胰島素注射技術(shù)課件

1、《 2011版中國糖尿病藥物注射技術(shù)指南》介紹,,《2011版糖尿病藥物注射技術(shù)指南》目錄,,第一章：醫(yī)護(hù)人員的職責(zé)第二章：注射前的心理準(zhǔn)備第三章：注射治療的教育第四章：注射藥物第五章：注射裝置第六章：注射技術(shù)第七章：皮下脂肪增生與其他并發(fā)癥第八章：胰島素注射相關(guān)問題第九章：規(guī)范胰島素注射標(biāo)準(zhǔn)0步驟（胰島素筆）第十章：注射部位規(guī)范檢查3要素,,注射技術(shù)是糖尿病注射治療的三大關(guān)鍵因素之一,,注射技術(shù)：注射部位的選擇

2、注射部位的輪換注射部位的檢查和消毒選擇是否捏皮選擇進(jìn)針角度針頭留置時(shí)間注射器材的廢棄針頭重復(fù)使用的危害,關(guān)于注射部位選擇的推薦：,,注射餐時(shí)胰島素等短效胰島素，最好選擇腹部[1-7] A1希望胰島素的吸收速度較緩時(shí)，可以選擇臀部。臀部注射可以最大限度地降低注射至肌肉層的風(fēng)險(xiǎn)[8,9] A1給少兒患者注射中效或者長效胰島素時(shí)，最好選擇臀部或者大腿[10] A1,Frid A, Gunnarsson R, Gü

3、;ntner P, Linde B. Effects of accidental intramuskulær injection on insulin absorption in IDDM. Diabetes Care 1988; 11: 41-45. Frid A & B Linde (1993) Clinically important differences in insulin absorption from

4、 the abdomen in IDDM. Diabetes Research and Clinical Practice: Vol 21. No 2-3. 137-141. Frid A, Lindén B. Intraregional differences in the absorption of unmodified insulin from the abdominal wall. Diabet Med 1992;9

5、:236-9.Annersten M, Willman A. Performing subcutaneous injections: a literature review. Worldviews Evid Based Nurs 2005; 2: 122-30.Zehrer C, Hansen R, Bantle J. Reducing blood glucose variability by use of abdominal in

6、sulin injection sites. Diabetes Educ 1985;16:474-7.Henriksen JE, Djurhuus MS, Vaag A, Thye-Ronn P, Knudsen D. Hother-Nielsen O, et al. Impact of injection sites for soluble insulin on glycaemic control in type 1 (insuli

7、n-dependent) diabetic patients treated with a multiple insulin injection regimen. Diabetologia 1993;36:752-8.Sindelka G, Heinemann L, Berger M. Frenck W, Chantelau E. Effect of insulin concentration, subcutaneous fat th

8、ickness and skin temperature on subcutaneous insulin absorption in healthy subjects. Diabetologia 1994;37:377-40.Ahern J & ML Mazur (2001) Site rotation. Diabetes Forecast: Vol 54. No 4. 66-68. Wood L, Wilbourne J,

9、 Kyne-Grzebalski D, et al. administration of insulin by injection. Practice Diabetes International 2002; 19(Suppl 2-1): S1-S2.Smith CP, Sargent MA, Wilson BP, Price DA. Subcutaneous or intramuscular insulin injections.

10、Arch Dis Child 1991;66:879-82.,,,腹部以肚臍為中心，半徑2.5cm外的距離。越靠近腰部兩側(cè)（即使是肥胖患者），皮下組織的厚度也會(huì)變薄，因此容易導(dǎo)致肌肉注射。,根據(jù)可操作性/神經(jīng)血管距離/皮下組織狀況：適合注射的部位,,上臂上臂側(cè)面或者后側(cè)部位；皮下組織較厚，導(dǎo)致肌肉注射的概率較低。,,臀部臀部上端外側(cè)部位；即使是少兒患者還是身材偏瘦的患者，該部位的皮下組織仍然豐富，最大限度降低肌肉注射的危險(xiǎn)性。,大

11、腿大腿外側(cè)；皮下組織較厚，離大腿血管和坐骨神經(jīng)較遠(yuǎn)，針頭導(dǎo)致外傷的概率較低。,推薦的注射部位,,,,,注射部位還應(yīng)考慮胰島素在不同部位的吸收差異,不同注射部位胰島素吸收不同（分鐘）： —研究顯示，50%胰島素吸收所需要的時(shí)間腹部最快，手臂中等，大腿和臀部較慢1,1.The American Journal of Nursing, Vol. 98, No.7, pp. 55+57,關(guān)于注射部位輪換的推薦：,,一種已經(jīng)證實(shí)有效

12、的注射部位輪換方案：將注射部位分為四個(gè)等分區(qū)域（大腿或臀部可等分為兩個(gè)等分區(qū)域），每周使用一個(gè)等分區(qū)域并始終按順時(shí)針方向進(jìn)行輪換[1,2] A3在任何一個(gè)等分區(qū)域內(nèi)注射時(shí)，每次的注射點(diǎn)都應(yīng)間隔至少1cm，以避免重復(fù)的組織損傷 A3從注射治療一開始，就應(yīng)教會(huì)患者掌握一套簡單易行的注射部位輪換方案[3] A2每次患者就診時(shí)，醫(yī)護(hù)人員都應(yīng)檢查患者輪換方案的執(zhí)行情況 A3,Diagrams courtesy of Lourd

13、es Saez-de Ibarra and Ruth Gaspar, Diabetes Nurses and Specialist Educators from La Paz Hospital, Madrid, Spain.Lumber T. Tips for site rotation. When it comes to insulin. where you inject is just as important as how mu

14、ch and when. Diabetes Forecast 2004;57:68-70.Thatcher G. Insulin injections. The case against random rotation. Am J Nurs 1985; 85: 690-2.,注射部位的輪換：不同注射部位之間的輪換,午餐前,晚餐前,不同注射部位之間的輪換：“每天同一時(shí)間注射同一部位，每天不同時(shí)間注射不同部位”,早餐前,午餐前,晚餐前,

15、早餐前,睡前,一天注射三次：,一天注射四次：,注射部位的輪換：左右輪換,注射部位左右輪換：左邊一周，右邊一周，部位對(duì)稱輪換左邊一次，右邊一次，部位對(duì)稱輪換,注射部位的輪換：同一注射部位內(nèi)的輪換,同一注射部位內(nèi)的輪換：每次注射時(shí)離上次注射點(diǎn)之間距離至少間隔1cm,關(guān)于注射部位檢查和消毒的推薦：,,患者應(yīng)于注射前檢查注射部位[1,2] A3一旦發(fā)現(xiàn)注射部位若出現(xiàn)脂肪增生、炎癥或感染，應(yīng)更換注射部位[3-10] A2注射時(shí)，應(yīng)保

16、持注射部位的清潔[11] A2當(dāng)注射部位不潔凈，或者患者處于感染已于傳播的環(huán)境（如：醫(yī)院或療養(yǎng)院），注射前應(yīng)消毒注射部位[2,12,16-18] A3,Danish Nurses Organization. Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus, 2nd edition, Decem

17、ber 2006.Association for Diabetescare Professionals (EADV). Guideline: The Administration of Insulin with the Insulin Pen. September 2008.Johansson U. Amsberg S, Hannerz L, Wredling R, Adamson U, Arnqvist HJ & P Li

18、ns (2005) Impaired Absorption of insulin Aspart from Lipohypertrophic Injection Sites. Diabetes Care: Vol 28, No 8, 2025-2027. Ariza-Andraca CR, Altamirano-Bustamante E, Frati-Munari AC, Altamirano-Bustamante P, Graef-S

19、anchez A. Delayed insulin absorption due to subcutaneous edema. Arch Invest Med 1991;22:229-33.Saez-de Ibarra L, Gallego F. Factors related to lipohypertrophy in insulin-treated diabetic patients; role of educational in

20、tervention. Pract Diabetes Int 1998;15:9-11.Young RJ, Hannan WJ, Frier BM, Steel JM, Duncan LJ. Young RJ, Hannan WJ, Frier BM, Steel JM Diabetic lipohypertrophy delays insulin absorption. Diabetes Care 1984;7:479-80.Ch

21、owdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ 2003;327:383-4.Johansson UB. Impaired absorption of insulin aspart from lipohypertrophic injection sites. Diabetes Care 2005;

22、28:2025-7.Overland J, Molyneaux L, Tewari S., Fatouros R, Melville P, Foote D, et al. Lipohypertrophy: Does it matter in daily life? A study using a continuous glucose monitoring system. Diabetes Obes Metab2009;11:460-3

23、.Frid A, Linden B. Computed tomography of injection sites in patients with diabetes mellitus. Injection and Absorption of Insulin. Stockholm: Thesis, 1992.Gorman KC. Good hygiene versus alcohol swabs before insulin inj

24、ections (Letter). Diabetes Care 1993;16:960-1.Schuler G, Pelz K, Kerp L. Is the reuse of needles for insulin injection systems associated with a higher risk of cutaneous complications? Diabetes Res Clin Pract 1992;16:20

25、9-12.Workman B. Safe injection techniques. Nurs Stand 1999;13:47-53.Bain A, Graham A. How do patients dispose of syringes? Pract Diabetes Int 1998; 15: 19-21.Chantelau E, Schiffers T, Schutze J, Hansen B. Effect of pa

26、tient-selected intensive insulin therapy on quality of life. Patient Educ Couns 1997 Feb; 30(2): 167-73.Le Floch JP, Herbreteau C, Lange F, Perlemuter L. Biologic material in needles and cartridges after insulin injecti

27、on with a pen in diabetic patients. Diabetes Care 1998;21:1502-4.McCarthy JA, Covarrubias B, Sink P. Is the traditional alcohol wipe necessary before an insulin injection? Dogma disputed (Letter). Diabetes Care 1993;16:

28、402.Swahn A. Erfarenheter av 94000 osterilt givna insulininjektioner (Experiences from 94000 insulin injections given without skin swab). Sv Lakaresallskapets Handlingar Hygiea 1982;92:160(3O).,關(guān)于捏皮的推薦：,,所有患者在起始胰島素治療時(shí)就應(yīng)

29、掌握捏皮的正確方法 A3捏皮時(shí)力度不得過大導(dǎo)致皮膚發(fā)白或疼痛 A3不能用整只手來提捏皮膚，以避免將肌肉及皮下組織一同捏起最佳的注射步驟為：捏起皮膚形成皮褶 和皮褶表面呈90°角進(jìn)針后，緩慢推注胰島素 當(dāng)活塞完全推壓到底后，針頭在皮膚內(nèi)停留10秒鐘（采用胰島素筆注射） 拔出針頭 松開皮褶 A3,Clauson PG, Linde B. Absorption of rapid-acting insulin i

30、n obese and nonobese NIDDM patients. Diabetes Care 1995;18:986-91.Jamal R, Ross SA, Parkes JL, Pardo S, Ginsberg BH. Role of injection technique in use of insulin pens: prospective evaluation of a 31-gauge, 8mm insulin

31、pen needle. Endocr Pract 1999;5:245-50.Birkebaek N, Solvig J, Hansen B, Jorgensen C, Smedegaard J, Christiansen J. A 4mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in

32、 lean diabetic children and adults. Diabetes Care. 2008 Sep;22(9): e65. Gibney MA, Arce CH, Byron KJ, Hirsch LJ. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections

33、: Implications for needle length recommendations. Curr MedRes Opin 2010;26:1519-30.Hirsch L, Klaff L, Bailey T, Gibney M, Albanese J, Qu S, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm\

34、32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41.Kreugel G, Keers JC, Jongbloed A, Verweij-Gjaltema AH, Wolffenbuttel BHR. The influence of needle length on glycemic control and patient

35、preference in obese diabetic patients. Diabetes 2009;58:A117.Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size for SC insulin administration on metabolic control and patien

36、t acceptance. Europ Diab Nursing 2007;4:1-5.Van Doorn LG, Alberda A, Lytzen L. Insulin leakage and pain perception with NovoFine 6 mm and NovoFine 12 mm needle lengths in patients with type 1 or type 2 diabetes. Diabet

37、Med 1998;1:S50.Solvig J, Christiansen JS, Hansen B, Lytzen L. Localisation of potential insulin deposition in normal weight and obese patients with diabetes using Novofine 6 mm and Novofine 12 mm needles. Meeting Federa

38、tion European Nurses in Diabetes, Jerusalem, Israel, 2000 (Abstract).Schwartz S, Hassman D, Shelmet J, Sievers R, Weinstein R, Liang J, Lyness W. A multicenter, open-label, randomized, two-period crossover trial compar

39、ing glycemic control, satisfaction, and preference achieved with a 31 gauge x 6mm needle versus a 29 gauge x 12.7mm needle in obese patients with diabetes mellitus. Clin Ther 2004;26:1663-78.Frid A, Lindén B. Where

40、 do lean diabetics inject their insulin? A study using computed tomography. BMJ 1986; 292:1638.,關(guān)于進(jìn)針角度的推薦：,,使用較短（4mm或5mm）的針頭時(shí)，大部分患者無需捏起皮膚，并可90°進(jìn)針[1-9] A1使用較長（≥8mm）的針頭時(shí)，需要捏皮或45°角以降低肌肉注射風(fēng)險(xiǎn)[10,11] A1,針頭留置時(shí)間,藥液的

41、流速還與注射筆針頭的內(nèi)徑有關(guān)，注射筆針頭的內(nèi)徑越大，其藥液流速更快。目前，臨床上有采用 “薄壁”設(shè)計(jì)的針頭，在同等外徑的情況下內(nèi)徑更大，在降低注射引起不適感的同時(shí)保證胰島素的流速，更利于機(jī)體對(duì)胰島素的吸收,* Frid A. New injection recommendations for patients with diabetes.Diabetes & Metabolism 36 (2010) S3-S18,*,A3,

42、,,關(guān)于注射器材廢棄的推薦,,醫(yī)護(hù)人員和患者必須熟知國家有關(guān)醫(yī)療廢棄物處理的相關(guān)規(guī)定[1] A3所有醫(yī)護(hù)人員從注射治療的開始，就應(yīng)教會(huì)患者如何正確廢棄注射器材[2] A3醫(yī)護(hù)人員應(yīng)向患者說明可能發(fā)生于患者家人（如刺傷兒童）和服務(wù)人員（如垃圾收運(yùn)工和清潔工）的不良事件 A3任何情況下都不能將注射器材丟入公共垃圾桶或者垃圾場(chǎng) A3,Workman B. Safe injection techniques. Nurs Stand

43、 1999;13:47-53.Bain A, Graham A. How do patients dispose of syringes? Pract Diabetes Int 1998; 15: 19-21.,針頭重復(fù)使用有危害,,注射筆針頭應(yīng)一次性使用[1-7] A2,Chantelau E, Lee DM, Hemmann DM, Zipfel U, Echterhoff S. What makes insulin injec

44、tions painful? British Medical Journal 1991; 303: 26-27.Strauss K, De Gols H, Letondeur C, Matyjaszczyk M, Frid A. The second injection technique event (SITE), May 2000, Barcelona, Spain. Pract Diabetes Int 2002; 19: 17

45、-21.Danish Nurses Organization. Evidence-based Clinical Guidelines for Injection of Insulin for Adults with Diabetes Mellitus, 2nd edition, December 2006.Association for Diabetescare Professionals (EADV). Guideline: Th

46、e Administration of Insulin with the Insulin Pen. September 2008.Schuler G, Pelz K, Kerp L. Is the reuse of needles for insulin injection systems associated with a higher risk of cutaneous complications? Diabetes Res Cl

47、in Pract 1992;16:209-12.Maljaars C. Scherpe studie naalden voor eenmalig gebruik [Sharp study needles for single use]; Diabetes and Levery 2002;4:36-7.Torrance T. An unexpected hazard of insulin injection. Pract Diabet

48、es Int 2002;19:63.,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之一：影響注射劑量的準(zhǔn)確性,,,,,注射漏液,藥液流失,溫度降低時(shí)胰島素體積收縮導(dǎo)致空氣進(jìn)入筆芯，產(chǎn)生氣泡導(dǎo)致注射時(shí)間的延長產(chǎn)生漏液現(xiàn)象,溫度升高時(shí)胰島素體積膨脹而從筆芯泄漏浪費(fèi)胰島素改變混合胰島素的濃度,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之二：針頭斷裂或針管堵塞,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之三：疼痛增加,新針頭,多次使用后的針頭,（高倍電子顯微鏡下的針

49、頭形狀）,1.Bangstad H-J. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium.Pediatric Diabetes 2009:10(Suppl.12):82-99.2.Chantelau E, et al. What makes insulin injections painful? British Medical Journal 1

50、991;303: 26-27.,重復(fù)使用注射筆針頭具有多重風(fēng)險(xiǎn)之四：導(dǎo)致皮下脂肪增生和硬結(jié),下腹部皮下脂肪增生,上腹部皮下脂肪增生,腹部兩側(cè)皮下脂肪增生,Diabetes & Metabolism 36 (2010) S3-S18,注射過程多種情況引發(fā)疼痛增加,,,,,,,,,,,因注射疼痛導(dǎo)致的不愿進(jìn)行胰島素治療的比例達(dá)50.8%,溫度較低的胰島素誘發(fā)疼痛和不適感,消毒皮膚的酒精未干會(huì)從針眼帶到皮下引起疼痛,體毛根部附近神經(jīng)

51、末梢豐富,直徑較小、長度較短的注射筆針頭具有較好的安全性和耐受性,注射筆針頭重復(fù)使用后卷邊反刺，針頭表面潤滑層發(fā)生脫落，增加患者疼痛,低溫胰島素,消毒酒精未干,注射在體毛根部,針頭的直徑和長度,針頭重復(fù)使用,關(guān)于胰島素貯存的推薦：,,已開封的瓶裝胰島素或胰島素筆芯可在室溫下保存（保存期為開啟后一個(gè)月內(nèi)，且不能超過保質(zhì)期） A2未開封的瓶裝胰島素或胰島素筆芯應(yīng)儲(chǔ)藏在2℃~8℃的環(huán)境中，切勿冷凍 A2避免受熱或陽光照射，防止震

52、蕩 有必要培訓(xùn)患者，在抽取胰島素之前，先確認(rèn)是否存在結(jié)晶體、浮游物或者顏色變化等異?，F(xiàn)象,Perriello G, Torlone E, Di Santo S. Fanelli C. De Feo P. Santusanio F. Brunetti P, Bolli GB. Effect of storage temperature on pharmacokinetics and pharmadynamics of insulin m

53、ixtures injected subcutaneously in subjects with type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1988;31:811 -815.,關(guān)于胰島素混勻的推薦：,,在使用云霧狀胰島素（如NPH和預(yù)混胰島素）之前，應(yīng)將胰島素水平滾動(dòng)和上下翻動(dòng)各10次，使瓶內(nèi)藥液充分混勻，直至胰島素轉(zhuǎn)變成均勻的云霧狀白色液體[1-5] A2,

54、King L. Subcutaneous insulin injection technique. Nurs Stand. 2003;17:45-52.Jehle PM, Micheler C, Jehle DR, Breitig D, Boehm BO. Inadequate suspension of neutral protamine Hagendorn (NPH) insulin in pens. Lancet 1999;35

55、4:1604-7.Brown A, Steel JM, Duncan C, Duncun A, McBain AM. An assessment of the adequacy of suspension of insulin in pen injectors. Diabet Med 2004;21:604-608.Nath C. Mixing insulin: shake, rattle or roll? Nursing 2002

56、;32:10.Springs MH. Shake, rattle, or roll?.Challenging traditional insulin injection practices Am J Nurs 1999; 99: 14.,《2011版中國糖尿病藥物注射技術(shù)指南》注射藥物篇,超短效胰島素類似物注射的相關(guān)推薦：,,,超短效胰島素類似物的吸收速率不受注射部位的影響，可以在任何注射部位給藥[1-5] A1盡管有研究表明，超

57、短效胰島素類似物在脂肪組織和非運(yùn)動(dòng)狀態(tài)下肌肉組織的吸收率相似，但仍不應(yīng)肌肉注射此類藥物[2,3,6] A2目前，尚無關(guān)于超短效胰島素類似物在運(yùn)動(dòng)狀態(tài)肌肉中吸收率的研究，仍需要避免肌肉注射[2,3,6] A2,Mudaliar SR, Lindberg FA, Joyce M, Beerdsen P, Strange P, Lin A, Henry RR. Insulin aspart (B28 asp-insulin): a fa

58、st-acting analog of human insulin: absorption kinetics and action profile compared with regular human insulin in healthy nondiabetic subjects. Diabetes Care 1999;22:1501-6.Rave K, Heise T, Weyer C, Herrnberger J, Bender

59、 R, Hirschberger S, et al. Intramuscular versus subcutaneous injection of soluble and lispro insulin: comparison of metabolic effects in healthy subjects. Diabet Med 1998;15:747-51.Frid A. Fat thickness and insulin admi

60、nistration, what do we know? Infusystems Int 2006;5:17-9.Guerci B, Sauvanet JP. Subcutaneous insulin: pharmacokinetic variability and glycemic variability. Diabetes Metab 2005;31:4S7-4S24.Braakter EW, Woodworth JR, Bia

61、nchi R. Cermele B. Erkelens DW. Thijssen JH, et al. Injection site effects on the pharmacokinetics and glucodynamics of insulin lispro and regular insulin. Diabetes Care 1996;19:1437-40.Lippert WC, Wall EJ. Optimal intr

62、amuscular needle-penetration depth. Pediatrics 2008;122:e556-63.,短效胰島素注射的相關(guān)推薦：,,,胰島素在腹部的吸收速度較快，因此短效胰島素的注射部位首選腹部[1-6] A1,Frid A & B Linde (1993) Clinically important differences in insulin absorption from the abdomen

63、 in IDDM. Diabetes Research and Clinical Practice: Vol 21. No 2-3. 137-141. Frid A, Lindén B. Intraregional differences in the absorption of unmodified insulin from the abdominal wall. Diabet Med 1992;9:236-9.Anne

64、rsten M, Willman A. Performing subcutaneous injections: a literature review. Worldviews Evid Based Nurs 2005; 2: 122-30.Zehrer C, Hansen R, Bantle J. Reducing blood glucose variability by use of abdominal insulin inject

65、ion sites. Diabetes Educ 1985;16:474-7.Henriksen JE, Djurhuus MS, Vaag A, Thye-Ronn P, Knudsen D. Hother-Nielsen O, et al. Impact of injection sites for soluble insulin on glycaemic control in type 1 (insulin-dependent)

66、 diabetic patients treated with a multiple insulin injection regimen. Diabetologia 1993;36:752-8.Sindelka G, Heinemann L, Berger M. Frenck W, Chantelau E. Effect of insulin concentration, subcutaneous fat thickness and

67、skin temperature on subcutaneous insulin absorption in healthy subjects. Diabetologia 1994;37:377-40.,中效胰島素注射的相關(guān)推薦：,,,為避免因快速吸收引發(fā)的嚴(yán)重低血糖反應(yīng)，因此應(yīng)避免肌肉注射NPH [1,2] A1胰島素在大腿和臀部的吸收速度較慢，因此當(dāng)NPH作為基礎(chǔ)胰島素時(shí)，其首選注射部位是大腿和臀部 [3,4] A1,Frid

68、 A, Ostman J, Linde B. Hypoglycemia risk during exercise after intramuscular injection of insulin in thigh in IDDM. Diabetes Care 1990;13:473-7.Vaag A, Handberg A, Lauritzen M, Henriksen JE, Pedersen KD, Beck-Nielsen H.

69、 Variation in absorption of NPH insulin due to intramuscular injection. Diabetes Care 1990;13:74-6.Bantle JP, Neal L, Frankamp LM. Effects of the anatomical region used for insulin injections on glycaemia in type 1 diab

70、etes subjects. Diabetes Care 1993;16:1592-7.Henriksen JE, Vaag A, Hansen IR, Lauritzen M, Djurhuus MS, Beck-Nielsen H. Absorption of NPH (isophane) insulin in resting diabetic patients; evidence for subcutaneous injecti