|Year : 2013 | Volume
| Issue : 1 | Page : 1-3
An acute need for awareness of insulin injection guidelines in operative and intensive care units
Sukhminder Jit Singh Bajwa1, Sanjay Kalra2, Manash P Baruah3, Sukhwinder Kaur Bajwa4
1 Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
2 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
3 Excel Center (Excel Care Hospitals), Guwahati, Assam, India
4 Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
|Date of Web Publication||26-Jun-2013|
Sukhminder Jit Singh Bajwa
Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab
Source of Support: None, Conflict of Interest: None
|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
|How to cite this URL:|
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 [serial online] 2013 [cited 2019 Aug 18];7:1-3. Available from: http://www.aeronline.org/text.asp?2013/7/1/1/113976
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. , 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. 
| 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. , In-depth knowledge of insulin injection techniques is very important to achieve a desirable outcome in diabetic patients as it is highly operator-dependent.  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.  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. 
| New Guidelines for Insulin Injection Practices|| |
Recently First Insulin Technique (FIT) India guidelines have 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.  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 pre-requisites is essential to completely adapt these guidelines which can be summarized as:
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.
- 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.
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. 
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. 
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. 
| 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. 
| Common Pitfalls and Solutions in Injection Practices in ICU|| |
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 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 immuno-compromised 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. ,
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.
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