Touch Site, sound?

Dr Pete Davies

To cover• 4 cases• Theme

• Injection sites• Learning outcomes

• Which sites to use?• Differences between sites• Injection site problems

• How they present• Potential solutions

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”

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?”

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?”

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

Suggested Sites for Injection

Which give fastest insulin absorption?

1st

2nd

3rd

4th

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!

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

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 (?)

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”

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?

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?

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!

Think injection sites, think lipos!• Variable glucose

values• Unexplained hypos or

hyperglycaemia• Look (stand up)• Feel• Avoid lipos!

• Rotation of sites• No needle reuse!