for air bubbles. These must be removed by gently tapping the syringe to ensure the patient is not under-dosed. Of note, insulin syringe markings are in units rather than milliliters to enable more precise dosing. Patients should be counseled that other syringe types are not interchangeable. Insulin vials should be refrigerated until opened and then stored at room temperature while in use for a maximum of 30 days or per manufacturer guidance. A new insu- lin vial should be allowed to warm to room temperature prior to administration to reduce potential for pain upon injection. Insulin should never be frozen. If needed to be taken on an excursion on a hot day, insulin can be stored in an insulated container, such as a lunch box, but care should be taken not to accidentally freeze insulin by placing it on ice. Insulin pens function similarly, but the patient does not need to withdraw the dose from a vial into a syringe (ADA et al., 2022f). Instead, the syringe and insulin supply are combined into a single device. Prior to use, the pen must be primed with an attached subcutaneous needle by dialing the dose to a small volume (e.g., 2 units) and pushing the thumb depressor until at least one drop of insulin appears. Priming the pen ensures unobstructed flow and complete delivery of the desired dose. After priming, the patient’s dose can be dialed and directly injected. As with syringe injec- tions, a new needle must be used for each injection. Storage and stability instructions are similar to insulin vials but should always be confirmed per manufacturer labeling. Needle selection and insulin injection technique are critical for successful management of insulin in diabetes (Frid et al., 2016). Needle gauges range from 22 to 33, but a 23- to 25-gauge nee- dle 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 admin- istration and run the risk of breaking in patients with thicker skin. In terms of needle length, 4 mm is almost always adequate to penetrate subcutaneous tissue, but the thickness of the skin and the distance from skin to muscle varies per patient based on a variety of factors (Frid et al., 2016). In general, prepubertal and low-BMI patients have a thinner subcutaneous layer than older, higher-BMI individuals. If a longer needle is prescribed, patients must ensure administration is still subcutaneous and not intramus- cular. Accidental intramuscular injection results in unpredictable absorption of insulin, which may cause hypoglycemia or hyper- glycemia, depending on the rate of absorption. Intramuscular in- jection also tends to result in more pain and bruising. In general, the shorter the needle, the lower the likelihood of inadvertent intramuscular injection, which is key for therapeutic success. Once the dose is prepared and an appropriate needle is selected, the patient must identify the site of administration for injection. Appropriate locations include the abdomen, the upper third an- terior lateral aspect of both thighs, the posterior 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 to avoid lipohypertrophy, which is swelling and hardening of fat tissue. This complication may lead to unpredictable and variable absorption of insulin if injections continue to be administered in the hardened location. Injection sites should be spaced at a minimum distance of 1 cen- timeter from previous injections, and areas of infection or swelling should be avoided. Prior to injection, the injector should wash their hands, and the site of injection should be disinfected with alcohol and allowed to dry completely (Frid et al., 2016). Once prepared, the needle attached to the syringe or pen should be injected into the skin at a 90-degree angle. After injection, the syringe can be depressed, or the pen’s thumb button can be pushed. For pens, it is rec- ommended to hold the needle in the skin and count to 10 be- fore withdrawing to ensure the 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
must be disposed of immediately in a sharps container. For all injection methods, needles should never be reused or shared. Self-Assessment Quiz Question #6 Which of the following is FALSE regarding insulin injection tech- nique? a. A 4-mm needle is typically adequate to penetrate tissue. b. Insulin should always be injected intramuscularly. c. Insulin injection sites should be rotated frequently. d. Prior to injection, the injector should wash their hands. If multiple daily doses of insulin are required in addition to basal dosing, insulin pump therapy may be considered, although this is not standard therapy in T2DM (ADA et al., 2022f). Insulin pump therapy, also referred to as continuous subcutaneous insulin in- fusion, delivers continuous, rapid-acting insulin at a basal rate in lieu of long-acting insulin. Bolus doses can be programmed throughout the day for meals or hyperglycemia. Insulin reservoirs containing rapid-acting insulin are either directly affixed to the skin via a patch or connected to an infusion set via a catheter. As with syringe and pen methods of administration, infusion sites should be rotated with each application (Frid et al., 2016). Selec- tion of an insulin pump will depend on patient preference, insur- ance coverage, insulin requirements, and other desired features. Some pumps are waterproof, others can be paired with serum glucose monitors, and select pumps feature automated suspen- sion of basal administration upon detection of hypoglycemia. While pumps have many benefits, they do have the potential to fail, and failure may result in poor glycemic control or even DKA in patients with absolute insulin deficiency. As such, it is a good idea to frequently assess insulin pump function via glucose monitoring. Patients and caregivers must retain the ability to administer insulin via conventional methods as a back-up for failures. Self-Assessment Quiz Question #7 Insulin injections may be required for type 2 diabetes manage- ment. Which of the following insulin types is appropriate for once-daily injections? a. Insulin glargine. b. Insulin lispro. c. Insulin glulisine. d. Insulin aspart. The most notable adverse effect of insulin therapy is hypoglyce- mia, which is defined as blood glucose 70 mg/dL (ADA et al., 2022e). Signs of hypoglycemia include irritability, shakiness, con- fusion, and hunger. Younger patients may be prone to hypoglyce- mia unawareness, as they are unable to detect and communicate symptoms until they are severe. In a conscious patient, the pre- ferred treatment of hypoglycemia is oral administration of glucose in the form of an easily digested carbohydrate. Dosing ranges from 15 to 20 grams of glucose, which is roughly equivalent to: ● ~3 to 4 glucose tablets. A repeat blood glucose level should be measured 15 minutes postingestion. If the glucose is still <70 mg/dL, the treatment can be repeated. Once the hypoglycemia is resolved, the patient should eat a meal or snack to prevent future episodes. All patients at risk of moderate to severe hypoglycemia should be prescribed glucagon along with their insulin therapy (ADA et al., 2022e). Glucagon works via stimulation of adenylate cyclase, which increases cyclic AMP (Lexicomp, 2022). This mechanism re- sults in hepatic glycogenolysis and gluconeogenesis, and there- fore increases blood glucose levels without ingestion of exoge- nous glucose. Glucagon is available as a powder for reconstitution for injection, as a ready-to-inject subcutaneous syringe, and as an ● ~1 tube glucose gel. ● ~4 ounces fruit juice. ● ~15 pieces Skittles. ● 1 tablespoon honey or syrup.
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Book Code: RPTX3024
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