May the z-tracking technique to minimize or avoid the pain of insulin injection be an alternative to the 10-second waiting technique?

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https://doi.org/10.1177/1932296817750405 Journal of Diabetes Science and Technology 2018, Vol. 12(3) 731 –732

Improving best practices in insulin injection technique is a main concern for both patients and the health care team.1_If

the injection technique is incorrect, then it can result in pain, insulin leakage, bleeding, inflammation, bruising, lipoatro-phy, and lipohypertrophy.2_{Pain is perhaps the most common}

adverse event associated with insulin use.3,4_{Pain on injection}

may be caused by inaccurate injection technique; however, information is lacking concerning how to minimize the injec-tion pain. Thus, the prompt mitigainjec-tion of anxiety about and fear of pain and, if possible, mitigation of the actual pain are of great importance to the health care team. In seeking to understand injection pain, patient self-reports become very important.3_{In a study by Kalra and colleagues}2_{just over half}

of Indian injectors reported having pain on injection. In a study by Zijlstra and colleagues4_{large volume and thigh}

injections were rated as being more painful, but injection speed did not influence pain sensation.

Application of best practice technique in insulin delivery is an important aspect of a successful insulin therapy.1_Recent

studies have indicated that leakage of liquid from the skin did not occur when administering subcutaneous tissue lateral to vertical lines drawn 5 cm away from the umbilicus with 30 units/mL in distilled water with shorter 4 mm prefilled pens needles by the Z technique. Studies have included both healthy volunteers and persons with diabetes, and their results have been consistent. This suggests that Z-tracking (the cutaneous tissues are pulled 2 cm caudad before insert-ing a 90° needle into the subcutaneous tissue after the button has been fully depressed, and then the needle is removed from the skin) may be an alternative to the 10-second hold in time (a 90° needle is directly inserted into the subcutaneous tissue and patients wait at least 10 seconds after the injection before the needle is withdrawn from the skin).5,6

It was felt necessary to conduct this study to compare the effects on pain sensation of the 10-second waiting technique and the Z-track technique, which is claimed to be helpful in this regard.5,6_{Perceived injection pain sensation was assessed}

using a 10-cm visual analog scale (VAS) (0 cm/no pain, 10

cm/extreme pain). The study conducted by Demirhan et al5

found that the healthy volunteers group using the Z tech-nique had a mean perceived injection pain sensation with VAS was 0.3 ± 0.8 cm, whereas with the 10-second waiting technique these values were 0.9 ± 1.8 cm, respectively. In their other works,6_{these authors found that in the persons}

with diabetes group with the Z technique mean perceived injection pain sensation with VAS was 0.4 ± 1.1 cm, whereas with the standard 10- seconds waiting group these values were 1.5 ± 1.8 cm, respectively. When compared to the 10 seconds waiting technique, the Z-tract insertion technique demonstrated a significantly lower mean perceived injection pain sensation with VAS from the skin with subcutaneous injections. These results suggest that the Z-tract insertion technique plays an important role in reducing injection pain. Painless (as opposed to painful) subcutaneous insulin injec-tions may increase treatment adherence. The results of this study may be of value for guiding patients to use the appro-priate injection technique to reduce their injection pain.

To prevent pain sensation or minimize pain, an insulin injection should be performed with Z-tract technique inser-tion of a thin needle in the cutaneous tissues, rather than with a 10-second waiting technique.

Abbreviation

VAS, visual analog scale.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

750405DSTXXX10.1177/1932296817750405Journal of Diabetes Science and TechnologyAltun

letter2018

1_{Faculty of Health Sciences, Department of Fundamentals in Nursing,}

İstinye University, Cevizlibağ, İstanbul, Turkey

Corresponding Author:

İnsaf Altun, RN, MSN, PhD, Faculty of Health Sciences, Department of Fundamentals in Nursing, İstinye University, Cevizlibağ, İstanbul, 34010, Turkey

Email: ialtun@istinye.edu.tr

May the Z-Tracking Technique to

Minimize or Avoid the Pain of Insulin

Injection Be an Alternative to the

10-Second Waiting Technique?

İnsaf Altun, RN, MSN, PhD

1

Keywords

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732 Journal of Diabetes Science and Technology 12(3)

Funding

The author received no financial support for the research, author-ship, and/or publication of this article.

References

1. Spollett G, Edelman SV, Mehner P, Walter C, Penfornis A. Improvement of insulin injection technique: examina-tion of current issues and recommendaexamina-tions. Diabetes Educ. 2016;42(4):379-394.

2. Kalra S, Mithal A, Sahay R, et al. Indian injection technique study: injecting complications, education, and the health care professional. Diabetes Ther. 2017;8(3):659-672.

3. Tandon N, Kalra S, Balhara YPS, et al. Forum for injection tech-nique and therapy expert recommendations, India: the Indian

recommendations for best practice in insulin injection technique, 2017. Indian J Endocrinol Metab. 2017;21(4):600-617.

4. Zijlstra E, Jahnke J, Fischer A, Kapitza C, Forst T. Impact of injection speed, volume, and site on pain sensation [pub-lished online ahead of print October 1, 2017]. J Diabetes Sci

Technol.

5. Demirhan Y, Altun İ, Peker A, Çetinarslan B. Comparison of the “90° technique” and the “Z-track technique” in subcu-taneous injections. Paper presented at: 12th Symposium on Diabetes; Trabzon, Turkey, 6-9 October 2016.

6. Demirhan Y, Altun İ, Peker A, Çetinarslan B. Comparison of the “10 seconds waiting” and the “Z-track” injection tech-niques in subcutaneous insulin administration. Paper presented at: 53rd National Diabetes Congress, 19th National Diabetes Nursing Symposium; Girne, Cyprus, 19-23 April 2017.