規(guī)范化胰島素注射與管理

規(guī)范化的胰島素注射與管理,中國(guó)糖尿病藥物注射技術(shù)指南解讀,目錄,案例,張女士，68歲，使用甘舒霖50R 26u，20u Bid治療，血糖控制不佳，時(shí)高時(shí)低，高時(shí)達(dá)25mmol/L，低時(shí)2.9mmol/L，診斷為脆性糖尿病。為了明確診斷（是否為脆性糖尿病），從護(hù)理的角度應(yīng)該做怎樣的評(píng)估？,評(píng)估患者胰島素注射技術(shù)！,注射技術(shù)是影響胰島素治療的三大關(guān)鍵因素之一,胰島素類型、濃度和劑量注射裝置皮下組織血流注射深度注射部位注射到皮下硬結(jié)胰島素抗體運(yùn)動(dòng),影響胰島素吸收的因素：,規(guī)范化胰島素注射與管理的意義,確保準(zhǔn)確劑量的胰島素被恰當(dāng)吸收最大限度減少注射的不良反應(yīng)將患者的不適感降到最低,目錄,規(guī)范化的胰島素注射管理內(nèi)容,注射部位的選擇注射部位的輪換選擇合適的針頭正確的胰島素注射方法關(guān)于針頭重復(fù)使用的建議胰島素的儲(chǔ)存與管理,中國(guó)糖尿病藥物注射技術(shù)指南2011版,關(guān)于注射部位選擇的推薦,注射餐時(shí)胰島素等短效胰島素，最好選擇腹部1-7；A1希望胰島素的吸收速度較緩時(shí)，可以選擇臀部。臀部注射可以最大限度地降低注射至肌肉層的風(fēng)險(xiǎn)8,9；A1給少兒患者注射中效或者長(zhǎng)效胰島素時(shí)，最好選擇臀部或者大腿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 & B Linde (1993) Clinically important differences in insulin absorption from the abdomen in IDDM. Diabetes Research and Clinical Practice: Vol 21. No 2-3. 137-141. Frid A, Lindn B. Intraregional differences in the absorption of unmodified 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. Diabetes 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.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. 66-68. 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.,中國(guó)糖尿病藥物注射技術(shù)指南2011版,腹部以肚臍為中心，半徑2.5cm外的距離。越靠近腰部?jī)蓚?cè)（即使是肥胖患者），皮下組織的厚度也會(huì)變薄，因此容易導(dǎo)致肌肉注射。,根據(jù)可操作性/神經(jīng)血管距離/皮下組織狀況：適合注射的部位,上臂上臂側(cè)面或者后側(cè)部位；皮下組織較厚，導(dǎo)致肌肉注射的概率較低。,臀部臀部上端外側(cè)部位；即使是少兒患者還是身材偏瘦的患者，該部位的皮下組織仍然豐富，最大限度降低肌肉注射的危險(xiǎn)性。,大腿大腿外側(cè)；皮下組織較厚，離大腿血管和坐骨神經(jīng)較遠(yuǎn)，針頭導(dǎo)致外傷的概率較低。,推薦的注射部位,注射部位還應(yīng)考慮胰島素在不同部位的吸收差異,不同注射部位胰島素吸收不同（分鐘）： 研究顯示，50%胰島素吸收所需要的時(shí)間腹部最快，手臂中等，大腿和臀部較慢1,1.The American Journal of Nursing, Vol. 98, No.7, pp. 55+57,不同注射部位吸收胰島素速度快慢不一,125I標(biāo)記清除占初始劑量的百分比（%）,時(shí)間（分鐘）,時(shí)間（分鐘）,*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.,根據(jù)注射需求選擇注射部位,胰島素注射部位的選擇,預(yù)混胰島素或胰島素類似物理想的注射部位為：早晨腹部；傍晚大腿或臀部短效胰島素或速效胰島素類似物理想的注射部位為：腹部中長(zhǎng)效胰島素（NPH）或長(zhǎng)效胰島素類似物理想的注射部位：大腿或臀部,如存在脂肪增生、皮膚移植或軀體殘障（如關(guān)節(jié)炎、癱瘓等），可選擇臀部代替大腿。,關(guān)于注射部位輪換的推薦,一種已經(jīng)證實(shí)有效的注射部位輪換方案：將注射部位分為四個(gè)象限（大腿或臀部可等分為兩個(gè)等分區(qū)域），每周使用一個(gè)象限并始終按順時(shí)針?lè)较蜻M(jìn)行輪換1,2；A3在任何一個(gè)象限或等分區(qū)域內(nèi)注射時(shí)，每次的注射點(diǎn)都應(yīng)間隔至少1cm，以避免重復(fù)的組織損傷；A3從注射治療一開(kāi)始，就應(yīng)教會(huì)患者掌握一套簡(jiǎn)單易行的注射部位輪換方案3；A2每次患者就診時(shí)，醫(yī)護(hù)人員都應(yīng)檢查患者輪換方案的執(zhí)行情況。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.,中國(guó)糖尿病藥物注射技術(shù)指南2011版,注射部位的輪換：不同注射部位之間的輪換,午餐前,晚餐前,不同注射部位之間的輪換：“每天同一時(shí)間注射同一部位，每天不同時(shí)間注射不同部位”,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：,注射部位的輪換：左右輪換,注射部位左右輪換：左邊一周，右邊一周，部位對(duì)稱輪換左邊一次，右邊一次，部位對(duì)稱輪換,注射部位的輪換：同一注射部位內(nèi)的輪換,同一注射部位內(nèi)的輪換：每次注射時(shí)離上次注射點(diǎn)之間距離至少1cm的距離,關(guān)于注射針頭的選擇：成年,4mm、5mm和6mm針頭適用于所有成人患者，包括肥胖患者 1-8；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.,中國(guó)糖尿病藥物注射技術(shù)指南2011版,針頭的發(fā)展歷程,針頭的粗細(xì)由外徑直徑來(lái)衡量，以英文字母G代表，G=Gauge，G值越大，針頭越細(xì)；針頭的長(zhǎng)度由毫米（mm）來(lái)衡量；,選擇適當(dāng)?shù)尼橆^長(zhǎng)度,注射到肌肉層的危害：加快胰島素的吸收速度，導(dǎo)致體內(nèi)血糖控制不穩(wěn)定，增加低血糖風(fēng)險(xiǎn)疼痛感增加注射到表皮層的危害：影響胰島素起效和作用持續(xù)時(shí)間導(dǎo)致胰島素的滲出、疼痛、無(wú)菌膿腫及因淋巴細(xì)胞刺激而胰島素免疫反應(yīng)增強(qiáng),King L, et al. Nursing Standard 2003; 17: 45-52,即使消瘦患者，絕大多數(shù)皮膚表面至肌肉厚度超過(guò)6mm,67.9%6mm,84.9%6mm,皮膚表面至肌肉層厚度：所有患者中67.9%超過(guò)6mm,皮膚表面至肌肉層厚度：所有患者中84.9%超過(guò)6mm,研究納入21例體型消瘦的兒童糖尿病患者（16例男性）和32例體形消瘦的成年糖尿病患者（23例男性），BMI-Z評(píng)分20IU/次）胰島素注射時(shí)，應(yīng)適當(dāng)延長(zhǎng)停留時(shí)間至15s以上。,韓紅霞等，武警醫(yī)學(xué)院學(xué)報(bào).2007.16(4): 447,關(guān)于針頭重復(fù)使用的建議,注射筆針頭應(yīng)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 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.,重復(fù)使用注射筆針頭的常見(jiàn)原因,知識(shí)缺乏不了解重復(fù)使用針頭的危害,經(jīng)濟(jì)條件太貴了，不能承受,個(gè)人經(jīng)驗(yàn)多次重復(fù)使用未感到風(fēng)險(xiǎn),風(fēng)險(xiǎn)教育教育者沒(méi)有提過(guò),其他,中華現(xiàn)代護(hù)理雜志 2010,16(14): 1631-1632.,358例使用胰島素注射筆的糖尿病患者，年齡1982歲，以問(wèn)卷形式進(jìn)行調(diào)查其胰島素筆用針頭安全使用情況。,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之一：影響注射劑量的準(zhǔn)確性,注射漏液,藥液流失,溫度降低時(shí)胰島素體積收縮導(dǎo)致空氣進(jìn)入筆芯，產(chǎn)生氣泡導(dǎo)致注射時(shí)間的延長(zhǎng)產(chǎn)生漏液現(xiàn)象,溫度升高時(shí)胰島素體積膨脹而從筆芯泄漏浪費(fèi)胰島素改變混合胰島素的濃度,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之二：針頭斷裂或針管堵塞,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之三：疼痛增加,新針頭,多次使用后的針頭,（高倍電子顯微鏡下的針頭形狀）,1.Bangstad H-J. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium.Pediatric Diabetes 2009:10(Suppl.12):82-99.2.Chantelau E, et al. What makes insulin injections painful? British Medical Journal 1991;303: 26-27.,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之四：導(dǎo)致皮下脂肪增生和硬結(jié),下腹部皮下脂肪增生,上腹部皮下脂肪增生,腹部?jī)蓚?cè)皮下脂肪增生,Diabetes & Metabolism 36 (2010) S3-S18,注射器材的規(guī)范廢棄,胰島素注射筆針頭的廢棄,胰島素專用注射器的廢棄,廢棄針頭或者注射器的最佳方法是，將注射器或注射筆針頭放入專用廢棄容器內(nèi)再丟棄。如果沒(méi)有專用廢棄容器，也可使用加蓋的硬殼容器。,關(guān)于胰島素貯存的推薦,已開(kāi)封的瓶裝胰島素或胰島素筆芯可在室溫下保存（保存期為開(kāi)啟后一個(gè)月內(nèi)，且不能超過(guò)保質(zhì)期）；A2未開(kāi)封的瓶裝胰島素或胰島素筆芯應(yīng)儲(chǔ)藏在28的環(huán)境中，切勿冷凍；A2避免受熱或陽(yáng)光照射，防止震蕩；有必要培訓(xùn)患者，在抽取胰島素之前，先確認(rèn)是否存在結(jié)晶體、浮游物或者顏色變化等異?，F(xiàn)象。,Perriello G, Torlone E, Di Santo S. Fanelli C. De Feo P. Santusanio F. Brunetti P, Bolli GB. Effect of storage temperature on pharmacokinetics and pharmadynamics of insulin mixtures injected subcutaneously in subjects with type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1988;31:811 -815.,目錄,與注射相關(guān)的相關(guān)問(wèn)題,皮下脂肪營(yíng)養(yǎng)障礙與其他并發(fā)癥皮下脂肪營(yíng)養(yǎng)障礙疼痛出血和淤血,皮下脂肪營(yíng)養(yǎng)障礙,左側(cè)：正常的部位捏起皮膚較薄,右側(cè)：發(fā)生皮下脂肪營(yíng)養(yǎng)障礙的部位，捏起皮膚較厚,每次注射前都應(yīng)檢查注射部位，尤其是對(duì)已經(jīng)出現(xiàn)皮下脂肪增生的患者推薦方法：不僅需要視診而且需要觸診。正常皮膚能被緊緊的捏在一起，而發(fā)生皮膚硬結(jié)的皮膚卻不能判斷并避開(kāi)出現(xiàn)疼痛、皮膚凹陷、皮膚硬結(jié)、出血、瘀斑、感染的部位如發(fā)現(xiàn)皮膚硬結(jié)，請(qǐng)確認(rèn)出現(xiàn)硬結(jié)的部位及大小，避開(kāi)硬結(jié)進(jìn)行注射,關(guān)于皮下脂肪營(yíng)養(yǎng)障礙的推薦：（一）,患者（尤其是已經(jīng)出現(xiàn)皮下脂肪營(yíng)養(yǎng)障礙的患者）每次就診時(shí)，醫(yī)護(hù)人員應(yīng)對(duì)其注射部位進(jìn)行檢查。每個(gè)注射部位至少每年檢查一次（兒童患者最好每次就診時(shí)都檢查）。醫(yī)護(hù)人員應(yīng)教會(huì)患者自己檢查注射部位，并培訓(xùn)他們?nèi)绾伟l(fā)現(xiàn)皮下脂肪增生1,2；A2用墨水筆在皮下脂肪營(yíng)養(yǎng)障礙部位的兩端，即正常皮膚與“橡皮樣”病變的交界處做標(biāo)記，測(cè)量并記錄病變的大小以便長(zhǎng)期隨訪。若病變部位肉眼可見(jiàn)，應(yīng)同時(shí)拍照以便長(zhǎng)期隨訪；A3,Seyoum B, Abdulkadir J. Systematic inspection of insulin injection 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.,關(guān)于皮下脂肪營(yíng)養(yǎng)障礙的推薦：（二）,病變組織恢復(fù)正常通常需要數(shù)月至數(shù)年，在此之前，不得在此部位進(jìn)行注射1,2；A2注射部位由病變組織轉(zhuǎn)換至正常組織時(shí)，通常需要減少胰島素的注射劑量。注射劑量的實(shí)際變化因人而異，并在頻繁血糖監(jiān)測(cè)的指導(dǎo)下進(jìn)行2,3；A2目前，預(yù)防和治療皮下脂肪營(yíng)養(yǎng)障礙的策略包括：使用純化的人胰島素，每次注射時(shí)規(guī)范檢查注射部位，選擇注射部位時(shí)范圍更廣，不重復(fù)使用注射筆針頭4-9。A2,Hambridge 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 insulin administration techniques and devices (II). Av Diabetol 2008;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 implications 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 lipohypertrophy 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 Med 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.,關(guān)于疼痛的推薦：,減輕注射疼痛的方法包括：室溫保存正在使用的胰島素；如果使用酒精對(duì)注射部位進(jìn)行消毒，應(yīng)于酒精徹底揮發(fā)后進(jìn)行注射；避免在體毛根部注射；選用直徑較小、長(zhǎng)度較短的注射筆針頭；每次注射使用新的注射筆針頭1-5。A2,Bohannon NJ. Insulin delivery using pen devices. Simple-to-use tools may help young and old alike. Postgrad Med 1999;106:57-8.Dej