Objectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES. Historical Perspective. Insulin Pumps in Pregnancy. Insulin Pumps in the US

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1 Objectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES Jo M. Kendrick, APN BC, CDE Describe indications and contraindications for insulin pump use in hospitalized patients Differentiate between basal and bolus insulin as it applies to insulin pumps Discuss management with insulin pump interruption and when alternate insulin should be administered Historical Perspective I have no potential conflicts of interest and will not discuss off label drug or device use in this presentation. Insulin pumps first introduced in 1963 Blue Brick developed in 1970s d/c due to lack of accuracy 1980s and 1990s smaller and more user friendly pump designed Insulin Pumps in the US Type 1 diabetes accounts for 10% (3 million) of the 23 million individuals with diabetes 400,000 to 1.2 million (25 40%) type 1 individuals use insulin pumps (Ying, 2011) US leads insulin pump market globally Insulin Pumps in Pregnancy First documented use of insulin pump in pregnancy was in 1978 (Castorino, 2011) Successfully used pump from preconception to postpartum Women over the age of 20 comprise ½ of individuals with diabetes in US (ADA, 2009) 1

2 Plasma insulin (µu/ml) Physiological Serum Insulin Secretion Profile Breakfast Lunch Dinner Role of Insulin Pump Therapy or Continuous Subcutaneous Insulin Infusion (CSII) Imitate physiologic insulin release from pancreas Replace the need for multiple daily injections (MDI) 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Used by individuals with type 1 and type 2 diabetes mellitus (DM) Time Insulin Pump: Continuous Subcutaneous Insulin Infusion (CSII) A battery operated computerized device that delivers fast or rapid acting insulin stored in a syringe (reservoir/cartridge) located inside the pump or in a tubeless pod Insulin is delivered through a needle or soft cannula connected to a thin plastic tube (infusion set) attached to the pump or in a tubeless system with a handheld controller Insulin pumps simulate normal pancreatic function and are programmed to deliver subcutaneous insulin as a basal rate and bolus for meal coverage or correction Indications for Insulin Pump therapy in Hospitalized Patients Alert Oriented to person, place and time Competent to manage insulin pump or have family able to manage insulin pump JCAHO Requirements (2004) Standard MM.5.20 Self administered medications are safely and accurately administered. Procedures must be in place for safety and accuracy, training, supervision, and documentation Competency in medication administration must be determined before allowing non staff members to administer medications. Rich, DS (2004) New JCAHO medication management standards for 2004, Am J Health-Syst pharm,vol 61 2

3 Suggested Policy/Procedures Contraindications for pump use Consent for self administered medication outlining expectations Guidelines for discontinuation of pump or interruption of pump Use of communicating meter Physician orders Documentation flow sheet Hypoglycemia treatment Consents for Inpatient Insulin Pump Use Obtain consent for use of self administered medications from home insulin and insulin pump use Patient agreement to use insulin pump Patient/Family Responsibility for Inpatient Insulin Pump Use Basal or bolus changes are based on physician order Infusion set change at least every 3 days nurse to document Site change more frequently if: Signs or symptoms of site infection Bleeding at the site or blood back up in tubing Pump is showing a No delivery alarm Two consecutive blood glucose readings greater than 250 mg./dl. nurse to assess site and document findings in nurse s notes. Patient to administer rapid acting insulin by syringe and then trouble shoot pump. Patient/Family Responsibility Patient/family will demonstrate to the nurse the basal and bolus rates and this will be documented on CSII flow sheet upon admission and with any basal rate change based on physician order Contraindications for Insulin Pump Therapy in Hospitalized Patients Patient deemed to be critically ill Altered or unstable state of consciousness Patient/family refusal to sign patient agreement Patient at risk for suicide Patient s insulin pump is not working properly Patient does not have the appropriate supplies for the insulin pump Contraindications for Insulin Pump Therapy in Hospitalized Perinatal Patients Suicide risk Magnetic resonance imaging Lack of availability of pump trained diabetes specialist Inability of patient to participate in care Hyperglycemia accompanied by ketosis Lack of available pump supplies Relative contraindications: Intensive Care Repeated admissions for DKA 3

4 FDA Approved for Pregnancy Rapid acting insulin only Lispro Aspart Regular insulin U 500 regular insulin Pump Supplies External insulin pump Syringes (reservoirs,cartridges, pods) for the insulin Infusion sets (tubing) Dressings (if needed) Extra batteries for the pump If the patient runs out of supplies Physician must be notified and alternative insulin orders obtained unless written on admission External insulin pump cannot be used without supplies Communicating Meters for Pumps Some pumps have a blood glucose meter that automatically communicates BG results with the pump Compare hospital meter reading with personal blood glucose meter on admission and document to assess accuracy. If greater than 10% difference, use hospital meter. If a fingerstick blood glucose is taken prior to a meal, the pump can automatically calculate a correction dose prior to the meal and also cover the carbohydrates to be eaten at the meal. Continuous Glucose Monitoring Device that measures interstitial blood glucose continuously (288/day) Requires an additional site from pumpusually in hip Site change every 72 hours Can be real time and communicate with pump or be non c0mmunicating and nonvisualized by pumper Downloadable 4

5 Continuous Glucose Monitoring Basal Insulin Basal rate A continuous subcutaneous delivery of insulin. This is the amount of insulin the patient requires to maintain a normal metabolic state when not eating (fasting). Usually 40 to 50% of the total daily dose of insulin Basal Insulin Insulin given at rate per hour (U/hr) given in fractions May program 24 basal rates Usually begin with 2 basal rates one for nighttime and one for daytime with night time rate lower Most have at least 3 basal rates Bolus Insulin for Meals Insulin given to cover meals or snacks Programmed into pump in ratios for insulin to carbohydrates (CHO) ie 1 unit / 15 grams CHO Documented as Insulin to Carbohydrate ratio (ICR) May be programmed in pump with different rates for each meal Bolus Insulin for Meals Extended delivery options used for high fat content meals, prolonged meals square wave or extended wave bolus dual wave or combo bolus May also be used with delayed gastric emptying or CHO absorption as with gastroparesis Bolus Insulin for Correction Insulin given to correct a glucose level outside of the intended or target range Target range examples MN to to to MN Based on patient s sensitivity how much 1 unit of insulin will lower blood glucose 5

6 Blood Glucose Corrections Now when the patient has a high BG the pump will suggest a correction Pump will factor in active insulin on board Patient can manually override the suggested dose Pump will factor in correction with meal bolus after patient has entered BG and carbohydrate for meal Decreases math errors but does not replace common sense Insulin Pump Physician Orders Include: Type of insulin and pump to be used Basal infusion rate(s) Bolus dosages for meals and correction Blood glucose testing times and when to be notified Backup insulin plan to be used if patient is unable to use pump for any reason Hypoglycemia treatment orders Continuous Subcutaneous Insulin Infusion Flowsheet Documentation Insulin: Basal rates (units/hr.) Finger stick BG Carbohydrate (grams) Meal bolus Correction bolus Site change other Pump Disconnection Disconnection from the insulin pump for more than 1 hour requires that the patient have an alternative delivery of insulin. An interruption of insulin delivery for more than 2 hours in a person with type 1 diabetes can lead to severe hyperglycemia and diabetic ketoacidosis (DKA) 6

7 Temporary Pump Disconnection Showering/bathing (if the insulin pump is not watertight) Procedures in which the pump might be exposed to water (e.g. whirlpool therapy) Pump Delivery Interruption Disconnect at site Suspend Mode: pump may be programmed to suspend delivery of insulin Remove for x rays, MRI and CT administer alternate insulin delivery if procedure to exceed 1 hour Trouble Shooting Trouble Shooting Availability of pump trained staff Unexplained hyperglycemia Administer SQ insulin Change pump site and insulin Inspect sites for signs of infection or lipohypertrophy /lipoatrophy Assess for other infection 24/7 phone access to support: number located on back of pump and on manufacturer s website and booklets Surgery and Insulin Pumps Insulin pumps may be continued during short operative procedures if the insertion site is not in the operative field Anesthesia staff will be responsible for pump management until release from Postanesthesia recovery Intrapartum/Intraoperative Insertion site should be moved to upper abdomen and changed every 2 3 days Immediate acting/rapid acting insulin available Basal rates are usually all that is required for labor and should be used if BG <120 mg/dl Bolus with BG >120 or increase basal rate may have to do manual override. 7

8 Intraoperative/Intrapartum Maternal hyperglycemia contributes to neonatal hypoglycemia Urine ketone checks with voids Serum ketones if BG>200 mg./dl. Increase insulin, hydration Administer rapid acting insulin SQ with BG>200 and then trouble shoot pump Post Partum Pump Management Decrease basal and bolus rates by 50% immediately after delivery or recalculate insulin requirements based on postpartum weight Postoperative frequency of BG testing: hourly until D/C from PAR then preprandial and postprandial, HS, and 2 3 am. Hyperglycemia in 200mg./dL. range impedes healing Hypoglycemia treatment orders Post Partum Pump Management Avoid hypoglycemia in postpartum period Infant rooming in contraindicated with recurrent hypoglycemia unless continuous assistance available Nutrition consult to recalculate needs based on PP weight and feeding type Follow up by phone with DM educator for insulin adjustments post d/c 8

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