|Year : 2013 | Volume
| Issue : 2 | Page : 68-75
Insulin injection guidelines for peri-operative and critically ill patients
Sukhminder Jit Singh Bajwa1, Sanjay Kalra2, Manash Baruah3, Sukhwinder Kaur Bajwa4
1 Department of Anaesthesiology and Intensive Care Medicine, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
2 Department of Endocrinology, BRIDE, Karnal, Haryana, India
3 Department of Endocrinology, Excel Hospitals, Guwahati, Assam, India
4 Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
|Date of Web Publication||23-Jul-2013|
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab
Source of Support: None, Conflict of Interest: None
Anesthesiologists and intensivists are encountering increasing number of diabetic patients in daily clinical practice. Majority of such patients may require insulin injections for control of hyperglycemia. Advancements in diabetes management have led to usage of newer insulin injections ranging from human insulin and insulin analogs to glucagon-like peptides-1 analogs. The adequacy of glycemic control and successful outcome with such therapeutic interventions depends upon the adoption of correct injection techniques and procedures. Peri-operative and critically ill diabetic patients are highly prone to develop acute complications of diabetes if appropriate therapeutic strategies are not formulated and implemented. As such, the in-depth knowledge and awareness about various injection technique guidelines is essential from the patient care and healthcare provider's perspective in the operative and critical care settings. This description is an abridged version of the Forum for Injection Techniques, India: The first Indian recommendations for best practice in insulin injection technique and their significance in peri-operative period and critically ill patients in intensive care units (ICU). These insulin injection techniques are based on evidence-based recommendations and are meant to improve the management of diabetes by the attending staff and physicians in operative and critical care arenas.
Keywords: Critically ill, diabetes, injection sites, insulin, insulin analogues, needle length, peri-operative, skin folds
|How to cite this article:|
Bajwa SJ, Kalra S, Baruah M, Bajwa SK. Insulin injection guidelines for peri-operative and critically ill patients. J Sci Soc 2013;40:68-75
| Introduction|| |
India has become the new diabetic capital of the world, and the prevalence of diabetes is rising at an alarming rate.  Diabetes is common in both outdoor and indoor patients. As a result, an ever increasing number of diabetic patients are getting admitted in critical care units and many more are presenting for operative procedures.  This subset of patients needs adequate control of their hyperglycemic status for a better outcome. Invariably, in majority of such patients, insulin is the mainstay of treatment. , In spite of numerous advancements in diabetes management, majority of the staff members and physicians are not totally aware of the various injection techniques. If insulin injection technique is incorrect, there is a high risk of poor glycemic control. If needles are reused or used improperly, it can result in pain, , bleeding and bruising, chances of breaking off and lodging of the needle under the skin, risk of contamination, dosage inaccuracy, and lipohypertrophy.  Hence, injection technique is an important part of indoor management.
| The Need for Guidelines|| |
Besides managing operation theaters (OT) as peri-operative physicians, anesthesiologists are managing intensive care units (ICUs) in majority of health centers and institutions across the country. Diabetes control with insulin injections has become an essential part of their management strategies in these arenas. Injection technique is critical to the therapeutic success of insulin and is highly operator-dependent. The factors influencing injection technique are shown in [Table 1]. ,
Anesthesiologist's, intensivists, and nursing staff's lack of in-depth knowledge, time constraints, and scarcity of guidelines adapted to local needs could be possible reasons contributing to such factors.  Guidelines are needed to ensure that the modifiable factors listed in table are optimized and that correct prescription of insulin technique is provided in ICUs and also during peri-operative period.
However, Indian guidelines are available that, if adopted uniformly throughout the country, can help in better management of peri-operative and critically ill population. This tutorial highlights relevant points from an indoor/OT perspective. This tutorial is an abridged version of the Forum for Injection Techniques, India: The first Indian recommendations for best practice in insulin injection technique. These exhaustive guidelines have been formulated by a national group of experts, based on published evidence, and have been reviewed by an international panel of referees.  All recommendations have been graded for strength of evidence and weight of recommendation, as per the method devised by Frid et al.  This includes an ABC scale for the strength of recommendation and 123 scales for scientific support: A: Strongly recommended, B: Recommended, C: Unresolved issue; 1: At least one randomized controlled study, 2: At least one nonrandomized (or non-controlled or epidemiologic study), 3: Consensus expert opinion based on extensive patient experience [Figure 1]. 
Much of this tutorial is adapted from the original guidelines, but only covering and elaborating on the critical care and operative diabetic patients. Such guidelines are required for every specialty and not just Endocrinology and Intensive Care patients. Few of the ideas have been adopted from the original article with due permission from the authors so as to make this tutorial immensely useful for the intensive care and operative patients. The present tutorial has been drafted by a core group consisting of one intensivist, two endocrinologists, and one obstetrician.
Clinical evaluation of patients
A thorough patient assessment should precede therapy initiation as majority of patients are paralyzed and sedated in ICU and operative patients can exhibit a variable anxiety during pre-op and post-period.  Dexterity problems, injection anxiety, misconceptions, denial of the benefits of timely injections, vision and hearing impairments, as well as other barriers can be concerning issues and should be checked for (B3). ,
Appropriate time of counseling
Pre-anesthetic evaluation is the ideal period to design the therapeutic strategies in the operative population. It is essential in pre-op and post-op period to reduce fear and discomfort.
Precautions during storage of insulin injections
Manufacturer's guidelines should be followed with regards to storage (A1). When not in use, insulin pens and vials should be stored at 4-8°C in a refrigerator in the lower shelf and, if insulin is frozen, it should be discarded (A1).  During active usage, insulin should be stored at room temperature (15-25°C) in a cool and dark place and should not be used beyond 30 days after the first use (A1).  Extremes of temperature should be strictly avoided as the room temperature may cross 40°C in some parts of India during summers, particularly in the northern part of the country (A3). If the vial is kept in a refrigerator as is the common practice in ICU and OT's, it should be taken out and kept at room temperature for at least 30 min before injecting.  Insulin should not be used beyond expiry period (A1). Needles should not be attached to the pens during storage.  The non-availability of continuous electricity or refrigerator facilities is a common scenario in peripheral health centers, and this barrier can be overcome partially by keeping the vial in a water-filled earthen pitcher after labeling them with water-proof stickers (B3).
Judicious selection of insulin and its usage
The dose and the expiry date must be verified prior to injection by the intensivist and staff nurse as there can be significant variations in expiry dates of different types of insulin pens and vials (A1). The need for selection of appropriate injection device, needle length, and gauge and type of insulin syringe is to be emphasized (A1).  Insulin vial should be examined carefully for evidence of any changes such as clumping, frosting, altered color, or clarity (A1). To ensure proper absorption of injected insulin and for the maintenance of appropriate concentrations of the remaining insulin, re-suspension of cloudy insulin is important and should be gently rolled and/or tipped (not shaken) for 20 cycles until the solution becomes milky white (A2). 
Compatibility of insulin syringe and vial
Injecting the right insulin strength with the right insulin syringe is highly important.  Both 40 U/mL and 100 U/mL insulin types are available in India. The main differentiating point between syringes include an orange cover and black scale markings denoting two units each on U100 insulin syringe, while U40 syringes have a red cover and red scale markings denoting one unit each.  It is important to use U100 vials with U100 insulin syringes and U40 vials with U40 insulin syringes only at the time of initiating a patient on insulin.
Available sizes of the needles
Three sizes of 6, 8, and 12.7 mm are available in needle lengths with syringes, while insulin syringe gauges are available in 31, 30, and 29 gauges, respectively. For insulin syringe with 31 gauge, both 6 and 8 mm needle length sizes are available. 
Selection of appropriate device
Different models of insulin pens with self-contained cartridges are available, including reusable (cartridge can be reloaded) and disposable pens (discarded once emptied).  Following facts have to be considered while selecting a pen: 
Sizes of pen needles
- Appropriate selection of insulin type and pen
- The dosage of insulin in each pen
- Quantity of dosage that can be injected at maximum
- Titration of the dose of insulin
- The marking indicators of dose of insulin for appropriate dosage
- The make and quality of the pen devices
- Numerical indicators on pen devices
- Physical force and dexterity aspects related to manual usage of pen devices
- Suitable rectification measures to adjust the wrong dose into the pen.
Pen needles of 32, 31, and 30 gauges are available in 4, 5, 6, and 8 mm sizes. The length of shorter needles is enough to pass into the fatty layer through the skin but is not that long to reach the muscle tissue. 
How long the needle length should be?
Length of the needle for subcutaneous injection is determined by multiple factors, like physical, pharmacological, and psychological, with an aim to deliver the medication directly into the subcutaneous tissue without any discomfort or leakage. Safety, efficacy, and tolerability of shorter needles (4-5 mm) as compared to longer ones have been reported, especially in obese patients (A1). , Furthermore, no increased incidence has been observed until date with usage of shorter needles with regards to leakage of insulin, pain, lipohypertrophy, worsened diabetes management, or other complications. , Lifting of skin fold is not necessary in adults particularly for 4-mm needles (A1). Injection should be administered at an angle of 90° to the skin surface with shorter needles but skin fold is required in case of injection into limbs or slim abdomen (A1). Patients already being treated with needles of ≥8 mm size, should be administered insulin with shorter needle or lift a skin fold and/or injected at 45° in order to avoid injecting into muscle.
Appropriate selection of the injection site
Routinely, insulin is injected subcutaneously but intravenous (IV), IV infusion, or intramuscular (IM) routes are preferred during ketoacidosis or stressful conditions as are commonly encountered during medical and surgical emergencies and in critically ill patients. Moreover, majority of times, critically ill patients and occasionally peri-operative patients have compromised hemodynamic variables. As such, the peripheral perfusion and absorption characteristics are grossly altered resulting in the erratic absorption of insulin from the subcutaneous sites.  The various injection sites include:
Abdomen is the most common injection site.  The injections at the abdominal site are usually administered below a horizontal line drawn 2.5 cm above the umbilicus and lateral to vertical lines drawn 5 cm away from the umbilicus. However, it becomes extremely difficult if the patient has undergone abdominal surgery.
The site includes the posterior mid-third of the arm between shoulder and elbow joint.
The preferred site is in the anterior and outer aspect of the mid-third of the thigh between the anterior superior iliac spine and knee joint.
Choose the upper outer quadrant of the buttock. Place your index finger on the iliac crest and make a right angle between the index finger and your thumb to locate the upper outer quadrant. The order of the rates of absorption at these sites is abdomen > arm > thigh > buttock.  Presence of a layer of fat and not many nerves at these regions makes injections easier.
Pre-injection cleansing and sterilization
The cleansing procedure is an important determinant in preventing healthcare-associated infections (A3). The site of injection should be meticulously and socially clean (one should be willing to touch the skin) before the injection is given. Alcohol swabs or cotton balls dipped in plain clean water can be used for this purpose (A2). Start by cleaning your hands with soap and water, followed by cleansing the injection site in the middle and moving outwards in a circular motion. Make sure that the skin is dry before injection.  It is recommended not to use soap-based detergents (A3).
Essentials of subcutaneous injections
Skin folds are used when the presumptive distance from the skin surface to the muscle is less than the needle length, especially in the lean and thin patients with normal body mass index (BMI). A proper skin fold is made with the help of thumb and index finger (possibly with the addition of the middle finger) (A1).  There can be risk of IM injections if the skin is lifted using the whole hand as the muscle can also get lifted.  Deeper injections can be prevented by using a skin fold as it avoids soft tissue compression (B3).  Skin blanching or pain should be prevented by lifting the skin fold gently and not squeezing so tightly (A3). The procedural sequence of skin fold lifting can be summarized as (A3): Make a lifted skin fold and insert needle into the skin at 90° angle → Administer insulin → Leave the needle in the subcutaneous tissue for 10 sec after the plunger has been fully depressed → Withdraw needle from the skin → Release skin fold.
The decision to lift the skin fold for a given length of needle at injection site must be examined individually (A3) and recommendations should be provided to the patient during discharge in writing along with teaching the correct technique of lifting the skin fold from the onset of injectable therapy (A3).
Keeping injection sites healthy
The injection site should be rotated systematically so as to maintain healthy injection site, reducing the risk of lipohypertrophy and optimizing insulin absorption. A commonly used scheme is to divide the injection site into quadrants (abdomen) or halves (thighs, buttocks, and arms), which can be used on a weekly basis (A3).  Injections within any quadrant or half should be spaced at least 1 or 2 cm apart to avoid repeat-tissue trauma as consistent rotation safeguards the tissue (A3). 
| Injection Technique|| |
Usage of syringe and the vial
Syringes are commonly used as a primary device for injection purposes throughout the globe including India. Insulin vial is kept at room temperature for 30 min after taking out from the refrigerator and the expiry date or any damage to the vial should be duly checked before injection (A1).
Insulin should be made to mix uniformly by rolling the vial between palms and inspect for any changes, i.e., clumping, frosting, or precipitation if using cloudy insulin (A3).
An alcohol swab should be used to clean the top of the vial and an amount of air equal to the dose of insulin needed has to be drawn up into the syringe and injected into the vial to avoid creating vacuum (A3). Plunger should be pulled gently in inverted position to the number of unites desired and any air bubbles should be checked in upright position. Extra units of insulin should be drawn if air bubbles are seen and re-inject the bubbles into the vial by pushing the plunger back to the desired dose marking. Slowly push insulin back into the vial and again pull the plunger very slowly to the required number of units if air bubbles still persist (A3). The procedure is repeated till no air bubbles are seen. Turn the syringe and the vial back over once the required dose is drawn into the syringe and carefully removes the needle straight out of the bottle holding the syringe by the barrel. 
Clean the injection site area with an alcohol swab and start injecting in the middle of the area and then moving outward in a circular motion clean the whole area. Alcohol should be completely dry before injection so as to reduce any stinging sensation.
The needle goes all the way into the skin if a skin fold is grasped between the thumb and index finger and the needle is pushed at the desired angle based on the needle length and other parameters and thereafter pushing the plunger to deliver the insulin. A count till 10 before pulling the needle out is quite helpful and one may have to count longer in case of heavier doses. An alcohol swab is pressed over the injected site after releasing the pinch and one should not massage the area (A3). Ideally, a needle should never be re-used (A2) and should be disposed after use (A1). ,
Appropriate method of using the pen
For injecting insulin, the method of device preparation remains same for both the reusable and prefilled disposable pens. Rolling the pen is essential for re-suspension of premixed or NPH insulin. A new pen needle is screwed after cleaning the edge of the pen and pen should be primed with two units of insulin as the first step (A3). This is then discarded and the actual dose has to be dialed in. The device's display window shows the appropriate dose dialed in and can be heard as an audible click in many pens.  Insert the needle, push the injection button, and count slowly to 10 before withdrawing the needle in order to get the full dose and prevent leakage of the medication (A1). Counting past 10 may be necessary for higher doses. Remove the pen needle from the pen and dispose safely (A2).  The injection site should not be massaged (A3). Needles should be detached from the pen and should be disposed off immediately after the injection to prevent entry of air into the cartridge as well as to prevent leakage of medication (A2). Needle breakage in the skin, clogging of the needle, inaccurate dosing, and indirect costs can be reduced by use of new needles every time (A3). Sharing of pen devices and cartridges is to be avoided as it increases the risk of cross-contamination, particularly in the critical care units (A2).
Ideal gap between mealtime and injection
The nutritional aspects and simultaneous diabetes management in ICU is always challenging. The staff engaged in intensive care must be aware that the time gap between injection and meal is critical for the control of glycemic levels and for insulin action (A1).  Regular insulin should ideally be administered 30 min before meal as it has a delayed onset,  whereas rapid-acting insulin (lispro, aspart, and glulisine) can be injected before or immediately after a meal.  Changing injection-meal time is a strategy used to accentuate or reduce the efficacy of insulin and should be supervised by an intensivist. NPH, detemir, and glargine can be given at the same time every day, without relation to meals. For ultra-long-acting insulin (degludec), the inter-injection period can vary between 8 and 40 h and no specific injection to meal time gap is recommended.
| Characteristics of Pre-Mixed Insulin|| |
In general, premixed insulin preparations are available in a wide range, which can be immensely helpful in critical care units as type of patients are admitted with diverse pathologies and clinical entities. However, at times, one has to mix rapid-/short- and intermediate-acting insulin, depending upon the degree of glycemic status. Patients that are well controlled on a particular mixed-insulin regimen pre-operatively should be administered the same standard insulin doses during the post-operative period as soon as feasible (A1). Regular insulin and rapid-acting analog can be mixed with NPH in the same syringe in appropriate ratio (A2).  Glargine and detemir must not be mixed with any other insulin (A2). If suitable premixed insulin is available, it should be used (A1).
| Avoiding Complications|| |
Minimizing and eliminating pain
Unless the needle touches free nerve endings, pain due to insulin injection is an infrequent occurrence. In ICU patients, pain on insulin injection may not pose much problems, but it can be a concern in post-operative patients. Some patients exhibit needle phobia or increased sensitivity to pain due to previous unwanted experiences. Pain can be minimized or avoided if good injection practices are followed. ,, Some methods of minimizing pain include the following:
Prevention of lipohypertrophy
- Use of new needles (clean, sharp, dry, and of the right length) for each injection (A2)
- Use short needles (4, 5, 6 mm) with fine gauge (A2)
- Insert the needle at 90° to the skin (A2)
- If large doses, consider splitting the dose, especially in critical care units (A2)
- Injections in use to be kept at room temperature (A2)
- Inject slowly and ensure that the thumb button/plunger is completely depressed (B2)
- Skin should be dry before injecting, if injection site cleaned with alcohol swabs (B2)
- Avoid injecting in the hair roots (B2).
Lipohypertrophy manifests as a localized lesion at the injection site, and this can be a menace in diabetic patients having a prolonged ICU stay. Reuse of needles, which is a common practice in majority of health set-ups in India, can result in lipohypertrophy. Non-rotation of injection sites may also result in localized lipohypertrophy or degeneration and atrophy. Injecting into lipohypertrophy sites may result in significantly unpredictable and delayed absorption, which can lead to hyperglycemia and/or hypoglycemia.  Some important methods to prevent lipohypertrophy include the following:
Avoidance of bleeding and bruising
- Changing of injection site every week (A2)
- Until the localized area of previously injected site returns to the normal, do not inject into the lipohypertrophic tissue (A2)
- Doses have to be decreased generally while switching injections from lipohypertrophic tissue to normal. This change of dose should be guided by frequent blood-glucose monitoring (A2)
- Avoid reuse of injection needles (A2)
- Use good quality insulin or insulin analogs from reputed manufacturers (A3).
Insulin injection needles can occasionally cause bleeding or bruising. A lesser frequency of bleeding/bruising has been reported by clinical studies with usage of shorter needles. The injection technique should be reviewed and sites with bleeding/bruising to be avoided until fully recovered if bruising occurs persistently (A2). Post-operative and conscious patients in ICU should be assured that bleeding/bruising have no adverse clinical consequences (A2).
Trypanophobia (Belonephobia) and psychological counseling
The fear of self-injection of insulin after discharge can compromise glycemic control and emotional well-being. Similarly, the fear of pricking can be a source of distress and may seriously hamper self-management. A brief trial of insulin therapy should be initiated in the hospital before discharge and the intensivist should try to re-establish the patient's sense of personal control and identify and acknowledge the patients personal obstacles (A2). Psychological counseling should be considered for patients who are really needle-phobic both pre and post-operatively (A2).
Prevention of needle-stick injuries
Needle stick injuries are common to intensivists and staff while recapping the needle. In intensive care settings, professionals should be advised against recapping a used insulin syringe (A2). Safety needles effectively protect health professionals against contaminated needle-stick injuries (B1). Education and training is needed to ensure that safety practices are followed (B3).  Viral markers should be done for all the patients in the ICU to ensure a safe therapeutic atmosphere for the working professionals. All needle stick injuries should be taken seriously and should be dealt immediately for prophylaxis, management, and reporting.
Maintaining needle/syringe hygiene
The United States Food and Drug Administration (USFDA) recommend injection needles for a single use only. However, such practices are rarely followed in developing nations like India due to economic constraints.
The thin tip of the needles become damaged and can get bent on reuse, and the silicone lubricant coating of the needles is also lost (A2). This results in a more painful injection with bleeding and bruising (A2). Breaking off and lodging of the needles under the skin can also occur on repeated usage. Furthermore, there is a higher chance for insulin to get deposited within the needle with reuse, making it harder to press on the plunger and deliver proper insulin doses (A2).
The risk of contamination and infection increases with reuse of needles as well (A2). Needle reuse also results in increased risk of lipodystrophy (A2). Manufacturers recommend removing insulin pen needles immediately after use. Practice of cleaning the needle with alcohol prior to use should be discouraged as it can remove the silicone lubricant and results in a more painful injection. Healthcare professionals and staff should be made aware regarding the potential adversities of needle reuse and encourage appropriate needle/syringe use (A2).
| Disposal of Injection Devices|| |
The use of puncture proof box or safety box to collect used needles or syringes properly labeled as biohazard has been recommended in the guidelines developed by NACO. The filled boxes should be disposed of at drop-in centers, where disinfection and disposal of sharps is carried out (A2).  Needle clipping devices that remove insulin syringe needles and pen needles safely and easily can be used. Awareness of local regulations should be created among patients and healthcare providers (A3).
| Missing/Changing Injections|| |
Nursing staff should be counseled about the negative effects of missing injections, especially in patients with uncontrolled diabetes. In case of extreme scarcity of insulin, especially in the peripheral health centers, insulin rationing may have to be resorted to (A2). However, ICU and OT staff should be made aware of the harmful effects of such a practice. If there is a change in the insulin during post-op period, then the relatives and the patient should be fully informed as to why there has been a change and the potential need for additional glucose monitoring (A3).
There should be no interchange made in the insulin species, type, or brand without any new indication (A2). If a patient is admitted in the emergency or ICU and there is no awareness of which insulin the patient uses, human insulin has to be administered until further information is available (B3).
| Immuno-Compromised Individuals|| |
One of the common problems in pre-operative patients includes insulin resistance, which can also be a major concern in immuno-compromised intensive care patients, including those with human immunodeficiency virus (HIV) and hepatitis B and C.  Hence, early initiation of insulin therapy should be considered in such patients as it improves therapeutic outcomes.  Injections and finger sticks administered to immune-compromised patients have a high risk of blood exposure to the staff and intensivists.  Hence, never reuse/recap used needles, syringes, or lancets (A2).
| Indoor Patients/Nursing Home Patients|| |
The sharing of cold chain facilities in ICU and recovery wards such as refrigerators mandates labeling of the individual insulin vials and pens with the names and registration number of the patients using indelible ink (A2). Limited availability of resources also acts as an important barrier in insulin therapy. A financial barrier exists for diabetic patients who lack insurance, especially after getting discharged from the hospital.  For majority of healthcare providers in India, a key issue is the lack of endocrinologists and trained diabetic educators. The solutions below have mainly focused on increasing availability and lowering cost. 
- Using pens instead of syringes offers cost benefits due to improved treatment adherence and reduced healthcare utilization, especially in patients with prolonged ICU stay (B3)
- Provision of enhanced training on insulin injection skills to nurses, especially in the critical care units, and stringent titration protocols to be followed by nonmedical practitioners (A2) 
- Funds for hiring a diabetes educator and for setting up an education Programme (B1) in respective institutes and health centers
- For successful achievement of best injection practices, it is desirable to choose a team leader from the hospital staff itself who can impart training to the rest of the staff members.
| Ongoing Patient and Physician Education|| |
Information may not be retained by patients if it is given in times of anxiety such as pre and post-op period. It is essential to revisit all aspects of injection technique regularly.  This can be easily achieved during discharge of the patients from ICU, recovery rooms, and wards of the hospital. The circumstances are highly conducive and the mental state of the patient is highly submissive and they are invariably ready to take any suggestions during discharge. Enough time has to be provided to meet individual learning needs and the learning style of each individual has to be assessed beforehand. Information given in short sessions and regularly reinforced is more easily retained. Education content and the style of teaching have to be adjusted to individual needs.  A quality management process should be put in place and ensured that the correct injection technique has been practiced regularly by the staff and patients and is also documented in the record (A3). 
| Conclusion|| |
The First Indian Insulin Injection Technique Guidelines developed have focused on the injection process. Recommendations have been provided on various topics such as needle length selection, injection process (use of skin folds and injection angle), choice of body sites, lipohypertrophy, disposal of injecting material, and patient and physician education. These recommendations guide the healthcare provider, staff, and patient toward using shorter needles and safe disposal practices. Such recommendations, if practiced religiously in all operation theaters and ICU, can bring down the morbidity and mortality drastically associated with wrong insulin injection practices. This helps in reducing the risk of contamination, increase the consistent delivery of insulin into the subcutaneous space, and achieve optimal glycemic control.
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|[Pubmed] | [DOI]|