規(guī)范化胰島素注射與管理

1、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?。瑥淖o(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

2、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

3、]；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, Güntner P, Linde B. Effects of accidental intramuskulær injection on insulin absorption in IDDM

4、. 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, Li

5、ndén 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

6、 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,

7、 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

8、;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 1

9、994;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

10、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

11、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

12、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）,*p<0.05 ，大腿 vs 上臂**p<0.05 ，上臂 vs. 腹部

13、***p<0.005，腹部vs. 大腿,注射胰島素后餐后血糖水平（mg/dl）,吸收速度：腹部>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

14、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)針方向進(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從注射治療一開始，就應(yīng)教會(huì)患者掌握一套

15、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 rotati

16、on. 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

17、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

18、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

19、, 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, Smedegaa

20、rd 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, B

21、yron 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,

22、Klaff L, Bailey T, Gibney M, Albanese J, Qu S, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm\32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41.Kreugel G,

23、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

24、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 leakag

25、e 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

26、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,8

27、4.9%>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<0，利用超聲評(píng)估不同部位皮膚表面至肌肉厚度。,Birkebaek NH, Solvig J, et al..Diabetes Care. 2008 Sep;31(9):e65.,成

28、人糖尿病患者使用較長(zhǎng)針頭極易注射到肌肉層,,Gibney MA, Arce CH, Byron KJ, Hirsch LJ.. Curr MedRes Opin 2010;26:1519-30.,BMI=25.2kg/m2不同長(zhǎng)度的針頭垂直注射,針頭長(zhǎng)度的選擇,因體脂分布的不同及隨著年齡的增加皮膚厚度變薄，建議使用短的針頭。6mm針頭對(duì)于大多數(shù)糖尿病患者是安全的選擇！,正確的注射方法,,關(guān)于NPH和預(yù)混胰島素的混勻,,混勻的正確手法

29、：,水平滾動(dòng)10次,上下顛倒10次,肉眼觀察是否混勻完全,混合前,混合7次后,混合20次后,肉眼觀察情況：,關(guān)于進(jìn)針與捏皮,,,成人采用較短針頭（4mm、5mm）注射時(shí)，針頭與皮膚表面呈90°角進(jìn)針[1-9]；A1在四肢或脂肪較少的腹部注射時(shí)，為防止肌肉注射，在使用4mm和5mm針頭時(shí)，可捏皮注射。使用6mm針頭時(shí)，可以采用捏皮或45°角注射[3,7,10-11]；A2使用長(zhǎng)度≥8mm針頭的患者，為避免肌肉注射，

30、應(yīng)捏皮或以45°角注射[10,11]。A2,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

31、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

32、 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

33、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, Q

34、u S, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm\32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41.Kreugel G, Keers JC, Jongbloed A, Verweij-Gjaltema AH

35、, 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. In

36、fluence 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 a

37、nd NovoFine 12 mm needle lengths in patients with type 1 or type 2 diabetes. Diabet Med 1998;1:S50.Solvig J, Christiansen JS, Hansen B, Lytzen L. Localisation of potential insulin deposition in normal weight and obese p

38、atients with diabetes using Novofine 6 mm and Novofine 12 mm needles. Meeting Federation European Nurses in Diabetes, Jerusalem, Israel, 2000 (Abstract).Schwartz S, Hassman D, Shelmet J, Sievers R, Weinstein R, Liang J,

39、 Lyness W. A multicenter, open-label, randomized, two-period crossover trial comparing glycemic control, satisfaction, and preference achieved with a 31 gauge x 6mm needle versus a 29 gauge x 12.7mm needle in obese patie

40、nts with diabetes mellitus. Clin Ther 2004;26:1663-78.Frid A, Lindén B. Where do lean diabetics inject their insulin? A study using computed tomography. BMJ 1986; 292:1638.,《中國(guó)糖尿病藥物注射技術(shù)指南2011版》,捏皮的手法,,捏皮時(shí)力度不得過(guò)大導(dǎo)致皮膚

41、發(fā)白或疼痛；不能用整只手來(lái)提捏皮膚，以避免將肌肉及皮下組織一同捏起；,正確的捏皮手法,錯(cuò)誤的捏皮手法,選擇進(jìn)針角度,,90°注射,45°注射,為保證將胰島素注射至皮下組織，在不捏皮的情況下可以45°角進(jìn)行注射，以增加皮下組織的厚度，降低胰島素注射至肌肉層的危險(xiǎn)。,針頭留置時(shí)間,藥液的流速還與注射筆針頭的內(nèi)徑有關(guān)，注射筆針頭的內(nèi)徑越大，其藥液流速更快。目前，臨床上有采用 “薄壁”設(shè)計(jì)的針頭，在同等外徑的情況

42、下內(nèi)徑更大，在降低注射引起不適感的同時(shí)保證胰島素的流速，更利于機(jī)體對(duì)胰島素的吸收,* Frid A. New injection recommendations for patients with diabetes.Diabetes & Metabolism 36 (2010) S3-S18,*,A3,,,注射溢液與針頭留置時(shí)間有關(guān),胰島素注射，特別是應(yīng)用較細(xì)、較短的針頭（如32G*4mm筆用針頭）、進(jìn)行較大劑量（>2

43、0IU/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;

44、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-bas

45、ed 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

46、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

47、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原因,知識(shí)缺乏不了解重復(fù)使

48、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19~82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)

49、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 Diab

50、etes 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 & Metabol

51、ism 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（保存期為開啟后一個(gè)月內(nèi)，且不能超過(guò)保質(zhì)期）；A2未開封的瓶裝胰島素或胰島素筆芯應(yīng)儲(chǔ)藏在2℃~8℃的環(huán)境中，切勿冷凍；A2避免受

52、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常現(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 o

53、f 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

54、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

55、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，應(yīng)同時(shí)拍照以便長(zhǎng)期隨訪；A3,Seyoum B, Abdulkadir J. Systematic inspection of insulin injec

56、tion 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：（

57、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 managemen

58、t of lipohypertrophy in diabetes care. Br J Nurs 2007;16:520-4.Jansà M, Colungo C, Vidal M. Actualización sobre técnicas y sistemas de administración de la insulina (II). [Update on insulin administr

59、ation 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 1

60、998;15:9-11.Teft G. Lipohypertrophy: patient awareness and implications for practice. J Diab Nursing 2002;6:20-3.Nielsen BB, Musaeus L, Gæde P. Attention to injection technique is associated with a lower frequency

61、 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 factor

62、s. 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 inje

63、ctions. 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

64、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

65、 1999;106:57-8.Dejgaard A, Murmann C. Air bubbles in insulin pens. Lancet 1989;334:871.Danish Nurses Organization. Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus, 2nd edit

66、ion, December 2006.Association for Diabetescare Professionals (EADV). Guideline: The Administration of Insulin with the Insulin Pen. September 2008.Chantelau E, Lee DM, Hemmann DM, Zipfel U, Echterhoff S. What makes in

67、sulin injections painful? BMJ 1991;303: 26-7.,注射過(guò)程多種情況引發(fā)疼痛增加,,,,,,,,,,,,因注射疼痛導(dǎo)致的不愿進(jìn)行胰島素治療的比例達(dá)50.8%,溫度較低的胰島素誘發(fā)疼痛和不適感,消毒皮膚的酒精未干會(huì)從針眼帶到皮下引起疼痛,體毛根部附近神經(jīng)末梢豐富,直徑較小、長(zhǎng)度較短的注射筆針頭具有較好的安全性和耐受性,注射筆針頭重復(fù)使用后卷邊反刺，針頭表面潤(rùn)滑層發(fā)生脫落，增加患者疼痛,低溫胰島素,

68、消毒酒精未干,注射在體毛根部,針頭的直徑和長(zhǎng)度,針頭重復(fù)使用,關(guān)于出血和淤血的推薦：,,,應(yīng)使患者放心，注射部位局部出血或淤血并不會(huì)給胰島素的吸收或者糖尿病的整體管理帶來(lái)不良的臨床后果。A2,注射時(shí)針頭有時(shí)會(huì)觸到血管，導(dǎo)致局部出血或淤血。更換注射筆針頭的長(zhǎng)度或者改變其他注射參數(shù)，似乎并不能改變出血或淤血的發(fā)生頻率，盡管一項(xiàng)研究提出5mm針頭注射可減少出血或淤血的發(fā)生。,Kahara T Kawara S. Shimizu A, Hi

69、sada A, Noto Y, Kida H. Subcutaneous hematoma due to frequent insulin injections in a single site. Intern Med 2004;43:148-9.Kreugel G, Beter HJM, Kerstens MN, Maaten ter JC, Sluiter WJ, Boot BS. Influence of needle size