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Child Health Guideline Identifier

Diabetes - insulin treatment of hospitalised patients with diabetes mellitus

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Background

The aim of insulin therapy is to obtain as close to physiological insulin replacement as possible and optimal glycemic control.

Types of insulin

Insulin action and duration varies according to insulin type.

insulin table

Food must be given within 15 minutes of an injection of rapid acting insulin (Novorapid/Humalog/Apidra). Food should be given 20 - 30 minutes after injection of short acting insulin (Actrapid/Humulin R).

Storage of insulin

Unopened vials and cartridges of insulin must be stored in the fridge between 2 - 8° until date of expiry.

Opened vials and cartridges of insulin can be stored at room temperature for 4 weeks. If opened insulin is being stored in the fridge on the ward, allow 15 - 20 minutes for it to rise to room temperature to avoid pain with injection.

Injection sites

Injection sites

  • Site of choice should be documented by the diabetes team on the Insulin Order Sheet.
  • Recommended sites include the abdomen and waistline, upper outer quadrant of the buttocks and less often the fronts and/or sides of the thighs.
  • Factors which influence absorption of insulin are age, fat mass, dose, site of injection, depth of injection, exercise, insulin type and both ambient and body temperature.
  • The abdomen provides the fastest and most consistent rate of insulin absorption and is less affected by exercise than other sites.
  • At the time of diagnosis, where there has been significant weight loss, the buttocks are generally the preferred site to ensure injections remain subcutaneous rather than intra-muscular. Buttocks are also generally the preferred site for infants and younger children.
  • Lipohypertrophy is a common problem when insulin is repeatedly injected into the same area and significantly affects insulin absorption. This can be avoided by rotation of injection sites.

Obtaining insulin doses for in patients with diabetes mellitus requiring insulin

All insulin doses administered within the inpatient setting must be prescribed by appropriately trained medical staff.

Insulin doses will be prescribed daily by the endocrine registrar.

Any additional phone orders for insulin doses must be documented clearly on the Insulin Order Sheet, and then countersigned by a second registered nurse and the prescribing physician within 24 hours.

Administration of insulin using syringe or pen device to inpatients with Diabetes Mellitus

  • Ensure simple hand washing to remove dirt and transient contaminants prior to injecting insulin.
  • A sharps container should be located close to injecting procedures.
  • Prepare the child for insulin administration using developmentally appropriate strategies (where appropriate utilise play specialists to support developmental adjustment to insulin injections).
  • Children (where developmentally appropriate) may learn to do their own injections under close supervision. Parents/carers of newly diagnosed children are encouraged to draw up and administer insulin injections at the time of diagnosis and are required to have confidently administered a minimum of two injections each prior to discharge. Nursing staff must supervise and document doses administered.
  • Insulin injections must be administered using an insulin syringe or pen device.
  • Hospital issue insulin syringe needles are 8 mm long. These are for once only use. They are available in various sizes (30, 50 and 100 units).
  • Pen device type will depend on the insulin type. Pen needles require changing every 2 - 3 days. Pen needles are available in various sizes (4 mm, 5mm and 8mm) however shorter needles are generally recommended in paediatric populations. Pen devices must be primed with at least 2 units of insulin following insertion of an insulin cartridge, and before each injection is administered.
  • Insulin injections should cause minimal discomfort. A skin pinch and 45° insertion angle is used for both 8mm insulin syringes and insulin pen devices fitted with 5 or 8mm pen needles unless documented otherwise by the diabetes team. Injections given at <30° angle may cause pain. Injections given at >45° angle may penetrate the muscle which may also cause pain. A 90° angle is recommended for pen devices fitted with a 4mm pen needle.
  • Slight bleeding and bruising will occur sometimes because the needle has passed through a capillary. This should not affect the absorption of the insulin however, bruising and bleeding may indicate inadvertent intramuscular injection.
  • Children who get used to having injections in the one same area may complain that injections are more painful when they move sites. Often, this is a psychological phenomenon and may be avoided by encouraging site rotation from the time of diagnosis.
  • All parents/caregivers of newly diagnosed children are required to have completed injections confidently prior to discharge (even if the child is developmentally able to self-inject). Nurses need to supervise and support the parent/patient (as developmentally appropriate) to administer prescribed insulin subcutaneously.
  • Clear details pertaining to administration must be documented clearly by nursing staff on the Insulin Order Sheet.

Problems with injections

Local hypersensitivity reactions to insulin injections are uncommon but when they do occur, please notify the endocrine registrar. Formal identification of the insulin (or more rarely preservative) responsible should be investigated. A trial of an alternative insulin preparation may solve the problem. If true allergy is suspected, desensitisation can be undertaken

Administration of insulin by families in the community

In the community, families are advised to use syringes twice before disposal in an appropriate sharps container. Sharps containers that are full must be taken to a community pharmacy for disposal. Sharps containers are available for families to purchase at Diabetes Auckland or at pharmacies throughout Auckland.

Information for Families

Insulin Injections Online Teaching Module
Insulin types and regimens Online Teaching Module

References

  1. Diabetes Care 2010 Sep; 33(9): 1940-1944. https://doi.org/10.2337/dc10-0871 Defining the Ideal Injection Techniques When Using 5-mm Needles in Children and Adults. Hofman, P., Derraik,J., Pinto, T., Tregurtha, S., Faherty, A., Peart, J., Drury, P., Robinson, E., Tehranchi, R., Donsmark, M., Cutfield, W. 
  2. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium. - Hypoglycemia: Assessment and management of hypoglycemia in children and adolescents with diabetes. Ly, T.T., Maahs, D.M., Rewers, A., Dunger, D., Oduwole, A., & Jones, T.W. Pediatric Diabetes 2014: 15 (Suppl. 20): 180-192.
  3. National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes in Children, Adolescents and Adults Craig, ME, Twigg, SM, Donaghue, KC, Cheung, NW, Cameron, FJ, Conn, J, Jenkins, AJ, Silink, M, for the Australian Type 1 Diabetes Guidelines Expert Advisory Group. Australian Government Department of Health And Ageing, Canberra 2011.
  4. Mayo Clinic Procedings Vol 91, Issue 9, September 2016. New insulin delivery recommendations. Pages 1231-1255. Frid, A., Kreugel, G., Grassi, Halimi, S.,Hicks, D.,  Hirsch, L., Smith, M., Wellhoener, R., Bode, B., Hirsch, I.,  Kalra, S., Ji, L., Strauss, K.

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Document Control

  • Date last published: 14 June 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Endocrinology
  • Author(s): Craig Jefferies, Fran Mouat, Rosalie Hornung
  • Owner: Paediatric Diabetes Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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