Once the appropriate needle is selected, an appropriate site of administration must be selected. Sites include the abdomen, the upper third anterior lateral aspect of both thighs, the posterial lateral aspect of the upper buttock, and the middle third posterior aspect of the upper arm (Frid et al., 2016). In children, it is preferred to inject at least two adult fingerbreadths away from the umbilicus. Sites of injection should be rotated frequently at a minimum distance of 1 centimeter from previous injections to avoid lipohypertrophy. Prior to injection, the injector should wash their hands, and the site of injection should be disinfected with alcohol and allowed to dry completely. The site of administration should be intact without swelling or signs of infection. Once prepared, the needle attached to the syringe or pen should be injected into the skin at a 90-degree angle. For very young children, pinching the skin may be required for perpendicular injection. After injection, the syringe can be depressed or the pen’s thumb button can be pushed. For pens, it is recommended to hold the needle in the skin and count to 10 before withdrawing to ensure a complete dose is administered. Throughout the duration of counting and withdrawing, pressure should be maintained on the thumb button. This practice is not necessary for syringe-injected doses. Once withdrawn, needles should be disposed of immediately in a sharps container. For all injection methods, needles should never be reused or shared. Self-Assessment Quiz Question #7 Rob is prescribed insulin glargine in the form of an insulin pen. All of the following are appropriate counseling points for insulin pens EXCEPT: a. Wash hands and swab the injection site with alcohol prior to injection. b. Do not push the thumb button until the needle is fully injected. c. Hold the needle in the skin and count to 10 prior to withdrawing. d. Always inject in the same location for consistency of absorption. Some insulin preparations appear cloudy, and others are clear. Insulin preparations that are cloudy, such as NPH, must be gently rolled between the palms 10 times for 5 seconds then tipped 10 times for 10 seconds at room temperature. This ensures that the insulin is resuspended throughout the solution. smartphone with calculators to assist with insulin bolus dosing. Insulin lispro and aspart may remain in the insulin pump reservoir for up to 6 days without replacement, while insulin glulisine must be replaced every 48 hours. As with syringe and pen methods of administration, infusion sites should be rotated with each application (Frid et al., 2016). Insulin pumps deliver continuous, rapid-acting insulin at a basal rate in lieu of long-acting insulin. This enables modulation of the basal rate throughout the day in response to activity, time of day, sleep, acute illness, and other variations in insulin requirement. Bolus doses in response to hyperglycemia or anticipated carbohydrate ingestion can be programmed for delivery, utilizing the same rapid-acting insulin as basal dosing. Minimum volumes are lower than that of insulin pens or syringes, which may increase dosing precision. Insulin pump therapy reduces the number of required injections and can result in improved glycemic control (Berget et al., 2019). In an observational study of over 30,000 children and adolescents with T1DM, insulin pump therapy, as compared with injection therapy, resulted in lower rates of severe hypoglycemia and
Healthcare Consideration: There are many types of insulin pens on the market, containing unique formulations of insulin at various concentrations. Most pens mark in whole unit increments, so calculated dosage requirements must be rounded to the nearest whole unit. In young pediatric patients, whole-unit rounding may have a clinically significant impact on blood glucose level. A few insulin pens provide half-unit increments, which can improve accuracy. These should be prescribed for small patients in need of precise dosing (ADA et al., 2022d). Insulin injection technique is critical for successful management of T1DM (Frid et al., 2016). Optimal administration starts with appropriate selection of subcutaneous needles. Needle gauges range from 22 to 33, but a 23- to 25-gauge needle is most commonly recommended for pediatric subcutaneous injection. The higher the gauge number, the thinner the needle. While thinner needles cause less pain, they require slower injection and run the risk of breaking in patients with thicker skin. Needle length ranges from 4 to 12.7 mm. While 4 mm is almost always an adequate length to penetrate subcutaneous tissue, the thickness of skin and distance of skin to muscle varies per patient based on a variety of factors (Frid et al., 2016). In general, prepubertal and low body mass index (BMI) patients have a thinner subcutaneous layer than older, high BMI individuals. If a longer needle is prescribed, patients must ensure administration is still subcutaneous and not intramuscular. Accidental intramuscular injection results in unpredictable absorption of insulin, which may destabilize blood glucose levels. If caregivers are uncertain, intramuscular injection tends to result in more pain and bruising. Another sign is if the syringe and needle are let go of while inserted in the skin, the needle may remain upright if in muscle, whereas in subcutaneous tissue, the syringe and needle would topple over. These are especially important counseling points for preschool children, as this age group typically has the thinnest amount of subcutaneous tissue. In general, the shorter the needle, the lower the likelihood of inadvertent intramuscular injection, which is key for therapeutic success. Healthcare Consideration: Lipohypertrophy presents as swelling and hardening of fat tissue and is a common finding in patients who inject insulin. The development of lipohypertrophy is best prevented through rotation of injection sites. If patients develop lipohypertrophy and continue to inject insulin into those areas, absorption can be unpredictable and variable. Some patients may experience decreased absorption, which can lead to hyperglycemia. If insulin doses are increased by a provider in response to these findings and then the patient injects into a nonlipohypertrophic area, absorption may be higher, which could put the patient at risk for hypoglycemia (Frid et al., 2016). Case study: Lucy Lucy is a 14-year-old female with known type 1 diabetes mellitus who presents to your office for a follow-up visit. She was diagnosed 8 years prior and has developed more independence managing her diabetes in the past few years. You review her laboratory results and notice her hemoglobin A1c increased from 8% to 9.2% since her last visit. Asking open-ended questions about her management, she shares that she is “sick of injecting herself so many times a day” and admits that she has been trying to lose weight and “feels skinnier” when she skips doses. As an alternative to multiple daily injections, insulin can be administered via continuous subcutaneous insulin infusion (CSII) or insulin pump therapy. Insulin pump therapy simplifies and personalizes care for patients and caregivers who demonstrate mastery of traditional insulin administration (ADA et al., 2022e). Insulin reservoirs are either directly affixed to the skin via a patch or connected to an infusion set via a catheter. The pump patches are controlled wirelessly and can typically be linked to a
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