Diabetes & Injections: Touch Site. Sound? Why Lipohypertrophy matters
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Transcript of Diabetes & Injections: Touch Site. Sound? Why Lipohypertrophy matters
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Touch Site, sound?
Dr Pete Davies
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To cover• 4 cases• Theme
• Injection sites• Learning outcomes
• Which sites to use?• Differences between sites• Injection site problems
• How they present• Potential solutions
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Young Adult MDT Clinic• 17 yo woman, T1 Diabetes 6 years• Variable glucose values “up and down”• Locum DSN asked to look at sites• 2 seconds later, “They look fine”
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YAC 2
• On palpation- large disc of tissue each side of tummy, just below belly-button
• Lipos often easier to feel than see• “Touch sites, sound?”
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Stakes are high!• 66 yr old man• “Help!- wife about to put him into care;
dementia and agression 2e hypos; DM control poor A1c 10%; wife gives insulin”
• Seen next day- unpredictable hypos, ‘from nowhere’ with unpredictable highs too
• “Where do you inject?”
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Stakes are high 2!
• “Where do you inject?”• “Where the DSN told me- in the arm” • O/E obvious lipos near each elbow• Switched sites- control stabilised• Wife continued to care for him at home
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Suggested Sites for Injection
Which give fastest insulin absorption?
1st
2nd
3rd
4th
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Injection sites• Different sites absorb faster/slower• Could use that property to patients’
advantage• Basal into slower areas• Quick acting into faster
• We ALL need to look at & feel injection sites!
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PJ• 46 yo woman• Type ?2 DM early 2008
• Learning difficulty; little self-care; unusual health-beliefs; ?agoraphobia
• Probably Type 1 all along• Commenced insulin summer 2008• DKA Dec 08- omitted insulin 4 days
• ITU admission• DN involvement on discharge; home visit
from community DSNs
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PJ 2• Seen urgently last week- LB & PHD
• Twice daily Novomix 30• 34 Units each dose
• Highly variable control• Glucose 6-26 mmol/l• Timing of DN tests unclear and vary• 3 visits from DN- am and evening shots
plus 8pm visit for HBG check (?)
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PJ 3• Not on insulin very long, but…• ? Injection site problem
• “Show me, where do DNs inject?”• Lower arm, over biceps!!
• O/E little s/c fat in that area• patient finding injections very painful
• good tummy/legs- “why not use these?”• “They ask me where I want it”
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PJ 4• Amended care plan-
• Avoid areas with little sc fat- go for tummy/legs
• [probably best to use same general area]• More clear record of BG patterns• Set our aims at a realistic level- safe glucose
control targets, not over ambitious• For discussion- How do different DNs know
they aren’t injecting into the same place?
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WS• 56yo woman, seen recently• T1D 2 years• Other PMH
• hysterectomy 2005• Highly variable control, hypos then “as if
insulin doesn’t work”• “Where do you inject?” Always tummy• Can you guess what the cause was yet?
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WS 2• Examined tummy• Scar from hysterectomy• All injections near to scar- why?
• “Don’t like injections, can’t feel them here”• Very reluctant to use other area- wider
tummy/legs• Process of ongoing negotiation!
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Think injection sites, think lipos!• Variable glucose
values• Unexplained hypos or
hyperglycaemia• Look (stand up)• Feel• Avoid lipos!
• Rotation of sites• No needle reuse!