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Diabetes Management
Table 1: Average Thickness of the Subcutaneous
The skin is the largest organ of the body, accounting for 15% of
Fat Layer in Normal-weight Adults
bodyweight.
13
The thickness of the skin varies between 1 and 3mm
throughout the body. Because there is no difference in skin thickness
Gender and Average Thickness of the between obese and non-obese patients, obese patients are able to use
Body Region Subcutaneous Fat Layer (mm)
the 5mm needles too.
14
The average thickness of the subcutaneous fat
Female abdomen 23
layer in a normal-weight adult’s abdomen and thigh is listed in Table 1.
15
Female thigh 14
The subcutaneous fat layer in the obese can vary but is significantly
Male abdomen 14
thicker than in normal-weight individuals.
15
Male thigh 7
Injection Sites
the refrigerator for up to one month, depending on the type of insulin. Insulin is absorbed differently from different sites. It is absorbed most
When stored, they should be positioned with the needle up so that quickly from the abdomen, followed by the arms and then the legs. The
insulin does not deposit within the needle, resulting in clogging. For slowest absorption is from the buttocks.
16
It is advisable not to change
comfort, when injected the insulin should be at room temperature. sites daily because of the different rates of absorption.
17
Better control
can be achieved by consistently rotating insulin injections within a
Injection Technique set area.
18
For example, the morning injection could be given in one
In preparation for injection, the insulin pen should be primed with two general area, with the noon injection in another, and the supper and
units of insulin. This is then discarded and the actual dose dialed in. The bedtime doses in other areas, depending on how many injections are
same should be done with insulin syringes. If insulin is being mixed, used per day. One could therefore inject a thigh in the morning and
however, the priming is performed with only the insulin that is drawn up rotate around that thigh with the morning injections for a week, then
from the first vial. For example, if 10 units of regular insulin are needed move on to the other thigh for the next week. This would be preferable
for the injection, 12 units should be drawn up. The syringe should then to injecting in the thigh on one morning and the abdomen on the next
be held vertically with the needle pointing up. Any air bubbles are then morning. Rotation is advisable within individual areas in order to
expelled by a quick flick of the finger on the barrel of the syringe prevent the formation of scars, fatty deposits, and hard lumps.
19
These
followed by expulsion of the two extra units of insulin. The goal is to areas might be less painful to inject into, but this should be avoided
inject just below the skin into the subcutaneous fat. Sites that are best because it can result in erratic insulin absorption, leading to marked
for this include the abdomen, the backs of the upper arms, the upper glycemic excursions.
20
buttocks or hips, and the outer portion of the thighs. Not all sites will be
appropriate for all patients. For example, abdominal injections are Sites that should not be injected include an approximate two-inch circle
not appropriate for patients who are thin, such as young children or around the umbilicus and near to moles and scars. The skin in such
well-muscled individuals who cannot pinch half an inch of fat. In areas can be tougher and thus can contribute to variable rates of insulin
these situations it is much more difficult to give the injection absorption.
4
It is also inadvisable to inject into areas that will be
subcutaneously and there is a greater risk that the insulin will be exercised, as this can cause an increased rate of absorption, resulting in
injected intramuscularly.
9
In one technique, after cleansing the skin with hypoglycemia; for example, this could occur in someone using his or her
an alcohol swab, the fat is pinched between the thumb and index right arm to play tennis. Injecting into the other arm or elsewhere would
fingers and rotated slightly to ensure that muscle has not been be preferable in this instance.
4,21
After injecting, the site should not be
gathered up. If muscle is injected, the injection will be more painful and massaged but rather light pressure should be applied to minimize
the insulin will be absorbed faster, which could result in hypoglycemia.
10
bruising. If it appears that a significant amount of insulin has leaked out
Shorter insulin needles have decreased the likelihood of intramuscular after the injection, the patient should monitor his or her blood sugar
injections.
11
Anecdotally, patients have employed the following painless more closely afterwards.
4
insulin injection technique, which has not yet undergone formal
investigation but is becoming more commonly used. The skin is first Needle Use and Re-use
swabbed with alcohol. It is not pinched. Instead, the skin is touched As per US Food and Drug Administration (FDA) guidelines,
22
insulin
lightly with the needle point until a spot is found that does not feel injection needles are sterile products and all must be labeled for single
sharp. The needle is then slid through the skin at that spot at a 90º use only. In spite of most insurance plans covering them on this basis,
angle. Much like the roots of a tree, the nerve endings branch out on some patients will re-use their needles anyway. Unfortunately, some
the surface of the skin. By inserting the needle between the ‘roots,’ a healthcare providers will advise patients to do so.
4
There are potential
truly painless injection can be administered. When using an 8mm problems if this is carried out.
needle, the angle of the injection can vary depending on the area of the
body being injected. A 90º angle is appropriate for areas of Needle Damage and Breakage
the body with more fat and a 45º angle with a pinch up for areas with With improvements in technology, insulin needles have become
less fat, thus avoiding intramuscular injection of insulin. The pinch up progressively shorter and thinner. They are strong enough for one use
should be released prior to withdrawing the needle. If using a 5mm but not repeated use.
23
With re-use the thin tips of the needles can
mini-pen needle no pinch up is necessary because the shorter needle become damaged and bent and the silicone lubricant coating the
cannot reach the muscle, except in very young children with very thin needles is lost. The result is a more painful injection, with bruising and
subcutaneous fat layers.
11,12
bleeding more likely to occur.
24
Repeated use of the needle can result in
50 US ENDOCRINOLOGY
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