Subcutaneous or intramuscular insulin injections.

Abstract

To find out whether diabetic children may inject their insulin intramuscularly rather than subcutaneously, a random sample of 32 patients aged 4-3-17*9 (median 11.3) years was studied. Distance from skin to muscle fascia was measured by ultrasonography at standard injection sites on the outer arm, anterior and lateral thigh, abdomen, buttock, and calf. Distances were greater in girls (n= 15) than in boys (n= 17). Whereas in most boys the distances were less than the length of the needle (12-5 mm) at all sites except the buttock, in most girls, the distances were greater than 12-5 mm except over the calf. Over the fascial plane just lateral to the rectus muscle the distance from skin to peritoneum was less than 12-5 mm in 14 of the 17 boys and one of the 15 girls. Twenty For many years diabetic patients were advised to inject insulin into a skinfold, inserting the needle at an angle of 45°. Since the introduction of disposable plastic insulin syringes, which have much shorter (12-5 mm) needles, the recommended injection technique was altered. Most patients were advised to insert the needle at an angle of about 90°to nearly its whole length. To obtain a painless injection they were advised to stretch the skin before injecting, although thin patients were sometimes advised to raise a skinfold. In this way it was felt that insulin would consistently be deposited into subcutaneous adipose tissue and the risk of penetrating muscle was considered to be negligible.Frid and Linden were the first to cast doubt on the latter assumption when they showed by computed tomography that the depth of subcutaneous fat over many sites in the thigh and abdomen was often less than 10 mm in lean adult patients.2 Their results were confirmed in a more recent report which showed by ultrasonography that the depth of subcutaneous fat over the deltoid muscle and the abdomen was less than 10 mm in 11 of 13 adult male volunteers.3 These results suggest that adults who use the perpendicular injection technique may sometimes deposit insulin into muscle rather than fat.Intermittent intramuscular administration of insulin could lead to variations in glycaemic control if the rate of absorption from muscle differed from that of the subcutaneous tissue. Recent studies in which modern imaging techniques were used to ensure accurate placement of insulin, have shown that insulin tends to be absorbed much faster from muscle than from subcutaneous adipose tissue.3'4To assess the risk of inadvertent intramuscular injection of insulin in children of different ages and stages of development, we measured the distance from skin to muscle fascia at recommended injection sites by high resolution real time ultrasonography.Patients and methods A random sample of 32 diabetic children was recruited from the paediatric diabetic clinic at this hospital. All the subjects were white, except one who was Afro-Caribbean. Details of the insulin injection technique, sites used, and whether parent or child gave the insulin were recorded for each child. Injection si...

Effects of Age, Gender, BMI, and Anatomical Site on Skin Thickness in Children and Adults with Diabetes

“…Similar to our results, Hofman et al showed no gender differences in the subcutis prior to puberty [2], but pubertal girls had thicker subcutis than boys [1], [2], [7]. Our findings also confirm the existing evidence that adult men have thinner subcutis and thicker dermis than women [8]–[17].…”

Pediatric Insulin Injection Technique: A Multi-Country Survey and Clinical Practice Implications

“…In 1991, when needles with a length of 12.7 mm were commonly used, Smith et al [11] used ultrasound to measure the distance from the skin to the muscle fascia in 32 boys and girls. These researchers found that the subcutaneous layers were much thinner than anticipated and concluded that ‘most boys and some girls who use the perpendicular injection technique may often inject insulin into muscle, and perhaps on occasions into the peritoneal cavity’.…”

Cutis/subcutis thickness at insulin injection sites and localization of simulated insulin boluses in children with Type 1 diabetes mellitus: need for individualization of injection technique?

“…These findings confirm earlier observations in diabetic and non-diabetic children. 6,16 At all measuring sites except medially on the buttock, several children had a distance from cutis to the muscle fascia less than the length of the shortest needle (8 mm). Compression of the skin (such as often occurs during an injection) radically reduced the thickness of cutis/subcutis, and even more children had a distance from cutis to muscle fascia of less than 8 mm under these circumstances.…”

“…4 Great variations in cutis/subcutis thickness at insulin injection sites have been demonstrated in adults 5 and in one study in children. 6 As many children are lean, and as they use insulin injection needles of the same length Sponsors: Novo Nordisk A/S, Denmark * Correspondence to: Dr Niels Birkebaek, Skovgårdsparken 44, DK-7080 Børkop, Denmark as adults (8,12 or 16 mm), they might be at risk of accidental, inappropriate, intramuscular insulin injection even when injecting at a 45°angle to the skin. Indeed, in a recent study of insulin injection in children, 30.5 % of children using a 12 or 16 mm needle were found to have injected intramuscularly.…”