A E R
Editor‑in‑Chief : Mohamad Said Maani Takrouri (KSA)
Open Access HTML Format
For entire Editorial Board visit : http://www.aeronline.org/editorialboard.asp
Anesthesia: Essays and Researches
Editorial
An acute need for awareness of insulin injection guidelines in operative and intensive care units The ever increasing number of peri-operative and critically ill diabetic patients in clinical settings have become a cause of serious concern. Invariably, such patients present with uncontrolled hyperglycemia which can be managed only with insulin therapy.[1,2] Besides the existing challenges in the management of uncontrolled diabetes and its related complications, another difficulty which is commonly faced by the nursing staff and the physicians, is the lack of awareness regarding insulin injection techniques. Inappropriate insulin injection practices can lead to various clinical complications such as poor glycemic control, pain, bleeding and bruising, breaking and lodging of needle tip beneath the skin, contamination leading to infection, lipohypertrophy, and inaccurate dose administration.[3]
SIGNIFICANCE OF INSULIN INJECTION TECHNIQUES Control of hyperglycemia is highly essential for a better operative outcome and an improved survival rate in critically ill patients.[4,5] In-depth knowledge of insulin injection techniques is very important to achieve a desirable outcome in diabetic patients as it is highly operator-dependent.[6] Besides physicians and nursing staff ’s lack of awareness, time constraints, and scarcity of local authentic guidelines, there are numerous other factors which are responsible for inappropriate insulin injection practices.[7] These factors include, but are not limited to site, dose, depth and method of injection administration, compliance, dexterity problems, fear, anxiety, physical handicap, intellectual level, financial constraints, and so on.[7]
NEW GUIDELINES FOR INSULIN INJECTION PRACTICES Recently First Insulin Technique (FIT) India guidelines have Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.113976
Quick Response Code
become available for general practice based on scientific strength and evidence and which can also be suitably modified to adapt to perioperative and Intensive Care Unit (ICU) setting.[8] The main emphasis for an intensivist is to bring an amalgamation of these guidelines with those of existing practices so as to smoothly implement these in critical care units. However, knowledge regarding few prerequisites is essential to completely adapt these guidelines which can be summarized as: • Establishing rapport with the patient if not sedated or paralyzed. • A complete physical and clinical evaluation of the patient. • Recommendations related to storage of insulin and devices. • Appropriate and judicious selection of insulin, pens and vials, needle length, and other physical characteristics of the insulin stored in the vial. • Use of correct insulin syringe and vial. • Appropriate selection of pens, pre-loaded insulin cartridges, number of insulin units in a vial, ability to titrate the dose of insulin, and flexibility in rectification of the wrong dose. • Selection of appropriate site and route depending upon the clinical state of the patient. • Maintaining strict asepsis to prevent infection and so on. Besides these pre-requisites, injection techniques, and its related recommendations play a major role in successful accomplishment of glycemic control. Insulin vial has to be kept at room temperature for 30 minutes prior to injection after taking out from refrigerator and one should ensure a uniform mixing without any precipitates or clumping in the vial. After wiping the top of the insulin vial, insulin should be drawn-up without any air-bubbles. Injection procedure should be preceded by wiping the Site with alcohol swab, moving to periphery in a circular manner, and thereafter, injecting into the middle of the area. After the injection, the needle should be discarded. Pens are being increasingly used for insulin administration and are easy to use as compared to insulin syringes as the dose of insulin can be easily titrated with pens. Care should be taken not to massage the injection site and the needle should be disposed immediately after the injection to prevent air entry into the cartridge.[9] 1
Bajwa, et al.: Insulin injection guidelines
Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
One of the most challenging aspects in ICU is to maintain the balance between nutrition and control of hyperglycemia as the insulin injection time and mealtime gap is very important to maintain normoglycemic status. Owing to delayed onset, regular insulin should be injected half an hour before meal while rapid acting insulin such as lispro, aspart, and glulisine should be injected immediately after meal. Intensivist plays a major role in either increasing or decreasing the efficacy of insulin by altering the injection mealtime gap as per the individual patient requirement. The inter-injection period can vary between 8-40 hours for ultra-long acting insulin such as degludec while Neutral Protamine Hagedorn (NPH), detemir and glargine can be given at the same time period, irrespective of the meal status.[10] Some pathologies of patients admitted in ICU with diabetes can be managed with pre-mixed insulin preparations. Combination of rapid acing, short acting, and intermediate acting insulin can be immensely helpful in achieving the normal glycemic status. For mixing, few precautions have to be taken as glargine and detemir cannot be mixed with any other insulin but regular insulin and rapid acting insulin analogues can be mixed with NPH.[11]
COMPLICATIONS OF INSULIN INJECTIONS Though rarely encountered in clinical practice, few complications with insulin injections have been reported with a variable incidence. Pain on insulin injection can be troublesome in post-operative patients as is the phobia and anxiety associated with injection. These can be minimized with use of short needles, injection at 90° to the skin surface, splitting the larger dose, injecting slowly, and avoiding injection at hair roots. Lipohypertrophy at insulin injection site can occur in patients with prolonged ICU stay. It can be prevented by rotation of the injection site, avoiding re-use of needles and use of good quality insulin or insulin analogues. Bleeding and bruising has also been reported with insulin injections and should be prevented by use of short needles and correct injection technique. Needle stick injuries can also occur to the intensivists and the nursing staff and it is generally advised not to re-cap the needles. Needles should not be re-used as has been recommended by United States Food and Drug Administration (USFDA) as the older needles tend to break-off, get damaged, and lose silicone lubricant coating thus making the injection more painful.[8]
COMMON PITFALLS AND SOLUTIONS IN INJECTION PRACTICES IN ICU
switching over the type and brand of insulin is to be done by the nursing staff without permission from the intensivist. Human insulin should be administered to control hyperglycemia in unconscious patients if there is no clarity of type of insulin being used previously by the patient or relatives are not able to give definite history. Care should be taken while treating immunocompromised individuals in ICU as inappropriate injection practices can lead to high risk of contracting fatal viral infections such as Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), and so on. Insulin resistance is another concern in such patients and mandates an early initiation of insulin therapy so as to achieve a better outcome.[12,13] Insulin should be labeled with patient’s registration numbers and name during storage in common facilities in ICU such as refrigerators so as to avoid possible contamination and cross infections. Cost-benefit ratio is improved by use of pens instead of syringes. Improvement in injection practices in ICU can be brought by imparting training on insulin injection skills to nursing staff and paramedical personals. These training schedules can be further strengthened by hiring diabetes educator for setting up various education programs related to control of diabetes. Educational content and the style of teaching have to be adjusted to individual’s intellectual level and needs. Assuring and implementing quality insulin injection practices will go a long way in controlling this ever increasing global epidemic.
Sukhminder Jit Singh Bajwa, Sanjay Kalra1, Manash P. Baruah2, Sukhwinder Kaur Bajwa3
Departments of Anesthesiology and Intensive Care, and Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, Departments of Endocrinology, 1 Bharti Hospital and BRIDE, Karnal, Haryana, 2Excel Center (Excel Care Hospitals), Guwahati, Assam, India E-mail: [email protected] 3
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.
Another concern is the frequent missing of regular insulin injections in ICU by the nursing staff especially if nurse-patient ratio is very low. Also, no change or 2
9.
Crasto W, Jarvis J, Khunti K, Davies MJ. New insulins and new insulin regimens: A review of their role in improving glycaemic control in patients with diabetes. Postgrad Med J 2009;85:257-67. Bajwa SS, Kalra S. Diabeto-anaesthesia: A subspecialty needing endocrine introspection. Indian J Anaesth 2012;56:513-7. Dolinar R. The importance of good insulin injection practices in diabetes management. US Endocrinol 2009;5:49-52. Bajwa SJ. Intensive care management of critically sick diabetic patients. Indian J Endocrinol Metab 2011;15:349-50. Bajwa SS, Kalra S. Glycaemic control in ICU. In: Bajaj S, editor. Endocrine Society of India Manual of Clinical Endocrinology. vol. 1. 2012. p. 115-23. Kumar A, Kalra S. Insulin initiation and intensification: Insights from new studies. J Assoc Physicians India 2011;(Suppl 59):17-22. Davidson JA. New injection recommendations for patients with diabetes. Diabetes Metab 2010;36(Suppl 2):S2. Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, Chowdhury S, et al. Forum for injection techniques, India: The first Indian recommendations for best practice in insulin injection technique. Indian J Endocrinol Metab 2012;16:876-85. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, et al. New
Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
10. 11. 12. 13.
injection recommendations for patients with diabetes. Diabetes Metab 2010;36(Suppl 2):S3-18. Czupryniak L, Drzewoski J. Insulin injection mean time interval it is not its length that matters. Pract Diab Int 2001;18:338. Deckert T. Intermediate-acting insulin preparations: NPH and lente. Diabetes Care 1980;3:623-6. Palios J, Kadoglou NP, Lampropoulos S. The pathophysiology of HIV-/ HAART-related metabolic syndrome leading to cardiovascular disorders: The emerging role of adipokines. Exp Diabetes Res 2012;2012:103063. Kalra S, Unnikrishnan AG, Raza SA, Bantwal G, Baruah MP, Latt TS, et al. South Asian Consensus Guidelines for the rational management of diabetes
Bajwa, et al.: Insulin injection guidelines in human immunodeficiency virus/acquired immunodeficiency syndrome. Indian J Endocrinol Metab 2011;15:242-50.
How to cite this article: Bajwa SJ, Kalra S, Baruah MP, Bajwa SK. An acute need for awareness of insulin injection guidelines in operative and intensive care units. Anesth Essays Res 2013;7:1-3. Source of Support: Nil, Conflict of Interest: None declared.
Staying in touch with the journal 1) Table of Contents (TOC) email alert Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to www.aeroline.org.in/signup.asp. 2) RSS feeds Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add www.aeroline.org.in/rssfeed.asp as one of the feeds. 3
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editor‑in‑Chief : Mohamad Said Maani Takrouri (KSA)
Open Access HTML Format
For entire Editorial Board visit : http://www.aeronline.org/editorialboard.asp
Anesthesia: Essays and Researches
Editorial
An acute need for awareness of insulin injection guidelines in operative and intensive care units The ever increasing number of peri-operative and critically ill diabetic patients in clinical settings have become a cause of serious concern. Invariably, such patients present with uncontrolled hyperglycemia which can be managed only with insulin therapy.[1,2] Besides the existing challenges in the management of uncontrolled diabetes and its related complications, another difficulty which is commonly faced by the nursing staff and the physicians, is the lack of awareness regarding insulin injection techniques. Inappropriate insulin injection practices can lead to various clinical complications such as poor glycemic control, pain, bleeding and bruising, breaking and lodging of needle tip beneath the skin, contamination leading to infection, lipohypertrophy, and inaccurate dose administration.[3]
SIGNIFICANCE OF INSULIN INJECTION TECHNIQUES Control of hyperglycemia is highly essential for a better operative outcome and an improved survival rate in critically ill patients.[4,5] In-depth knowledge of insulin injection techniques is very important to achieve a desirable outcome in diabetic patients as it is highly operator-dependent.[6] Besides physicians and nursing staff ’s lack of awareness, time constraints, and scarcity of local authentic guidelines, there are numerous other factors which are responsible for inappropriate insulin injection practices.[7] These factors include, but are not limited to site, dose, depth and method of injection administration, compliance, dexterity problems, fear, anxiety, physical handicap, intellectual level, financial constraints, and so on.[7]
NEW GUIDELINES FOR INSULIN INJECTION PRACTICES Recently First Insulin Technique (FIT) India guidelines have Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.113976
Quick Response Code
become available for general practice based on scientific strength and evidence and which can also be suitably modified to adapt to perioperative and Intensive Care Unit (ICU) setting.[8] The main emphasis for an intensivist is to bring an amalgamation of these guidelines with those of existing practices so as to smoothly implement these in critical care units. However, knowledge regarding few prerequisites is essential to completely adapt these guidelines which can be summarized as: • Establishing rapport with the patient if not sedated or paralyzed. • A complete physical and clinical evaluation of the patient. • Recommendations related to storage of insulin and devices. • Appropriate and judicious selection of insulin, pens and vials, needle length, and other physical characteristics of the insulin stored in the vial. • Use of correct insulin syringe and vial. • Appropriate selection of pens, pre-loaded insulin cartridges, number of insulin units in a vial, ability to titrate the dose of insulin, and flexibility in rectification of the wrong dose. • Selection of appropriate site and route depending upon the clinical state of the patient. • Maintaining strict asepsis to prevent infection and so on. Besides these pre-requisites, injection techniques, and its related recommendations play a major role in successful accomplishment of glycemic control. Insulin vial has to be kept at room temperature for 30 minutes prior to injection after taking out from refrigerator and one should ensure a uniform mixing without any precipitates or clumping in the vial. After wiping the top of the insulin vial, insulin should be drawn-up without any air-bubbles. Injection procedure should be preceded by wiping the Site with alcohol swab, moving to periphery in a circular manner, and thereafter, injecting into the middle of the area. After the injection, the needle should be discarded. Pens are being increasingly used for insulin administration and are easy to use as compared to insulin syringes as the dose of insulin can be easily titrated with pens. Care should be taken not to massage the injection site and the needle should be disposed immediately after the injection to prevent air entry into the cartridge.[9] 1
Bajwa, et al.: Insulin injection guidelines
Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
One of the most challenging aspects in ICU is to maintain the balance between nutrition and control of hyperglycemia as the insulin injection time and mealtime gap is very important to maintain normoglycemic status. Owing to delayed onset, regular insulin should be injected half an hour before meal while rapid acting insulin such as lispro, aspart, and glulisine should be injected immediately after meal. Intensivist plays a major role in either increasing or decreasing the efficacy of insulin by altering the injection mealtime gap as per the individual patient requirement. The inter-injection period can vary between 8-40 hours for ultra-long acting insulin such as degludec while Neutral Protamine Hagedorn (NPH), detemir and glargine can be given at the same time period, irrespective of the meal status.[10] Some pathologies of patients admitted in ICU with diabetes can be managed with pre-mixed insulin preparations. Combination of rapid acing, short acting, and intermediate acting insulin can be immensely helpful in achieving the normal glycemic status. For mixing, few precautions have to be taken as glargine and detemir cannot be mixed with any other insulin but regular insulin and rapid acting insulin analogues can be mixed with NPH.[11]
COMPLICATIONS OF INSULIN INJECTIONS Though rarely encountered in clinical practice, few complications with insulin injections have been reported with a variable incidence. Pain on insulin injection can be troublesome in post-operative patients as is the phobia and anxiety associated with injection. These can be minimized with use of short needles, injection at 90° to the skin surface, splitting the larger dose, injecting slowly, and avoiding injection at hair roots. Lipohypertrophy at insulin injection site can occur in patients with prolonged ICU stay. It can be prevented by rotation of the injection site, avoiding re-use of needles and use of good quality insulin or insulin analogues. Bleeding and bruising has also been reported with insulin injections and should be prevented by use of short needles and correct injection technique. Needle stick injuries can also occur to the intensivists and the nursing staff and it is generally advised not to re-cap the needles. Needles should not be re-used as has been recommended by United States Food and Drug Administration (USFDA) as the older needles tend to break-off, get damaged, and lose silicone lubricant coating thus making the injection more painful.[8]
COMMON PITFALLS AND SOLUTIONS IN INJECTION PRACTICES IN ICU
switching over the type and brand of insulin is to be done by the nursing staff without permission from the intensivist. Human insulin should be administered to control hyperglycemia in unconscious patients if there is no clarity of type of insulin being used previously by the patient or relatives are not able to give definite history. Care should be taken while treating immunocompromised individuals in ICU as inappropriate injection practices can lead to high risk of contracting fatal viral infections such as Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), and so on. Insulin resistance is another concern in such patients and mandates an early initiation of insulin therapy so as to achieve a better outcome.[12,13] Insulin should be labeled with patient’s registration numbers and name during storage in common facilities in ICU such as refrigerators so as to avoid possible contamination and cross infections. Cost-benefit ratio is improved by use of pens instead of syringes. Improvement in injection practices in ICU can be brought by imparting training on insulin injection skills to nursing staff and paramedical personals. These training schedules can be further strengthened by hiring diabetes educator for setting up various education programs related to control of diabetes. Educational content and the style of teaching have to be adjusted to individual’s intellectual level and needs. Assuring and implementing quality insulin injection practices will go a long way in controlling this ever increasing global epidemic.
Sukhminder Jit Singh Bajwa, Sanjay Kalra1, Manash P. Baruah2, Sukhwinder Kaur Bajwa3
Departments of Anesthesiology and Intensive Care, and Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, Departments of Endocrinology, 1 Bharti Hospital and BRIDE, Karnal, Haryana, 2Excel Center (Excel Care Hospitals), Guwahati, Assam, India E-mail: [email protected] 3
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.
Another concern is the frequent missing of regular insulin injections in ICU by the nursing staff especially if nurse-patient ratio is very low. Also, no change or 2
9.
Crasto W, Jarvis J, Khunti K, Davies MJ. New insulins and new insulin regimens: A review of their role in improving glycaemic control in patients with diabetes. Postgrad Med J 2009;85:257-67. Bajwa SS, Kalra S. Diabeto-anaesthesia: A subspecialty needing endocrine introspection. Indian J Anaesth 2012;56:513-7. Dolinar R. The importance of good insulin injection practices in diabetes management. US Endocrinol 2009;5:49-52. Bajwa SJ. Intensive care management of critically sick diabetic patients. Indian J Endocrinol Metab 2011;15:349-50. Bajwa SS, Kalra S. Glycaemic control in ICU. In: Bajaj S, editor. Endocrine Society of India Manual of Clinical Endocrinology. vol. 1. 2012. p. 115-23. Kumar A, Kalra S. Insulin initiation and intensification: Insights from new studies. J Assoc Physicians India 2011;(Suppl 59):17-22. Davidson JA. New injection recommendations for patients with diabetes. Diabetes Metab 2010;36(Suppl 2):S2. Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, Chowdhury S, et al. Forum for injection techniques, India: The first Indian recommendations for best practice in insulin injection technique. Indian J Endocrinol Metab 2012;16:876-85. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, et al. New
Anesthesia: Essays and Researches; 7(1); Jan-Apr 2013
10. 11. 12. 13.
injection recommendations for patients with diabetes. Diabetes Metab 2010;36(Suppl 2):S3-18. Czupryniak L, Drzewoski J. Insulin injection mean time interval it is not its length that matters. Pract Diab Int 2001;18:338. Deckert T. Intermediate-acting insulin preparations: NPH and lente. Diabetes Care 1980;3:623-6. Palios J, Kadoglou NP, Lampropoulos S. The pathophysiology of HIV-/ HAART-related metabolic syndrome leading to cardiovascular disorders: The emerging role of adipokines. Exp Diabetes Res 2012;2012:103063. Kalra S, Unnikrishnan AG, Raza SA, Bantwal G, Baruah MP, Latt TS, et al. South Asian Consensus Guidelines for the rational management of diabetes
Bajwa, et al.: Insulin injection guidelines in human immunodeficiency virus/acquired immunodeficiency syndrome. Indian J Endocrinol Metab 2011;15:242-50.
How to cite this article: Bajwa SJ, Kalra S, Baruah MP, Bajwa SK. An acute need for awareness of insulin injection guidelines in operative and intensive care units. Anesth Essays Res 2013;7:1-3. Source of Support: Nil, Conflict of Interest: None declared.
Staying in touch with the journal 1) Table of Contents (TOC) email alert Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to www.aeroline.org.in/signup.asp. 2) RSS feeds Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add www.aeroline.org.in/rssfeed.asp as one of the feeds. 3
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
