Excellent reference texts. Common basal-bolus problem 1. Got pumping skills? What we see. Common basal-bolus problem 3. Common basal-bolus problem 2

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1 Excellent reference texts Practical insulin pumping: beyond just button pushing Stephen W. Ponder MD, FAAP, CDE Pediatric Endocrinology Driscoll Children s Hospital Specific and thorough General and lifestyle oriented Got pumping skills? What we see Changing sites but not reservoirs! Priming while still connected to a pump! Not priming at all! Not filling cannula Overfilling cannula Poor infusion site rotation Poor site preparation techniques Lack of any clean technique (touching site with finger after prep) Improper use of inserter devices Air bubbles in tubing Mystery boluses Common basal-bolus problem 1 Not bolusing or injecting insulin for each meal and snack. Non-bolusing is almost impossible to detect with injections. Pumps have memories and can be reviewed. They also have reminders. Common basal-bolus problem 2 Poor carbohydrate counting skills Review your top favorite foods and get comfortable with the carbs in them! Some pumps have a builtin carbohydrate database Common basal-bolus problem 3 Not performing enough blood sugar checks Not reviewing the BG results you do check for patterns or other helpful information Stay in touch with your diabetes doc and/or learn pattern control and use it!

2 Ponder s Pumping Principles I. A pump is no better or worse than the human being attached to it II. Glycemic variability is the NORM in diabetes: it s a matter of how much! III. IV. Age is not a limiting factor A good pump doc is more a coach (educator) than a prescriber V. Simple is always a good start Ponder s Pumping Principles VI. Quality diabetes self care is more of a PROCESS than it is an OUTCOME VII. Hardware and software change: people don t VIII. Consistency is a virtue IX. Success is relative X. Don t ever be afraid to start over Most pump wearers have non-physiologic settings in their pumps. This creates significant errors in dosing. All pump settings are best selected from standard formulas and readjusted through BG checks Garbage GIGO in Garbage out Common pump management errors Failure to recognize need for management adjustments Not reviewing BG, A1c or pump history data Patient-related errors Outdated pump settings Failure to get on-going pump educational support or training Before Missed Boluses Cause High A1c s 6 mos Control +Rmindr Bolusfor every bite! Use your pump reminders or other reminder Review pump history once a week and work toward increasing the number of boluses Work toward solutions without blame Normally, Ruby s timing was excellent 48 youth in poor control (A1c > 8%). All put on a Deltec Cozmo pump, with half using reminders. Significant reduction for reminder at 3 mos but no difference after 6 mos. H. Peter Chase et al: Diabetes Care 29: , 2006

3 Importance Of Bolus Timing This figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal Premeal BG Low Normal Bolus timing depends on your sugar level Bolus Timing Use fast carbs, check IOB, and give carb bolus at start of meal Bolus 15 to 20 minutes before meal Normal glucose and insulin profiles are shown in the shaded areas High Give carb bolus and correction boluses early but don t forget to eat! Check blood sugar 2 hours later to verify dose Most Carbs are much faster than Rapid Insulin One hour after a meal, half of a meal s glucose rise has occurred, but 80% of rapid insulin activity remains Time over which most meals affect the BG % bolus activity remaining Take Home Message: Bolus 15 to 30 minutes before meals Use extended boluses sparingly. Fine tuning your pump Simple Steps To Better Pump Control First stop lows Set a realistic duration of insulin action (aka: DIA, IOB, BOB) Determine an optimum total daily dose (TDD) Set and assess the basal rates Determine starting carb factor with 450 Rule (450/TDD) and correction factor with 2000 Rule (2000/TDD) Periodically check basal/bolus balance Look for and correct unwanted patterns Stop The Lows First Better control and more stability Mild lows cause followup lows Small epinephrine release makes muscles sensitive to insulin Can lead to another low as much as 36 hours after the first More carbs than usual are needed Severe lows cause highs Higher stress hormone release makes sugar rise for 6-10 hrs Excess carb intake leads to highs Boluses may be reduced/skipped More insulin than usual needed To stop the lows, lower the TDD!!!

4 Starting Carb Factor Corr. Factor TDD 50% Basal 500 Rule 2000 Rule 20 u 0.42 u/h 25 grams 100 mg/dl 25 u 0.52 u/h 20 grams 80 mg/dl 30 u 0.63 u/h 17 grams 67 mg/dl 35 u 0.73 u/h 14 grams 57 mg/dl 3.1 mmol 40 u 0.83 u/h 13 grams 50 mg/dl 50 u 1.04 u/h 10 grams 40 mg/dl 60 u 1.25 u/h 8 grams 33 mg/dl An accurate TDD solves most control problems! Rules for finding your optimum doses! Start with an accurate TDD 1. How much total insulin do you average a day? 2. Adjust the TDD are highs or lows the primary problem? Stay in basal/bolus balance 50/50 or 45-65% as basal Use the 450 and 2000 Rules to estimate starting carb and correction factors, respectively. Then adjust your basal and bolus doses by CHECKING your blood glucose LOOKING for blood sugar patterns ADJUSTING basals and boluses from your patterns Duration Of Insulin Action (DIA) Time An accurate DIA (IOB, or BOB) is essential to success with a smart pump Most research suggests that DIA times are NOT different between children and adults Shorter for those more sensitive to insulin, but NOT children in general However, immediate factors can affect insulin action time: Shorter DIA with activity and exercise Shorter DIA in hot weather Longer DIA with fat in diet DIA Tips If your smart pump often suggests boluses that you know are not enough, do not shorten your DIA it s usually NOT the problem Consider what is causing the highs, and where more insulin is needed in basal rates, in carb boluses, or both Exercise or activity can mobilize insulin faster but DO NOT shorten the DIA for occasional activity. Instead: lower boluses or basals ahead of time for planned activities or eat more carbs or lower basals for unplanned activities An inappropriately low basal rate makes the DIA appear SHORT! Bolus Size (Relative to weight) affects the DIA Measured as units per kg (2.2 lb) How long a bolus will lower the BG: 4 hrs Larger boluses have a longer duration of action. For 50 kg (110 lb) person: 0.3 u/kg = 15 u 15 u/kg = 7.5 u u/kg = 3.75 u Recommendations for DIA times DIAs on current pumps can be set from 2 to 8 hours. An inaccurate DIA can significantly affect control. Becker et al. Diabetes. 2005; 54 (Suppl. 1): 1367P Mudaliar et al: Diabetes Care, 22: 1501, 1999

5 When Major Control Problems Occur Adjust the TDD first 1. Determine the current TDD 2. Lower it: For frequent lows TDD too low or too high? If both highs AND lows occur which comes first? 3. Raise it: For a high A1c or a high average BG on your meter 4. While keeping basal rates and the daily carb bolus total balanced (40-60 or 50-50) Adjust The TDD For A High Avg. BG or A1C Example: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units. Consider changing the TDD for A change in your diet A loss or gain in weight Seasonal changes An overall change in your activity level Starting/stopping a sport Vacation Growth or start of puberty Menses Monitoring your control The Challenge Of Diabetes Bringing down the A1c smoothly takes work SMBG: The best tool to help stay in control BG in mg/dl (mmol) 300 (16.7) 200 (11.1) 100 (5.5) Uncontrolled A1C ~9% Controlled A1C <7% A1C ~6% Normal A1C 4% 6% Time of Day for this you need ADVANCED therapy But, only if you know what it s telling you!

6 Look For Patterns Frequent highs Frequent lows High at B/L/D/Bed Low at B/L/D/Bed Low to high High to low

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9 Check insulin use using your pump s history summary How similar are the TDDs from day to day? Basal/Bolus balance (ideally 40-60%) Correction bolus % (ideally < 8% of TDD) PHOTO OF SUMMARY SCREEN HERE Influenced by basal (complete the open spots) Influenced by boluses Checks overnight basal(s)

10 Our Liver and the Insulin switch Low insulin balance = glucose release by the liver High insulin balance = glucose uptake by the liver Insulin Insulin glucose Insulin Insulin Fix the fasting first Hepatic gluconeogenesis and glycogenolysis are kept in check by insulin Clinically, the fasting (prebreakfast) blood sugar control sets the trend for the rest of the day So make control of the fasting BG the first priority Tips for assessing insulin use in T1DM Total insulin dose (units/kg/day) Proper insulin storage and preparation (don t freeze, keep in a mattress, discard opened bottles after a month) Insulin amounts taken per injection and their proportionality 0.5 to 1.5 units/kg/day < 0.5 = honeymoon > 1.5 = resistance or non-adherence 0.8 is average for prepubertal 1.2 is average for pubertal 1.0 is average for adults Date AM Lunch PM Bedtime 5/18/ /19/ /20/ /21/ /22/ /23/ /24/ /25/ Hemoglobin A1c 6.1% Hemoglobin A1c 8.8% Date AM Lunch PM Bedtime 3/28/ /29/ /30/ /31/ /1/ /2/ /3/ /4/ /5/ Hemoglobin A1c 7.0%

11 Date AM Lunch PM Bedtime 3/28/ /29/ /30/ /31/ /1/ /2/ /3/ /4/ /5/ Hemoglobin A1c 7.0% Date AM Lunch PM Bedtime 3/28/ /29/ /30/ /31/ /1/ /2/ /3/ /4/ /5/ Hemoglobin A1c 7.0% Date AM Lunch PM Bedtime 3/28/06 3/29/ /30/ /31/ /1/06 4/2/ /3/ /4/ /5/ Hemoglobin A1c 7.0% Recognizing false BS data Repeated numbers Round figures Low variability No omitted values Written at same time Inconsistent with A1C Too perfect? Outgrowing an insulin dose? Toddler Tips Most toddlers are very insulin sensitive Single basal rates often work well If two rates, keep nighttime rate lower Set target BG level at 150 mg/dl Food boluses can be given after meals as needed Use lock out feature and set bolus limits low to reduce risk of an inadvertent bolus Ranges: I:CHO (1: 30 1:60); ISF (1:75 1:200)

12 Young Children Most preadolescents stay fairly insulin sensitive Single basal rates give way to multi-rates Keep early nighttime rate (12-3A) slightly lower Set target BG level at mg/dl Try to bolus before all meals/snacks as tolerated Ranges: I:CHO (1: 10 1:30); ISF (1:30 1:100) Teen Pump Tips Adolescents tend to be less insulin sensitive Multi-basal rates usually needed Keep early nighttime rate (12-3A) lower 3-8 AM basal rate (10-30%) to compensate for Dawn phenomenon Set target BG level range between mg/dl Check that they bolus before all meals/snacks Ranges: I:CHO (1: 5 1:15); ISF (1:20 1:50) Fasting ratios may be different than later in the day Glycemic Index: Different Carbs Have Different Speeds Fast Breads/Crackers Salty Snacks Potatoes Rice Cereals Sugary Candies Average Fruit Juice Pizza Soup Cake Slow Pasta Legumes Salad Veggies Dairy Chocolate Duration Of Carb Action High GI Med GI Low GI 0 hrs 1 hr 2 hrs 3 hrs 4 hrs Most carbs have most of their affect within 1 to 2.5 hours But delay can occur with complex carbs and more fat content Basic Troubleshooting: High Blood Sugar Troubleshooting problems Tubing kinked, disconnected, loose Air anywhere in system (did you prime after last site change?) Insulin old, not enough, gotten warm? Site when was last site change? Redness at site? Any leakage? Do you smell insulin? Check BG 2 hours AFTER any site change pus

13 Use Sterile Technique For Site Prep 30% of people are constant staph carriers and 25% are intermittent. MRSA is now common. Prevent infections: Wash hands Sterilize skin with IV Prep Place bio-occlusive IV3000 over site Insert infusion set through IV 3000 Steps for staph carriers: Use antiseptic soap all over body once every 1-2 weeks Occasionally, apply bacitracin ointment to inside of nose Troubleshooting breakfast highs Basic Troubleshooting: High Blood Sugar Bolus was it done right? Batteries ok? Level of activity compensated for? Basal rate set correctly? Reservoir pump properly reset prior to insertion, was there enough insulin? Time correct? Including AM or PM setting Tunneling A problem with Teflon infusion sets Back-leakage occurs due to a slightly dislodged catheter High BG is the only sign Tennis players, golfers and other vigorous activities Solution: Make a tape sandwich, use metal sets Dermal layer Subcutaneous layer Muscle tissue Time to reach 100 mg/dl (at ~ 4 mg/dl/min) Blood sugar mg/dl/min Nuts and Bolts Issues minutes

14 Management of a pump malfunction Disconnected pump Straight versus angled infusion sets

15 Insulin reservoir Tubing set

16 Managing pump malfunctions Option 1 Aspart or lispro (0.1U/kg) NPH ( U/kg) 1. Assume that insulin delivery might be compromised or interrupted. Check blood sugar frequently. 2. Have emergency supplies to take insulin by injection (rapid and long acting insulins). 3. Understand the limits of rapid acting insulin and the time required for injected insulin to start working. Basal rate 2 hours RULE: insulin action via a pump is short-lived. Rapid-acting injected insulin can serve as a bridge while longer acting insulin provides basal insulin coverage. Peak activity Duration Option 2 Basal rate RULE: insulin action via a pump is short-lived. Rapid-acting injected insulin can serve as a bridge while longer acting insulin provides basal insulin coverage. Aspart or lispro (0.1 U/kg) 2 hours Glargine (~basal dose) Duration Take Home Message Insulin pumps are machines and can be damaged or disconnected from the patient for several reasons. Once disconnected for over 1-2 hours, a person is at risk for high blood sugar with ketosis with rapid development of diabetic ketoacidosis unless steps are taken immediately to prevent it, preferably best performed by the patient or family. Common pump situations An person with type 1 diabetes has severe hypoglycemia and is brought to the ER by EMS after getting intravenous (IV) sugar. He is using an insulin pump. In the ER, the best course of action to take with her pump is to: A. Take it off B. Leave it on C. Suspend the pump and get further history Low blood sugar tip 15 grams of carbohydrates (Tablespoon of honey, 4 ounces apple juice, 3 glucose tabs) will raise BG 45 to 75 mg/dl in most adults. Except perhaps when the low is associated with a recent bolus, insulin still on board, or unexpected physical activity.

17 Common pump situations What information can be easily retrieved from all insulin pumps in an emergency? A. Recent doses given or not given (bolus history) B. Basal rates (basal review) C. Time D. All of the above Common pump situations A person on an insulin pump gets nauseated and vomits. What should be done? A. IMMEDIATELY Check blood sugar AND ketones B. Check infusion site, look for bubbles, pump program, age of insulin in reservoir. If ANY question, change site and insulin IMMEDIATELY C. Monitor more often (sugars AND ketones) D. Go to ER or Hospital as needed Pump 101 What insulin can be used in an insulin pump? ONLY rapid or fast acting insulin can be used in an insulin pump. Novolog (insulin aspart) Humalog (insulin lispro) Apidra (insulin glulisine) Buffered Regular insulin D NS Surgery and the Pump If possible, wear the pump. It s the best way to control blood sugar during the operation, especially for minor procedures (e.g., dental) If the infusion site is in the operating field, simply relocate the site The anesthesiologist can monitor blood sugar and adjust IV sugar (dextrose) as needed to keep sugar levels under control. TIP: IV sugar will easily OVERWHELM a pump s ability to deliver insulin. Questions