《2011版中國(guó)糖尿病藥物注射技術(shù)指南》介紹《2011版糖尿病藥物注射技術(shù)指南》

目錄第一章：醫(yī)護(hù)人員的職責(zé)第二章：注射前的心理準(zhǔn)備第三章：注射治療的教育第四章：注射藥物第五章：注射裝置第六章：注射技術(shù)第七章：皮下脂肪增生與其他并發(fā)癥第八章：胰島素注射相關(guān)問題第九章：規(guī)范胰島素注射標(biāo)準(zhǔn)步驟（胰島素筆）第十章：注射部位規(guī)范檢查3要素《指南》中的推薦意見分級(jí)每條推薦意見后面均標(biāo)有一個(gè)字母和一個(gè)數(shù)字（如，A2）對(duì)于推薦的強(qiáng)度，我們采用如下分級(jí)標(biāo)準(zhǔn):強(qiáng)烈推薦推薦尚未決定的問題對(duì)于科學(xué)證據(jù)的支持程度，我們采用如下分級(jí)標(biāo)準(zhǔn):至少具備一項(xiàng)隨機(jī)、對(duì)照臨床研究至少具備一項(xiàng)非隨機(jī)（或非對(duì)照或流行病學(xué)）臨床研究以大量患者經(jīng)驗(yàn)為基礎(chǔ)的專家共識(shí)下面以“注射技術(shù)篇”為例給大家講解《指南》中所涉及到的一些問題！

《2011版中國(guó)糖尿病藥物注射技術(shù)指南》注射技術(shù)篇注射技術(shù)是糖尿病注射治療的三大關(guān)鍵因素之一注射技術(shù)：注射部位的選擇注射部位的輪換注射部位的檢查和消毒選擇是否捏皮選擇進(jìn)針角度針頭留置時(shí)間注射器材的廢棄針頭重復(fù)使用的危害關(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]

A1FridA,GunnarssonR,GüntnerP,LindeB.Effectsofaccidentalintramuskul?rinjectiononinsulinabsorptioninIDDM.DiabetesCare1988;11:41-45.FridA&BLinde(1993)ClinicallyimportantdifferencesininsulinabsorptionfromtheabdomeninIDDM.DiabetesResearchandClinicalPractice:Vol21.No2-3.137-141.FridA,LindénB.Intraregionaldifferencesintheabsorptionofunmodifiedinsulinfromtheabdominalwall.DiabetMed1992;9:236-9.AnnerstenM,WillmanA.Performingsubcutaneousinjections:aliteraturereview.WorldviewsEvidBasedNurs2005;2:122-30.ZehrerC,HansenR,BantleJ.Reducingbloodglucosevariabilitybyuseofabdominalinsulininjectionsites.DiabetesEduc1985;16:474-7.HenriksenJE,DjurhuusMS,VaagA,Thye-RonnP,KnudsenD.Hother-NielsenO,etal.Impactofinjectionsitesforsolubleinsulinonglycaemiccontrolintype1(insulin-dependent)diabeticpatientstreatedwithamultipleinsulininjectionregimen.Diabetologia1993;36:752-8.SindelkaG,HeinemannL,BergerM.FrenckW,ChantelauE.Effectofinsulinconcentration,subcutaneousfatthicknessandskintemperatureonsubcutaneousinsulinabsorptioninhealthysubjects.Diabetologia1994;37:377-40.AhernJ&MLMazur(2001)Siterotation.DiabetesForecast:Vol54.No4.66-68.WoodL,WilbourneJ,Kyne-GrzebalskiD,etal.administrationofinsulinbyinjection.PracticeDiabetesInternational2002;19(Suppl2-1):S1-S2.SmithCP,SargentMA,WilsonBP,PriceDA.Subcutaneousorintramuscularinsulininjections.ArchDisChild1991;66:879-82.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腹部87分鐘

50%較快適合短效胰島素臀部較慢適合長(zhǎng)效胰島素或中效胰島素大腿164分鐘

50%中等至較慢手臂141分鐘

50%中等至較慢適合長(zhǎng)效胰島素或中效胰島素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11.TheAmericanJournalofNursing,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***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MudallarSR,etal.DiabetesCare1999;22:1501-1506.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)等分區(qū)域（大腿或臀部可等分為兩個(gè)等分區(qū)域），每周使用一個(gè)等分區(qū)域并始終按順時(shí)針方向進(jìn)行輪換[1,2]

A3在任何一個(gè)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A3DiagramscourtesyofLourdesSaez-deIbarraandRuthGaspar,DiabetesNursesandSpecialistEducatorsfromLaPazHospital,Madrid,Spain.LumberT.Tipsforsiterotation.Whenitcomestoinsulin.whereyouinjectisjustasimportantashowmuchandwhen.DiabetesForecast2004;57:68-70.ThatcherG.Insulininjections.Thecaseagainstrandomrotation.AmJNurs1985;85:690-2.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)之間距離至少間隔1cm關(guān)于注射部位檢查和消毒的推薦：患者應(yīng)于注射前檢查注射部位[1,2]

A3一旦發(fā)現(xiàn)注射部位若出現(xiàn)脂肪增生、炎癥或感染，應(yīng)更換注射部位[3-10]

A2注射時(shí)，應(yīng)保持注射部位的清潔[11]

A2當(dāng)注射部位不潔凈，或者患者處于感染已于傳播的環(huán)境（如：醫(yī)院或療養(yǎng)院），注射前應(yīng)消毒注射部位[2,12,16-18]

A3DanishNursesOrganization.Evidence-basedClinicalGuidelinesforInjectionofInsulinforAdultswithDiabetesMellitus,2ndedition,December2006.AssociationforDiabetescareProfessionals(EADV).Guideline:TheAdministrationofInsulinwiththeInsulinPen.September2008.JohanssonU.AmsbergS,HannerzL,WredlingR,AdamsonU,ArnqvistHJ&PLins(2005)ImpairedAbsorptionofinsulinAspartfromLipohypertrophicInjectionSites.DiabetesCare:Vol28,No8,2025-2027.Ariza-AndracaCR,Altamirano-BustamanteE,Frati-MunariAC,Altamirano-BustamanteP,Graef-SanchezA.Delayedinsulinabsorptionduetosubcutaneousedema.ArchInvestMed1991;22:229-33.Saez-deIbarraL,GallegoF.Factorsrelatedtolipohypertrophyininsulin-treateddiabeticpatients;roleofeducationalintervention.PractDiabetesInt1998;15:9-11.YoungRJ,HannanWJ,FrierBM,SteelJM,DuncanLJ.YoungRJ,HannanWJ,FrierBM,SteelJMDiabeticlipohypertrophydelaysinsulinabsorption.DiabetesCare1984;7:479-80.ChowdhuryTA,EscudierV.Poorglycaemiccontrolcausedbyinsulininducedlipohypertrophy.BMJ2003;327:383-4.JohanssonUB.Impairedabsorptionofinsulinaspartfromlipohypertrophicinjectionsites.DiabetesCare2005;28:2025-7.OverlandJ,MolyneauxL,TewariS.,FatourosR,MelvilleP,FooteD,etal.Lipohypertrophy:Doesitmatterindailylife?Astudyusingacontinuousglucosemonitoringsystem.DiabetesObesMetab2009;11:460-3.FridA,LindenB.Computedtomographyofinjectionsitesinpatientswithdiabetesmellitus.InjectionandAbsorptionofInsulin.Stockholm:Thesis,1992.GormanKC.Goodhygieneversusalcoholswabsbeforeinsulininjections(Letter).DiabetesCare1993;16:960-1.SchulerG,PelzK,KerpL.Isthereuseofneedlesforinsulininjectionsystemsassociatedwithahigherriskofcutaneouscomplications?DiabetesResClinPract1992;16:209-12.WorkmanB.Safeinjectiontechniques.NursStand1999;13:47-53.BainA,GrahamA.Howdopatientsdisposeofsyringes?PractDiabetesInt1998;15:19-21.ChantelauE,SchiffersT,SchutzeJ,HansenB.Effectofpatient-selectedintensiveinsulintherapyonqualityoflife.PatientEducCouns1997Feb;30(2):167-73.LeFlochJP,HerbreteauC,LangeF,PerlemuterL.Biologicmaterialinneedlesandcartridgesafterinsulininjectionwithapenindiabeticpatients.DiabetesCare1998;21:1502-4.McCarthyJA,CovarrubiasB,SinkP.Isthetraditionalalcoholwipenecessarybeforeaninsulininjection?Dogmadisputed(Letter).DiabetesCare1993;16:402.SwahnA.Erfarenheterav94000osteriltgivnainsulininjektioner(Experiencesfrom94000insulininjectionsgivenwithoutskinswab).SvLakaresallskapetsHandlingarHygiea1982;92:160(3O).關(guān)于捏皮的推薦：所有患者在起始胰島素治療時(shí)就應(yīng)掌握捏皮的正確方法

A3捏皮時(shí)力度不得過大導(dǎo)致皮膚發(fā)白或疼痛A3不能用整只手來提捏皮膚，以避免將肌肉及皮下組織一同捏起最佳的注射步驟為：捏起皮膚形成皮褶和皮褶表面呈90°角進(jìn)針后，緩慢推注胰島素當(dāng)活塞完全推壓到底后，針頭在皮膚內(nèi)停留10秒鐘（采用胰島素筆注射）拔出針頭松開皮褶A3正確的捏皮手法錯(cuò)誤的捏皮手法ClausonPG,LindeB.Absorptionofrapid-actinginsulininobeseandnonobeseNIDDMpatients.DiabetesCare1995;18:986-91.JamalR,RossSA,ParkesJL,PardoS,GinsbergBH.Roleofinjectiontechniqueinuseofinsulinpens:prospectiveevaluationofa31-gauge,8mminsulinpenneedle.EndocrPract1999;5:245-50.BirkebaekN,SolvigJ,HansenB,JorgensenC,SmedegaardJ,ChristiansenJ.A4mmneedlereducestheriskofintramuscularinjectionswithoutincreasingbackflowtoskinsurfaceinleandiabeticchildrenandadults.DiabetesCare.2008Sep;22(9):e65.GibneyMA,ArceCH,ByronKJ,HirschLJ.Skinandsubcutaneousadiposelayerthicknessinadultswithdiabetesatsitesusedforinsulininjections:Implicationsforneedlelengthrecommendations.CurrMedResOpin2010;26:1519-30.HirschL,KlaffL,BaileyT,GibneyM,AlbaneseJ,QuS,etal.Comparativeglycemiccontrol,safetyandpatientratingsforanew4mm\32Ginsulinpenneedleinadultswithdiabetes.CurrMedResOpin2010;26:1531-41.KreugelG,KeersJC,JongbloedA,Verweij-GjaltemaAH,WolffenbuttelBHR.Theinfluenceofneedlelengthonglycemiccontrolandpatientpreferenceinobesediabeticpatients.Diabetes2009;58:A117.KreugelG,BeijerHJM,KerstensMN,terMaatenJC,SluiterWJ,BootBS.InfluenceofneedlesizeforSCinsulinadministrationonmetaboliccontrolandpatientacceptance.EuropDiabNursing2007;4:1-5.VanDoornLG,AlberdaA,LytzenL.InsulinleakageandpainperceptionwithNovoFine6mmandNovoFine12mmneedlelengthsinpatientswithtype1ortype2diabetes.DiabetMed1998;1:S50.SolvigJ,ChristiansenJS,HansenB,LytzenL.LocalisationofpotentialinsulindepositioninnormalweightandobesepatientswithdiabetesusingNovofine6mmandNovofine12mmneedles.MeetingFederationEuropeanNursesinDiabetes,Jerusalem,Israel,2000(Abstract).SchwartzS,HassmanD,ShelmetJ,SieversR,WeinsteinR,LiangJ,LynessW.Amulticenter,open-label,randomized,two-periodcrossovertrialcomparingglycemiccontrol,satisfaction,andpreferenceachievedwitha31gaugex6mmneedleversusa29gaugex12.7mmneedleinobesepatientswithdiabetesmellitus.ClinTher2004;26:1663-78.FridA,LindénB.Wheredoleandiabeticsinjecttheirinsulin?Astudyusingcomputedtomography.BMJ1986;292:1638.關(guān)于進(jìn)針角度的推薦：使用較短（4mm或5mm）的針頭時(shí)，大部分患者無需捏起皮膚，并可90°進(jìn)針[1-9]

A1使用較長(zhǎng)（≥8mm）的針頭時(shí)，需要捏皮或45°角以降低肌肉注射風(fēng)險(xiǎn)[10,11]

A1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*FridA.Newinjectionrecommendationsforpatientswithdiabetes.

Diabetes&Metabolism36(2010)S3-S18*A3關(guān)于注射器材廢棄的推薦醫(yī)護(hù)人員和患者必須熟知國(guó)家有關(guān)醫(yī)療廢棄物處理的相關(guān)規(guī)定[1]

A3所有醫(yī)護(hù)人員從注射治療的開始，就應(yīng)教會(huì)患者如何正確廢棄注射器材[2]

A3醫(yī)護(hù)人員應(yīng)向患者說明可能發(fā)生于患者家人（如刺傷兒童）和服務(wù)人員（如垃圾收運(yùn)工和清潔工）的不良事件A3任何情況下都不能將注射器材丟入公共垃圾桶或者垃圾場(chǎng)

A3WorkmanB.Safeinjectiontechniques.NursStand1999;13:47-53.BainA,GrahamA.Howdopatientsdisposeofsyringes?PractDiabetesInt1998;15:19-21.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。針頭重復(fù)使用有危害注射筆針頭應(yīng)一次性使用[1-7]

A2ChantelauE,LeeDM,HemmannDM,ZipfelU,EchterhoffS.Whatmakesinsulininjectionspainful?BritishMedicalJournal1991;303:26-27.StraussK,DeGolsH,LetondeurC,MatyjaszczykM,FridA.Thesecondinjectiontechniqueevent(SITE),May2000,Barcelona,Spain.PractDiabetesInt2002;19:17-21.DanishNursesOrganization.Evidence-basedClinicalGuidelinesforInjectionofInsulinforAdultswithDiabetesMellitus,2ndedition,December2006.AssociationforDiabetescareProfessionals(EADV).Guideline:TheAdministrationofInsulinwiththeInsulinPen.September2008.SchulerG,PelzK,KerpL.Isthereuseofneedlesforinsulininjectionsystemsassociatedwithahigherriskofcutaneouscomplications?DiabetesResClinPra