Basal and Bolus Insulin 7/16/2014. Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE. BASAL: Small amount of insulin infused every few minutes

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1 Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE Insulin Pump Therapy Open looped system in which a small amount of insulin is continuously infused through a cannula or needle (basal rate) Larger doses of insulin (boluses) are given prior to meals and to correct high blood glucose. Boluses have to be programmed by the patient each time needed. Basal and Bolus Insulin BASAL: Small amount of insulin infused every few minutes BOLUS Programmed before each meal and for high blood glucose. Burst of insulin Insulin used in pumps: Humalog, Novolog, Apidra, Humulin Regular u 500 1

2 Infusion Sets Angled cannulas: Comfort, Inset 30,Silhouette, Tender 13mm and 17mm length 90 degree cannulas: Cleos, Insets, Mios Quicksets, Mios 6 or 9mm length Metal needles(contact Detach and Sure T) Pods Most infusion needle sets have inserters Inserters recommended or insertion needs to be done quickly. Infusion Needle Sites Abdomen Stay at least 2 inches away from the belly button. Avoid scars Hips Tops and side of legs Upper buttocks Back of Arms Rotate, Rotate, Rotate infusion sites Check patient infusion sites at every appointment. Quick set inserted and connected 2

3 Pods Indications for Insulin Pump Therapy Inability to normalize blood glucose levels with multiple daily injections Recurrent hypoglycemia Patient preference to normalize lifestyle Motivated checking blood sugars 4 or more times a day Taking multiple daily insulin injections Pregnancy Benefits of Insulin Pump Therapy Improved glucose control potential Less variation in blood glucose levels Less injections Potentially less frequent hypoglycemia More flexibility with more normal lifestyle Improved sense of well being 3

4 Risks Associated With Insulin Pump Therapy Infusion interruptions which can lead to hyperglycemia and ketoacidosis Infusion needle site reactions and/or infections Weight gain Pump failure Candidate Evaluation Conducted by someone with a knowledge of pumps Evaluate current diabetes practices Beginning pump education Determine support system available Financial considerations Psychological considerations Financial Considerations Dependent on Insurance Company Insulin pumps and supplies fall under durable medical equipment(dme) Maximum allowable vary by company Financial implications: Out of pocket cost for an insulin pump is around $7000. Supplies are about $ /month Insulin costs stay about the same 4

5 Insurance Requirements Insurance requirements vary but may include: Letter of medical necessity, signed by the prescribing provider 4 times a day blood sugar testing Already on multiple daily insulin injections Diagnosis of Diabetes for at least 6 months (dependent on insurance) Completed a comprehensive diabetes education program HbA1C greater than 7% Medicare and Medicaid requires a fasting C Peptide and concurrent serum glucose and/or positive insulin antibody test. c peptide must be <110% of lower limit or if renal disease < 200% of lower limit fasting serum glucose < 225 or less, same time c peptide is done For uninterrupted coverage of pump supplies Medicare and Medicaid require at least every 3 month appointments. BCBS recently added Type 2 coverage if the patient s BMI is less than 35 Insurances might require the patient be seen by a diabetes specialist or endocrinologist. Patient Requirements Willingness and ability to do a minimum of 4 times a day blood glucose testing Responsible and emotionally stable Willing to quantitate food intake Count carbohydrates/points/calories/exchanges Willing to keep regular appointments Good problem solver Boluses For Food intake and hyperglycemia Correction factor/insulin Sensitivity Give when the blood sugar is elevated Amount one unit of insulin will decrease the blood sugar Use the 1800 Rule for calculating Example of 1800 Rule: TDD of insulin 60 units 1800 divided by the TDD 60 units =30 1 unit of insulin will decrease the blood sugar by 30 points Use 500 Rule for calculating carb ratios Divide the TDD into 500 for carb calculation Example 500 divided by 60 = 8.3 or 1 units will cover 8 grams of carb intake. Can also give insulin boluses using the point system, calorie counting and exchange system 5

6 Prevention of DKA Monitor blood glucose at least 4 times a day When blood glucose is > 250 check urine ketones Use care when suspending the insulin pump Do not disconnect from the pump for > than one hour without replacing the insulin Change infusion needle site at least every 3 days Treatment of DKA/Hyperglycemia Check ketones for all blood glucose > 250 mg/dl Indicates a lack of insulin Give insulin correction bolus By syringe if the ketones are positive Drink at least one cup of water per hour If ketones are positive add ½ cup clear sugared liquids Change infusion needle Prevention of Site Abscesses Change site every 2 3 days Aseptic technique Wash hands Use of alcohol, skin or IV prep pads to clean the skin 6

7 Disconnecting from the pump Indications: Contact sports, swimming, bathing Should not be disconnected for more than one hour Replace insulin lost by doing a bolus prior to or after disconnecting Keep pump connected for a few minutes after replacement bolus has infused When off pump for 30 minutes the blood glucose starts elevating one mg/dl per every minute off Supplies needed when away from home Blood glucose test strips Ketone test strips Alcohol swabs Insulin (Humalog, Novolog, or Apidra) Insulin syringe Pump cartridge/reservoir Infusion needle and tubing Alcohol, IV prep, or Skin prep pads Supporting the child/adolescent pump wearer in the school setting Monitor and document blood glucose Check ketones when blood glucose is > than 250 Look at the pump to be sure bolus is programmed and delivering. Assist with infusion site changes if needed Wash hands Clean skin with alcohol, IV prep or Skin prep pads 7

8 SUPPLIES NEEDED AT SCHOOL Blood glucose test strips Ketone test strips, good for only 6 months after opening Alcohol swabs Insulin (Humalog, Novolog, or Apidra) Insulin syringe Pump cartridge/reservoir Infusion needle and tubing IV prep, or Skin prep pads One of the First Insulin Pumps INSULIN PUMP BRANDS Medtronic: Paradigm Revel or 530G Animas: OT PING Accuchek: Combo Omnipod T Slim 8

9 Medtronic Paradigm Pump Revel or 530G One Touch PING Insulin Pump Accuchek Combo Pump 9

10 Omnipod: The Tubeless Insulin Pump T Slim Insulin Pump Continuous Glucose Monitoring Dexcom G4 and Medtronic Enlite sensors 10

11 Continuous Glucose Monitoring Systems Enzyme coated sensor inserted into the subcutaneous tissue Relies on oxidation of glucose by glucose oxidase to produce hydrogen peroxide, which is further oxidized producing electrons and generating measurable electric current Senses glucose in interstitial fluid continuously (lag time from finger stick) Averages and gives a numerical reading every 5 minutes Customizable alerts that can be set to warn patients of impending hypo or hyperglycemia Requires finger stick calibration FDA approved for adjunctive use. Does not replace fingerstick testing Sensing glucose in interstitial fluid Epidermis Dermis Subcutaneous Tissue Muscle Reference electrode should sit beneath the skin in the Subcutaneous Tissue Fingerstick blood glucose monitoring in the past. Glucose (mg/dl) Time (hours) 11

12 What continuous glucose monitoring can offer Time (hours) Benefits & Barriers Who will benefit? Motivated to improve glucose control Extremely insulin sensitive Frequent high or low BG Nocturnal hypoglycemia Hypoglycemia unawareness Fear of hypoglycemia Uncontrolled or erratic blood glucose What are Common Barriers? Additional site to wear Minimal technical skills are required Must check BG prior to treatment Calibration Unrealistic Expectations Cost issues Overwhelmed with too much information Alarm fatigue Important to look at monitor frequently and watch TRENDS, and NOT to Over React Personal CGM Devices Medtronic Paradigm Real-Time & Guardian Real-Time Real-Time 12

13 Dexcom Studio Reports Medtronic Sensor Augmented Pump Dashboard 24 hour visual analysis SENSOR USE IN SCHOOLS Always verify sensor alarms with a fingerstick blood sugar check, Silence alarm If sensor comes out at school, notify parent for replacement 13

14 Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE Children s Mercy Wichita Specialty Clinics 3243 East Murdock Street, Ste 201 Wichita, Kansas