PDCI Core Kit 12 Insulin Injection Technique Dr. Hendra Zufri

Curriculum(Vitae
A.(Personal(Iden5ty
B.(Educa5on&(Training(
(
C.(Organiza5on(
Insulin Injection
Technique
Interna5onal(Diabetes(Federa5on(Atlas,(2012(
Slide 4
Simpang Lima, Banda Aceh, 4 September 2015
Interna5onal(Diabetes(Federa5on(Atlas,(2012(
Long term studies have provided conclusive

evidence than maintaining tight glycemic
Fluid Therapy
in Type
control can
delay 2 the progression of
Diabetes
Management:
microvascular
complication
Focus on Acute Complication, Diabetic Nephropathy &
Parenteral Nutrition
Hendra Zufry, MD, FINASIM

Internal Medicine Specialist
Endocrinology, Metabolism & Diabetes Consultant Physician
Interventional Thyroidologist
Dr. Zainoel Abididn General Teaching Hospital
Banda Aceh-Indonesia
Glycaemic Variability as the enemy

Sustained chronic hyperglycemia has
deleterious vascular consequences
Fluid Therapy
in Type
2 amplify the effect of
Glucose
swings
Diabetes Management:
chronic hyperglycemia

Key Barriers to Insulin Initiation

More than 50% of patients are very worried about
starting on Insulin
More than 50% of patients believe that starting on
Insulin mean that they have failed to manage their
disease
Only 20% believe that
Insulin can help them
manage their disease
More than 33% of HCPs postpone
Insulin until absolutely essential
67% use Insulin as a threat for their patients
Rubin RR et al. Diabetes Care 2006;29:124955.
Good injection
technique
leads to good
Fluid Therapy
in Type
2
blood glucose control which is vital in
preventing the long term complications of

Focus on Acute Complication, Diabetic Nephropathy
diabetes&

Variability in insulin action : Why ??

Inter individual variability or intraindividual
variability
Exogenous Factor of variation
Insulin2preparation
Fluid Therapy in Type
Injection conditions
Endogeneous Factor
Focus on Acute Complication,
Diabetic
Nephropathy
Insulin
sendiri
: diffusion&of insulin or the
Parenteralinteraction
Nutrition between insulin and its receptor

Factors of glycemic variability in

insulin-treated patients
Injection technique
Site of injection
Fluid Therapy in
Type
2 of injection
Site
and depth
Injection into lipohyperthrophy

So...
The Key to achieving optimal glycemic
control is the patient adherence to
treatment
regimen
in diabetes
Fluid Therapy
in Type
2
management
Good Injection practices should be
Diabetic Nephropathy
&
adressed
at every patient
visit

Helping Patients With

Injectable Therapy
Educate patient on proper use and on new
devices with smaller needles.
Demonstrate self-injection in the office
Fluid Therapy
in Type 2
with patient.
Diabetes
Management:
Ask
patient if he or she is willing to try an
injectable therapy for a short period of
time before
Parenteral
Nutrition making a final decision.

The History of Insulin
1921
s/d 1983
1983
1999
: Insulin Invented
: Animal Insulin Era
: Human Insulin Era
: Analog insulin
1926
First syringe just for insulin injection
Fluid Therapy in Type 2


The Proper Use of Pen

Pens are for a single patients and should never be
shared
Needle should be disposed of immediately after use
Pen needlein
should
be used
Fluid Therapy
Type
2 only once
Patients
should count slowly to 10 before withdrawing
Diabetes
Management:
the needle

Injecting Process
Injection should only into the subcutaneous
Avoid insertion into intramuscular area
The site should be inspected by the patient prior to
injection
Change sites if the current one shows signs of
Diabetes
Management:
lipohypertrophy, inflammation, edema or infection
Most insulin
injection
are not &
painful
Diabetic
Nephropathy

Needle Length
The goal of injections with
insulin is to reliably deliver the
medication into the SC space,
without leakage and with
Fluid
Therapy in Type
minimal discomfort.
2
Choosing an appropriate
Focus on
Acutelength
Complication,
Diabetic
needle
is crucial
for Nephropathy &
Parenteral
Nutrition
accomlishing
this goal.


Needle Evolution


Needle length for patients


10
Needle Length
Initial therapy should begin with the shorter lengths
Injection with shorter needles (4,5,6 mm) should be
given in adults at 900 to the skin surfaces
Fluid Therapy
ininjecting
T ypeat2450 should be considered for
Skin fold or
injections
into the limbs or slim abdomen
Diabetes
Management:

Blood vessels penetrate each

layer of skin
11
But BLOOD FLOW differs considerably from

one layer to another
Dermis : small but swift flow and highly

variable
Subcutaneous : slow flow and very stable
Muscle : large, swift flow and highly
Injection Sites
12
Adults
Studies have shown that IM Injections occur
in 12 -34 % of injections depending on :
Injection site
Body habitus of patient
Length of needle
Use of pinch or not
How long pinch held and when realesed
Thickness of SC in mm
13
Injection Site Rotation
Pen Injection Technique

Injection Techniques


14
Injecting high doses of Insulin

(> 40 Unit)
Leave the needle inserted in the skin a longer
time at the end of the injection
Split the dose into two consecutive injections
The maximum volume requiring a split of the
dose is not universally agreed
How is the correct Pinch Up?
15
Role of Rising a Skin Folds (pinching)

It is used when the presumptive distance from skin
surface to the muscle is less than the length of the
needle
Fluid Therapy
insite
Type
Each injection
should2
be examined individually
All patients
should be taught the correct technique for
Diabetes
Management:
lifting a skin fold from the onset of insulin therapy

Angle of Needle with a pinch
16
Pregnant Women
1.
Should give all injection using raised skin fold

2. Avoid around umbilicus during 3th semester



SUMMARY
17
Insulin Storage and Suspension

Store insulin in current use at room temperature
(max 1 month and within expiry date )
Store unopenes insulin in an area of the
refrigerator when freezing in unlikely to occur

Cloudu insulin must be gently rolled and /or tipped
Diabetes
Management:
( not shaken) for 20 cycles until the solution
becomes milky white


Efek Samping Penyuntikan Insulin

LYPODYSTROPHY
&
Focus on Acute Complication, LYPOHYPERTROPHY
Diabetic Nephropathy &

18
Lipohypertrophy
Sites should be inspected by the HCP at very visit
Making two ink marks at opposites edges of the
lipohypertrophy
Patients should not inject into areas of lipohypersthrophy
until the abnormal tissue returns to normal
Switching injections from lipohyperthropy to normal tissue
The best current presentative and therapeutic strategies
for lipohypertrophy
Patients feels less pain when injecting in the lipohypertrophy
19
Slide 39
Tips of Making Injection Less

Painful
Keep insulin in use at room temperature
If using alcohol, injecting only when the alcohol has
fully dried

Avoid
injecting at hair roots
Diabetes
Management:
Using shorter length and smaller dismeter needle

Nephropathy
&
Using newDiabetic
needle at
each injection

20



Re-suspension required for Pre-mix
and Intermediate acting Insulin
Gerakkan pena insulin
keatas dan ke bawah
sebanyak 10 x
Gulung Pena Insulin

diantara kedua telapak
tangan sampai dengan 10 x
&
21

Removing the Outer Cap

Ensure that no air bubbles are present in
the pen
22
Needle length choice and injection

technique
Re-use needle
23
Coincidence between lipohypertrophies and

multiple reuse of pen needles
The increase of the risk for lipohypertrophies is significant

the more frequent pen needles are reused
24
Slide
49
Thank You For Your

Attention
My Family...
Foto ini diambil bukan dengan kamera iPhone-6
25

PDCI Core Kit 12 Insulin Injection Technique Dr. Hendra Zufri

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Curriculum(Vitae

Simpang Lima, Banda Aceh, 4 September 2015

Long term studies have provided conclusive

Hendra Zufry, MD, FINASIM

Glycaemic Variability as the enemy

Hendra Zufry, MD, FINASIM

Key Barriers to Insulin Initiation

67% use Insulin as a threat for their patients

Rubin RR et al. Diabetes Care 2006;29:124955.

preventing the long term complications of

Hendra Zufry, MD, FINASIM

Variability in insulin action : Why ??

Hendra Zufry, MD, FINASIM

Factors of glycemic variability in

Hendra Zufry, MD, FINASIM

Hendra Zufry, MD, FINASIM

Helping Patients With

Hendra Zufry, MD, FINASIM

The History of Insulin

Fluid Therapy in Type 2

Hendra Zufry, MD, FINASIM

The Proper Use of Pen

Hendra Zufry, MD, FINASIM

Hendra Zufry, MD, FINASIM

Hendra Zufry, MD, FINASIM

Fluid Therapy in Type 2

Focus on Acute Complication, Diabetic Nephropathy &

Hendra Zufry, MD, FINASIM

Needle length for patients

Fluid Therapy in Type 2

Hendra Zufry, MD, FINASIM

Hendra Zufry, MD, FINASIM

Blood vessels penetrate each

But BLOOD FLOW differs considerably from

Dermis : small but swift flow and highly

Injection Site Rotation

Pen Injection Technique

Fluid Therapy in Type 2

Hendra Zufry, MD, FINASIM

Injecting high doses of Insulin

How is the correct Pinch Up?

Role of Rising a Skin Folds (pinching)

Hendra Zufry, MD, FINASIM

Angle of Needle with a pinch

Should give all injection using raised skin fold

Fluid Therapy in Type 2

Focus on Acute Complication, Diabetic Nephropathy &

Hendra Zufry, MD, FINASIM

Insulin Storage and Suspension

Fluid Therapy in Type 2

becomes milky white

Hendra Zufry, MD, FINASIM

Efek Samping Penyuntikan Insulin

Fluid Therapy in Type 2

Hendra Zufry, MD, FINASIM

Tips of Making Injection Less

Fluid Therapy in Type 2

Using shorter length and smaller dismeter needle

Hendra Zufry, MD, FINASIM

Fluid Therapy in Type 2

Hendra Zufry, MD, FINASIM

Pen Injection Technique

Gulung Pena Insulin

Pen Injection Technique