizeforSCinsulinadministrationonmetaboliccontrolandpatientacceptance.EuropDiabNursing2007;4:1-5.VanDoornLG,AlberdaA,LytzenL.InsulinleakageandpainperceptionwithNovoFine6mmandNovoFine12mmneedlelengthsinpatientswithtype1ortype2diabetes.DiabetMed1998;1:S50.SolvigJ,ChristiansenJS,HansenB,LytzenL.LocalisationofpotentialinsulindepositioninnormalweightandobesepatientswithdiabetesusingNovofine6mmandNovofine12mmneedles.MeetingFederationEuropeanNursesinDiabetes,Jerusalem,Israel,2000(Abstract).SchwartzS,HassmanD,ShelmetJ,SieversR,WeinsteinR,LiangJ,LynessW.Amulticenter,open-label,randomized,two-periodcrossovertrialcomparingglycemiccontrol,satisfaction,andpreferenceachievedwitha31gaugex6mmneedleversusa29gaugex12.7mmneedleinobesepatientswithdiabetesmellitus.ClinTher2004;26:1663-78.FridA,LindénB.Wheredoleandiabeticsinjecttheirinsulin?Astudyusingcomputedtomography.BMJ1986;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 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*FridA.Newinjectionrecommendationsforpatientswithdiabetes.Diabetes&Metabolism36(2010)S3-S18*A3 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A3WorkmanB.Safeinjectiontechniques.NursStand1999;13:47-53.BainA,GrahamA.Howdopatientsdisposeofsyringes?PractDiabetesInt1998;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。 针头重复使用有危害注射笔针头应一次性使用[1-7]A2ChantelauE,LeeDM,HemmannDM,ZipfelU,EchterhoffS.Whatmakesinsulininjectionspainful?BritishMedicalJournal1991;303:26-27.StraussK,DeGolsH,LetondeurC,MatyjaszczykM,FridA.Thesecondinjectiontechniqueevent(SITE),May2000,Barcelona,Spain.PractDiabetesInt2002;19:17-21.DanishNursesOrganization.Evidence-basedClinicalGuidelinesforInjectionofInsulinforAdultswithDiabetesMellitus,2ndedition,December2006.AssociationforDiabetescareProfessionals(EADV).Guideline:TheAdministrationofInsulinwiththeInsulinPen.September2008.SchulerG,PelzK,KerpL.Isthereuseofneedlesforinsulininjectionsystemsassociatedwithahigherriskofcutaneouscomplications?DiabetesResClinPract1992;16:209-12.MaljaarsC.Scherpestudienaaldenvooreenmaliggebruik[Sharpstudyneedlesforsingleuse];DiabetesandLevery2002;4:36-7.TorranceT.Anunexpectedhazardofinsulininjection.PractDiabetesInt2002;19:63. 重复使用注射笔针头的常见原因知识缺乏不了解重复使用针头的危害经济条件太贵了，不能承受个人经验多次重复使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2010,16(14):1631-1632.358例使用胰岛素注射笔的糖尿病患者，年龄19~82岁，以问卷形式进行调查其胰岛素笔用针头安全使用情况。 重复使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长产生漏液现象温度升高时胰岛素体积膨胀而从笔芯泄漏浪费胰岛素改变混合胰岛素的浓度 重复使用注射笔针头具有多重风险之二：针头断裂或针管堵塞 重复使用注射笔针头具有多重风险之三：疼痛增加新针头多次使用后的针头（高倍电子显微镜下的针头形状）1.BangstadH-J.ISPADClinicalPracticeConsensusGuidelines2009Compendium.PediatricDiabetes2009:10(Suppl.12):82-99.2.ChantelauE,etal.Whatmakesinsulininjectionspainful?BritishMedicalJournal1991;303:26-27. 重复使用注射笔针头具有多重风险之四：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&Metabolism36(2010)S3-S18 注射相关问题皮下脂肪营养障碍与其他并发症皮下脂肪营养障碍疼痛出血和淤血胰岛素的贮存胰岛素的混匀特殊人群的胰岛素注射儿童妊娠 皮下脂肪营养障碍左侧：正常的部位捏起皮肤较薄右侧：发生皮下脂肪营养障碍的部位，捏起皮肤较厚每次注射前都应检查注射部位，尤其是对已经出现皮下脂肪增生的患者推荐方法：不仅需要视诊而且需要触诊。正常皮肤能被紧紧的捏在一起，而发生皮肤硬结的皮肤却不能判断并避开出现疼痛、皮肤凹陷、皮肤硬结、出血、瘀斑、感染的部位如发现皮肤硬结，请确认出现硬结的部位及大小，避开硬结进行注射 关于疼痛的推荐：减轻注射疼痛的方法包括：室温保存正在使用的胰岛素如果使用酒精对注射部位进行消毒，应于酒精彻底挥发后进行注射避免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使用新针头[1-5]A2BohannonNJ.Insulindeliveryusingpendevices.Simple-to-usetoolsmayhelpyoungandoldalike.PostgradMed1999;106:57-8.DejgaardA,MurmannC.Airbubblesininsulinpens.Lancet1989;334:871.DanishNursesOrganization.Evidence-basedClinicalGuidelinesforInjectionofInsulinforAdultswithDiabetesMellitus,2ndedition,December2006.AssociationforDiabetescareProfessionals(EADV).Guideline:TheAdministrationofInsulinwiththeInsulinPen.September2008.ChantelauE,LeeDM,HemmannDM,ZipfelU,EchterhoffS.Whatmakesinsulininjectionspainful?BMJ1991;303:26-7. 注射过程多种情况引发疼痛增加因注射疼痛导致的不愿进行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安全性和耐受性注射笔针头重复使用后卷边反刺，针头表面润滑层发生脱落，增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重复使用 关于出血和淤血的推荐：应使患者放心，注射部位局部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，导致局部出血或淤血。更换注射笔针头的长度或者改变其他注射参数，似乎并不能改变出血或淤血的发生频率，尽管一项研究提出5mm针头注射可减少出血或淤血的发生。KaharaTKawaraS.ShimizuA,HisadaA,NotoY,KidaH.Subcutaneoushematomaduetofrequentinsulininjectionsinasinglesite.InternMed2004;43:148-9.KreugelG,BeterHJM,KerstensMN,MaatenterJC,SluiterWJ,BootBS.Influenceofneedlesizeonmetaboliccontrolandpatientacceptance.EuropDiabNursing2007;4:51-5. 关于胰岛素贮存的推荐：已开封的瓶装胰岛素或胰岛素笔芯可在室温下保存（保存期为开启后一个月内，且不能超过保质期）A2未开封的瓶装胰岛素或胰岛素笔芯应储藏在2℃~8℃的环境中，切勿冷冻A2避免受热或阳光照射，防止震荡有必要培训患者，在抽取胰岛素之前，先确认是否存在结晶体、浮游物或者颜色变化等异常现象PerrielloG,TorloneE,DiSantoS.FanelliC.DeFeoP.SantusanioF.BrunettiP,BolliGB.Effectofstoragetemperatureonpharmacokineticsandpharmadynamicsofinsulinmixturesinjectedsubcutaneouslyinsubjectswithtype1(insulin-dependent)diabetesmellitus.Diabetologia1988;31:811-815. 关于胰岛素混匀的推荐：在使用云雾状胰岛素（如NPH和预混胰岛素）之前，应将胰岛素水平滚动和上下翻动各10次，使瓶内药液充分混匀，直至胰岛素转变成均匀的云雾状白色液体[1-5]A2KingL.Subcutaneousinsulininjectiontechnique.NursStand.2003;17:45-52.JehlePM,MichelerC,JehleDR,BreitigD,BoehmBO.InadequatesuspensionofneutralprotamineHagendorn(NPH)insulininpens.Lancet1999;354:1604-7.BrownA,SteelJM,DuncanC,DuncunA,McBainAM.Anassessmentoftheadequacyofsuspensionofinsulininpeninjectors.DiabetMed2004;21:604-608.NathC.Mixinginsulin:shake,rattleorroll?Nursing2002;32:10.SpringsMH.Shake,rattle,orroll?.ChallengingtraditionalinsulininjectionpracticesAmJNurs1999;99:14. 《2011版中国糖尿病药物注射技术指南》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的吸收速率不受注射部位的影响，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非运动状态下肌肉组织的吸收率相似，但仍不应肌肉注射此类药物[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，仍需要避免肌肉注射[2,3,6]A2MudaliarSR,LindbergFA,JoyceM,BeerdsenP,StrangeP,LinA,HenryRR.Insulinaspart(B28asp-insulin):afast-actinganalogofhumaninsulin:absorptionkineticsandactionprofilecomparedwithregularhumaninsulininhealthynondiabeticsubjects.DiabetesCare1999;22:1501-6.RaveK,HeiseT,WeyerC,HerrnbergerJ,BenderR,HirschbergerS,etal.Intramuscularversussubcutaneousinjectionofsolubleandlisproinsulin:comparisonofmetaboliceffectsinhealthysubjects.DiabetMed1998;15:747-51.FridA.Fatthicknessandinsulinadministration,whatdoweknow?InfusystemsInt2006;5:17-9.GuerciB,SauvanetJP.Subcutaneousinsulin:pharmacokineticvariabilityandglycemicvariability.DiabetesMetab2005;31:4S7-4S24.BraakterEW,WoodworthJR,BianchiR.CermeleB.ErkelensDW.ThijssenJH,etal.Injectionsiteeffectsonthepharmacokineticsandglucodynamicsofinsulinlisproandregularinsulin.DiabetesCare1996;19:1437-40.LippertWC,WallEJ.Optimalintramuscularneedle-penetrationdepth.Pediatrics2008;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]A1FridA&BLinde(1993)ClinicallyimportantdifferencesininsulinabsorptionfromtheabdomeninIDDM.DiabetesResearchandClinicalPractice:Vol21.No2-3.137-141.FridA,LindénB.Intraregionaldifferencesintheabsorptionofunmodifiedinsulinfromtheabdominalwall.DiabetMed1992;9:236-9.AnnerstenM,WillmanA.Performingsubcutaneousinjections:aliteraturereview.WorldviewsEvidBasedNurs2005;2:122-30.ZehrerC,HansenR,BantleJ.Reducingbloodglucosevariabilitybyuseofabdominalinsulininjectionsites.DiabetesEduc1985;16:474-7.HenriksenJE,DjurhuusMS,VaagA,Thye-RonnP,KnudsenD.Hother-NielsenO,etal.Impactofinjectionsitesforsolubleinsulinonglycaemiccontrolintype1(insulin-dependent)diabeticpatientstreatedwithamultipleinsulininjectionregimen.Diabetologia1993;36:752-8.SindelkaG,HeinemannL,BergerM.FrenckW,ChantelauE.Effectofinsulinconcentration,subcutaneousfatthicknessandskintemperatureonsubcutaneousinsulinabsorptioninhealthysubjects.Diabetologia1994;37:377-40. 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]A1FridA,OstmanJ,LindeB.HypoglycemiariskduringexerciseafterintramuscularinjectionofinsulininthighinIDDM.DiabetesCare1990;13:473-7.VaagA,HandbergA,LauritzenM,HenriksenJE,PedersenKD,Beck-NielsenH.VariationinabsorptionofNPHinsulinduetointramuscularinjection.DiabetesCare1990;13:74-6.BantleJP,NealL,FrankampLM.Effectsoftheanatomicalregionusedforinsulininjectionsonglycaemiaintype1diabetessubjects.DiabetesCare1993;16:1592-7.HenriksenJE,VaagA,HansenIR,LauritzenM,DjurhuusMS,Beck-NielsenH.AbsorptionofNPH(isophane)insulininrestingdiabeticpatients;evidenceforsubcutaneousinjectioninthethighaspreferredsite.DiabetMed1991;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]B2KargesB,BoehmBO,KargesW.Earlyhypoglycaemiaafteraccidentalintramuscularinjectionofinsulinglargine.DiabetMed2005;22:1444-5.FridA.PersonalCommunication(NovoNordisk,onfile).RassamAG,ZeiseTM,BurgeMR,SchadeDS.OptimalAdministrationofLisproInsulininHyperglycemicType1Diabetes.DiabetesCare1999;22:133-6.OwensDR,CoatesPA,LuzioSD,TinbergenJP,KurzhalsR.Pharmacokineticsof125I-labeledinsulinglargine(HOE901)inhealthymen:comparisonwithNPHinsulinandtheinfluenceofdifferentsubcutaneousinjectionsites.DiabetesCare2000;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]A1FridA,GunnarssonR,GüntnerP,LindeB.EffectsofaccidentalintramuskulærinjectiononinsulinabsorptioninIDDM.DiabetesCare1988;11:41-45.HenriksenJE,VaagA,HansenIR,LauritzenM,DjurhuusMS,Beck-NielsenH.AbsorptionofNPH(isophane)insulininrestingdiabeticpatients;evidenceforsubcutaneousinjectioninthethighaspreferredsite.DiabetMed1991;8:453-7.KΦendorfK,BojsenJ,DeckertT.Clinicalfactorsinfluencingtheabsorptionof125I-NPHinsulinindiabeticpatients.HormMetabRes1983;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]A1CalaraF,TaylorK,HanJ,ZabalaE,CarrEM,WintleM,FinemanM.Arandomized,open-label,crossoverstudyexaminingtheeffectofinjectionsiteonbioavailabilityofexenatide(syntheticexendin-4).ClinTher2005;27:210-5.ByettaPenUserManual.EliLillyandCompany,2007. 《2011版中国糖尿病药物注射技术指南》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） 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，注射器针头即可拔出，无需在皮下停留10秒[1-3]A3注射器只能一次性使用[4-10]A2AnnerstenM,FridA.Insulinpensdribblefromthetipoftheneedleafterinjection.PractDiabetesInt2000;17:109-11.GinsbergBH.ParkesJL,SparacinoC.Thekineticsofinsulinadministrationbyinsulinpens.HormMetabRes1994;26:584-7.BroadwayCA.Preventionofinsulinleakageaftersubcutaneousinjection,DiabetesEduc1991;17:90.ChantelauE,LeeDM,HemmannDM,ZipfelU,EchterhoffS.Whatmakesinsulininjectionspainful?BritishMedicalJournal1991;303:26-27.StraussK,DeGolsH,LetondeurC,MatyjaszczykM,FridA.Thesecondinjectiontechniqueevent(SITE),May2000,Barcelona,Spain.PractDiabetesInt2002;19:17-21.DanishNursesOrganization.Evidence-basedClinicalGuidelinesforInjectionofInsulinforAdultswithDiabetesMellitus,2ndedition,December2006.AssociationforDiabetescareProfessionals(EADV).Guideline:TheAdministrationofInsulinwiththeInsulinPen.September2008.SchulerG,PelzK,KerpL.Isthereuseofneedlesforinsulininjectionsystemsassociatedwithahigherriskofcutaneouscomplications?DiabetesResClinPract1992;16:209-12.MaljaarsC.Scherpestudienaaldenvooreenmaliggebruik[Sharpstudyneedlesforsingleuse];DiabetesandLevery2002;4:36-7.TorranceT.Anunexpectedhazardofinsulininjection.PractDiabetesInt2002;19:63. 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一个患者，绝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废弃，不得留在注射笔上[5-9]A2BohannonNJ.Insulindeliveryusingpendevices.Simple-to-usetoolsmayhelpyoungandoldalike.PostgradMed1999;106:57-8.DejgaardA,MurmannC.Airbubblesininsulinpens.Lancet1989;334:871.BartschU,ComtesseC,WetekamB.Insulinpensfortreatmentofdiabetes(articleinGerman).TherUmsch2006;63:398-404.LeFlochJP,HerbreteauC,LangeF,PerlemuterL.Biologicmaterialinneedlesandcartridgesafterinsulininjectionwithapenindiabeticpatients.DiabetesCare1998;21:1502-4.ByettaPenUserManual.EliLillyandCompany,2007.AnnerstenM,FridA.Insulinpensdribblefromthetipoftheneedleafterinjection.PractDiabetesInt2000;17:109-11.BartschU,ComtesseC,WetekamB.Insulinpensfortreatmentofdiabetes.TherUmsch2006;63:398-404.JamalR,RossSA,ParkesJL,PardoS,GinsbergBH.Roleofinjectiontechniqueinuseofinsulinpens:prospectiveevaluationofa31-gauge,8mminsulinpenneedle.EndocrPract1999;5:245-50.ChantelauE.HeinemannL,RossD.AirBubblesininsulinpens.Lancet1989;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]A1AnnerstenM,FridA.Insulinpensdribblefromthetipoftheneedleafterinjection.PractDiabetesInt2000;17:109-11.JamalR,RossSA,ParkesJL,PardoS,GinsbergBH.Roleofinjectiontechniqueinuseofinsulinpens:prospectiveevaluationofa31-gauge,8mminsulinpenneedle.EndocrPract1999;5:245-50.KingL.Subcutaneousinsulininjectiontechnique.NursStand.2003;17:45-52.GinsbergBH.ParkesJL,SparacinoC.Thekineticsofinsulinadministrationbyinsulinpens.HormMetabRes1994;26:584-7.RisslerJ,JΦrgensenC,RyeHansenM,HansenNA.Evaluationoftheinjectionforcedynamicsofamodifiedprefilledinsulinpen.ExpertOpinPharmacother2008;9:2217-22.BroadwayCA.Preventionofinsulinleakageaftersubcutaneousinjection,DiabetesEduc1991;17:90. 关于注射笔针头的推荐：儿童和青少年（1）儿童及青少年患者应使用长度为4、5或6mm的针头。身材较瘦或选择四肢部位进行注射的患者，尤其当选用5或6mm的针头时，需捏起皮肤形成皮褶后再行注射[1-12]A1在儿童和青少年中，没有任何医学证据推荐使用长度超过6mm的针头[13]A2使用6mm针头时可采取呈角度进针（45°角）以代替捏皮[9]A1FridA.Fatthicknessandinsulinadministration,whatdoweknow?InfusystemsInt2006;5:17-9.LippertWC,WallEJ.Optimalintramuscularneedle-penetrationdepth.Pediatrics2008;122:e556-63.KΦendorfK,BojsenJ,DeckertT.Clinicalfactorsinfluencingtheabsorptionof125I-NPHinsulinindiabeticpatients.HormMetabRes1983;15:274-8.SeidenariS,GiustiG,BertoniL,MagnoniC,PellacaniG..Thicknessandechogenicityoftheskininchildrenasassessedby20-MHzultrasound.Dermatology2000;201:218-22.TafeitE,MöllerR,JurimaeT,SudiK,WallnerSJ.Subcutaneousadiposetissuetopography(SAT-Top)developmentinchildrenandyoungadults.CollAntropol2007;31:395-402.BirkebaekN,SolvigJ,HansenB,JorgensenC,SmedegaardJ,ChristiansenJ.A4mmneedlereducestheriskofintramuscularinjectionswithoutincreasingbackflowtoskinsurfaceinleandiabeticchildrenandadults.DiabetesCare.2008Sep;22(9):e65.GibneyMA,ArceCH,ByronKJ,HirschLJ.Skinandsubcutaneousadiposelayerthicknessinadultswithdiabetesatsitesusedforinsulininjections:Implicationsforneedlelengthrecommendations.CurrMedResOpin2010;26:1519-30.HirschL,KlaffL,BaileyT,GibneyM,AlbaneseJ,QuS,etal.Comparativeglycemiccontrol,safetyandpatientratingsforanew4mm32Ginsulinpenneedleinadultswithdiabetes.CurrMedResOpin2010;26:1531-41.HofmanPL,LawtonSA,PeartJM,HoltJA,JefferiesCA,RobinsonE,etal.Anangledinsertiontechniqueusing6mmneedlesmarkedlyreducestheriskofIMinjectionsinchildrenandadolescents.DiabetMed2007;24:1400-5.PolakM.,BeregszasziM.,BelarbiN.,BenaliK.,HassanM.,CzernichowP.,Tubiana-RufiN.:Subcutaneousorintramuscularinjectionsofinsulininchildren.Areweinjectingwherewethinkweare?DiabetesCare1996Dec;19(12):1434-1436.StraussK.,HannetI.,McGonigleJ.,ParkesJ.L.,GinsbergB.,JamalR.,FridA.:Ultra-short(5mm)insulinneedles:trialresultsandclinicalrecommendations.PracticalDiabetesOct1999;16(7):218-222.Tubiana-RufiN,BelarbiN,DuPasquier-FediaevskyL,PolakM,KakouB,LeridonL,HassanM,CzernichowP.Shortneedles(8mm)reducetheriskofintramuscularinjectionsinchildrenwithtype1diabetes.DiabetesCare.1999Oct;22(10):1621-5.ChiarelliF,SeveriF,DamaccoF,VanelliM,LytzenL,CoronelG.InsulinleakageandpainperceptioninIDDMchildrenandadolescents,wheretheinjectionsareperformedwithNovoFine6mmneedlesandNovoFine8mmneedles.MeetingFederationEuropeanNursesinDiabetes,Jerusalem,Israel.2000(Abstract) 关于注射针头的推荐：儿童和青少年（2）在大多数儿童和青少年中，使用4mm针头可以不捏皮，90°垂直进针。但在有些可能仍须捏皮注射，尤其是较为消瘦的孩子[1]A1如果只有8mm针头（如目前使用注射器的患者），则应捏皮注射并以45°注射。另一种选择是使用针头缩短器，或选择在臀部注射[2-4]A1注射时应避免按压皮肤出现凹陷，以防止针头刺入过深而达到肌肉组织B3选择上臂为注射部位时需捏皮注射。考虑到操作难度，患者自行注射时，除非使用短针头（4mm、5mm），否则不推荐在上臂注射A3BirkebaekN,SolvigJ,HansenB,JorgensenC,SmedegaardJ,ChristiansenJ.A4mmneedlereducestheriskofintramuscularinjectionswithoutincreasingbackflowtoskinsurfaceinleandiabeticchildrenandadults.DiabetesCare.2008Sep;22(9):e65.BirkebaekNH,JohansenA,SolvigJ.Cutis/subcutisthicknessatinsulininjectionsitesandlocalizationofsimulatedinsulinbolusesinchildrenwithtype1diabetesmellitus;needforindividualizationofinjectiontechnique?DiabetMed1998;15:965-71.ChiarelliF,SeveriF,DamaccoF,VanelliM,LytzenL,CoronelG.InsulinleakageandpainperceptioninIDDMchildrenandadolescents,wheretheinjectionsareperformedwithNovoFine6mmneedlesandNovoFine8mmneedles.MeetingFederationEuropeanNursesinDiabetes,Jerusalem,Israel.2000(Abstract)RossSA,JamalR,LeiterLA,JosseRG,ParkesJL,QuS,etal.Evaluationof8mminsulinpenneedlesinpeoplewithtype1andtype2diabetes.PractDiabetesInt1999;16:145-8. 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°垂直进针[1-9]A1ClausonPG,LindeB.Absorptionofrapid-actinginsulininobeseandnonobeseNIDDMpatients.DiabetesCare1995;18:986-91.JamalR,RossSA,ParkesJL,PardoS,GinsbergBH.Roleofinjectiontechniqueinuseofinsulinpens:prospectiveevaluationofa31-gauge,8mminsulinpenneedle.EndocrPract1999;5:245-50.BirkebaekN,SolvigJ,HansenB,JorgensenC,SmedegaardJ,ChristiansenJ.A4mmneedlereducestheriskofintramuscularinjectionswithoutincreasingbackflowtoskinsurfaceinleandiabeticchildrenandadults.DiabetesCare.2008Sep;22(9):e65.GibneyMA,ArceCH,ByronKJ,HirschLJ.Skinandsubcutaneousadiposelayerthicknessinadultswithdiabetesatsitesusedforinsulininjections:Implicationsforneedlelengthrecommendations.CurrMedResOpin2010;26:1519-30.HirschL,KlaffL,BaileyT,GibneyM,AlbaneseJ,QuS,etal.Comparativeglycemiccontrol,safetyandpatientratingsforanew4mm32Ginsulinpenneedleinadultswithdiabetes.CurrMedResOpin2010;26:1531-41.KreugelG,KeersJC,JongbloedA,Verweij-GjaltemaAH,WolffenbuttelBHR.Theinfluenceofneedlelengthonglycemiccontrolandpatientpreferenceinobesediabeticpatients.Diabetes2009;58:A117.KreugelG,BeijerHJM,KerstensMN,terMaatenJC,SluiterWJ,BootBS.InfluenceofneedlesizeforSCinsulinadministrationonmetaboliccontrolandpatientacceptance.EuropDiabNursing2007;4:1-5.VanDoornLG,AlberdaA,LytzenL.InsulinleakageandpainperceptionwithNovoFine6mmandNovoFine12mmneedlelengthsinpatientswithtype1ortype2diabetes.DiabetMed1998;1:S50.SolvigJ,ChristiansenJS,HansenB,LytzenL.LocalisationofpotentialinsulindepositioninnormalweightandobesepatientswithdiabetesusingNovofine6mmandNovofine12mmneedles.MeetingFederationEuropeanNursesinDiabetes,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°注射[3,4]A2BirkebaekN,SolvigJ,HansenB,JorgensenC,SmedegaardJ,ChristiansenJ.A4mmneedlereducestheriskofintramuscularinjectionswithoutincreasingbackflowtoskinsurfaceinleandiabeticchildrenandadults.DiabetesCare.2008Sep;22(9):e65.KreugelG,BeijerHJM,KerstensMN,terMaatenJC,SluiterWJ,BootBS.InfluenceofneedlesizeforSCinsulinadministrationonmetaboliccontrolandpatientacceptance.EuropDiabNursing2007;4:1-5.SchwartzS,HassmanD,ShelmetJ,SieversR,WeinsteinR,LiangJ,LynessW.Amulticenter,open-label,randomized,two-periodcrossovertrialcomparingglycemiccontrol,satisfaction,andpreferenceachievedwitha31gaugex6mmneedleversusa29gaugex12.7mmneedleinobesepatientswithdiabetesmellitus.ClinTher2004;26:1663-78.FridA,LindénB.Wheredoleandiabeticsinjecttheirinsulin?Astudyusingcomputedtomography.BMJ1986;292:1638.RossSA,JamalR,LeiterLA,JosseRG,ParkesJL,QuS,etal.Evaluationof8mminsulinpenneedlesinpeoplewithtype1andtype2diabetes.PractDiabetesInt1999;16:145-8.FridA,LindénB.CTscanningofinjectionssitesin24diabeticpatientsafterinjectionofcontrastmediumusing8mmneedles.Diabetes1996;45:A444. 《2011版中国糖尿病药物注射技术指南》发布鉴于胰岛素使用者逐渐增加，新型糖尿病注射药物不断上市，注射技术在血糖达标中的地位越来越重要，在此背景下，中华医学会糖尿病学分会(CDS)首次组织全国糖尿病学及相关学科专家制定《中国糖尿病药物注射技术指南》，旨在为我国广大专业医护人员提供注射技术规范，使广大中国患者受益。 谢谢！