Page 64 - Demo

CPD ACTIVITY 63 Figure 2 The site of injection reduces the risk of IM injection. Rotating the site is important to reduce adverse effects. Figure 3: Injecting insulin into the abdomen results in more consistent insulin uptake and decreases the risk of injecting into a muscle. Figure 4: Short needles are preferred because long needles may result in inadvertent intramuscular injection. Figure 5: Correct skin fold technique is important. pinch the skin in a way where the muscle is also lifted.2 (Figure 5) Length of time insulin needle to remain under the skin For insulin pens the needle must remain under the skin (in situ) for at least 10 seconds after the plunger has been fully depressed (or for a time stated as per manufacturer’s guidelines).1 This helps prevent leaking from the injection site and ensures the patient receives the correct dose. Insulin injection quick guide Table 2 on page 65 is a step-by-step guide for injecting with a pen needle. For injection techniques for pregnant women, see the Clinical Guiding Principles for Subcutaneous Injection Technique document.1 TO PAGE 64 rotate injection sites within the body area/s recommended by their diabetes educator and GP.2 Needle length Insulin pen needles are available on the NDSS in 4mm, 5mm, 6mm, 8mm, 12mm and 12.7mm lengths, and insulin syringes are available in 6mm and 8mm lengths.8 Insulin needle length will inform the injection angle of administration and whether a skin fold is necessary or not. The skin is composed of the epidermis, the dermis and subcutaneous tissue. Below this there is muscle. It’s essential to use the correct needle length to ensure insulin is administered into the subcutaneous tissue. Using a needle that is too long (pen needles ≥6mm and syringes >6mm1,10 may result in inadvertent intramuscular administration, which can cause unstable blood glucose levels.11 (Figure 4) Intramuscular insulin can be absorbed more rapidly compared with subcutaneous injection, which can confer an increased risk of hypoglycaemia.12 Intradermal injection is highly unlikely even when using short 4mm needles, as in adults of all sizes, skin thickness is rarely more than 3mm.13 For initiation of insulin in children, adolescents and adults of all sizes, short pen needles (4mm and 5mm) are recommended.1 There is no evidence of benefit for the use of long needles.1 The use of pen needles longer than 5mm is not recommended despite their availability.1,2 Short needles are also appropriate in overweight and obese patients as there’s no benefit in using a larger needle for people who have more subcutaneous tissue.1 In the 2014-15 ITQ, 25.6 per cent of patients claimed to have never been educated about needle length.3 Pharmacists are in a perfect position to provide education on needle length as community pharmacies are the main place of supply of insulin needles. Angle of administration and the use of skin folds The angle of administration and whether or not a skin fold is to be used will depend on the size of the patient and the length of the insulin needle being used. Skin folds are more commonly required for small children (typically 6 years of age or below), slim adults or when using long needles.1,2 See Table 1 for a summary of needle size, angle of injection and whether or not to use a skin fold for people of different body sizes. If a skin fold is required, it’s important that the correct technique is used. To make a lifted skin fold, the thumb and index or middle finger can gently lift the subcutaneous tissue (away from the muscle).2 It’s important, though, not to RETAIL PHARMACY • JUL 2020