INSULIN PUMPS INFUSION SETS BRANDS OF PUMPS ADVANTAGES I INSULIN PUMP PHYSIOLOGIC INSULIN SECRETION. Daniel L. Metzger, MD, FAAP, FRCPC

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1 INSULIN PUMPS PHYSIOLOGIC INSULIN SECRETION Daniel L. Metzger, MD, FAAP, FRCPC INSULIN PUMP INFUSION SETS BOLUS BASAL Breakfast Bed Dinner Snack Lunch Breakfast BRANDS OF PUMPS ADVANTAGES I ANIMAS MINIMED ROCHE physiologic insulin delivery can be matched to needs flexibility in timing and size of meals normalization of lifestyle psychological adjustment to diabetes control while sick, travelling, exercising or working erratic schedules

2 ADVANTAGES II improved blood sugar control leads to fewer diabetes complications only taking rapid-acting insulin fewer and less severe lows precision of dosing improved overnight blood sugar profile can account for dawn phenomenon convenience DISADVANTAGES I no depot of insulin interruption leads to rapid in sugars and development of ketones tight control of blood sugars may lead to severe lows infection at site weight gain due to improved control DISADVANTAGES II constant reminder of presence of diabetes cost: $6800 pump + $150/month supplies amount of time spent on diabetes care up to 30 min/day burn-out CRITERIA FOR PUMP I diabetes for at least 1 year desire to improve diabetes control and/or increase flexibility in lifestyle motivated child/teen and parents family support and parental involvement demonstrated commitment to 4 pokes/day and recording able to problem-solve (math!) CRITERIA FOR PUMP II able to work with diabetes team willing and able to do abdominal injections able to count carbohydrates able to operate pump for young children, parents must be prepared to do all programming, including lunchtime adequate financial resources

3 PUMP PARAMETERS basal rate(s) insulin/carbohydrate ratio(s) insulin sensitivity factor(s) target blood glucose level(s) active insulin/insulin-on-board CONVERTING FROM CONVENTIONAL TO PUMP add up total daily dose (TDD) of insulin decrease TDD by 20 30% unless A1C no decrease in TDD if on true MDI give 50% TDD as basal initially divide by 24 to give hourly basal rate divide up other 50% by carbs BASAL RATES I convenient to think in blocks of time: midnight to 0300 h 0300 h to breakfast breakfast to lunch lunch to dinner dinner to bed bed to midnight may require use of patterns to account for weekend vs. weekday, etc.

4 BASAL RATES II will often need higher basal rates at 0300 h to account for dawn phenomenon will often need lower basal rates later in the day basal rates should remain 40 60% of TDD how to adjust basal rates: fix overnights, then skip or delay a meal and see what happens with BG, should be stable TEMPORARY BASAL RATES disconnect and remove for contact sports can decrease basal rates across the board for activity, post-activity can increase the basal rates across the board for illness, periods, IV glucose, travel all kids should be able to do this works differently on different pumps! can also set patterns CARB RATIO rule of 450: carb ratio = 450/TDD (500 for adults) food bolus: units = carbs carb ratio will need to bolus for every meal/snack >5 10 g carbs unless exercising may need to bolus extra for protein may need lower carb ratio (i.e. more insulin) for breakfast vs. rest of day how to adjust: check 2-h pc: does a bolus cover a known quantity of normal carbs SENSITIVITY FACTOR rule of 100: ISF = 100/TDD correction: (BG target)/isf may need lower ISF (i.e. more insulin) for morning may need higher ISF (i.e. less insulin) for evening how to adjust: check BG 2 h after correcting a high: is BG normalized? TARGET GLUCOSE usually 5 6 daytime, 7 8 bedtime may need to user higher targets for smaller children don t set too wide, or bolus calculator becomes less accurate ACTIVE INSULIN / IOB used to calculate residual insulin from previous bolus to start: <30 U: 3 h U: 4 h >60 U: 5 h

5 BOLUS CALCULATOR calculates the bolus: insulin for carbs using carb ratio ± insulin for highs/lows using ISF and target BG less insulin from previous bolus from active insulin/iob underestimates if active insulin set too high or BG targets too wide we recommend its use for all, to allow for better fine-tuning of carbs and ISF BOLUS TYPES normal bolus: OK for most simple meals square-wave/extended bolus: grazing, buffets? gastroparesis, protein dual-wave/combo bolus: the pizza bolus CGMS CGMS RESULTS continuous glucose monitoring system uses an implantable sensor lasting ~5 days measures ISF glucose continuously, gives value every 5 min RECOMMENDED BOOKS The Pump Trainer s Role Sharleen Herrmann, RN, BSN, CDE, CPT Endocrinology & Diabetes Unit BC Children s Hospital

6 What happens when someone is interested in a pump? Need to do their research! Are all the criteria met? Insulin Pump Therapy #1 handout to help guide research Attend insulin pump therapy info sessions Talk to their Diabetes Clinic Meet with reps If they decide to proceed, and are an appropriate candidate order pump When to start the pump The first month of pump therapy is time and energy consuming Like having a new baby! If this is already a high stress time, not a good time to start a pump Just before or during vacation, during exams, while spouse or parent is away, school vacations, starting new job NOT the best times to start a pump Pre-pump education Required reading and homework must be completed in advance: Review instructional media and literature that comes with pump Computer practice sessions (e.g. pump school) Do hands on practice with the pump Calculate carbs for all meals/snacks Carb Counting Quiz Read Pumping Insulin by John Walsh ch Set up pump downloading capabilities, i.e. Medtronic CareLink or Animas ezmanager Pump education session Pump programming and setup Site care and infusion sets Correcting high blood sugars/preventing DKA Managing illness Activity guidelines and temporary basal rates Managing low blood sugars Emergency supplies/travel Insulin instructions for pump start Pump primed with NS and inserted for 3 days of practice Bolus timing Bolus omission Food bolus given before eating Rapid-acting insulin is not that rapid! Bolusing after meals can A1C by 1% If unsure how much will be eaten: give correction + bolus for carbs likely to eat If more is eaten, the remainder of bolus can be given after the meal Missing 4 meal boluses/week: ~1% increase in A1C in children using insulin pumps (Burdick, et al.; Pediatrics 2004) Use of meal bolus alarms: transient, modest effect on improving bolus administration and A1C (Chase et al.; Diabetes Care 2006)

7 Bolus calculators Objective means of calculating insulin doses Insulin-to-carb ratios BG units Sensitivity (ISF) BG targets Active insulin time (3 4 hours) Settings need to be reevaluated Accounts for active insulin: but not BG trend! The Bolus Wizard Calculator MiniMed Estimate Details Est total: 7.5 U 60 gr Food intake: BG: Food: Correction: Active ins: ACT to proceed, ESC to back up U 2.5 U 1.0 U Allows Tighter Control Frequency Hypoglycemia Carbohydrate counting issues Portion sizes: underestimating by 15 g of carbs can BG by 2.7 mmol/l Large amounts of vegetables or free foods can add up to a carb serving Fat content of foods and large protein portions delay absorption of carbohydrate Fiber subtracted from carbs SWAG Infusion site care Wash hands Change set q 2 3 days Site rotation Change site if swelling, redness, or pain Check for tape allergies ahead of time Frequent need to change site? Evaluate infusion set: Cannula size Tubing length Location? using inserter correctly Type (straight, angled, metal) 30 angle infusion sets work better than 90 sets in smaller children and in lean or muscular individuals Illness Set or TBR depending on glucose trends Do not take pump off! fluid intake Check for ketones Nausea or vomiting is due to ketones until proven otherwise!!!

8 Blood vs. urine ketones Correcting high blood sugars URINE KETONES negative trace (<0.5 mmol/l) small (1+, 0.5 mmol/l) moderate (2+, 1.5 mmol/l) large (3+, 4 mmol/l) very large (4+, 8 mmol/l) β-hydroxybutyrate 0.5 mmol/l mmol/l mmol/l mmol/l mmol/l 3.0 mmol/l A correction bolus is given for BG > target The correction formula is: BG target BG ISF Use of bolus calculators on pumps should be encouraged: take active insulin into account Diabetic ketoacidosis (DKA) Preventing DKA No deposit of long-acting insulin Accelerated risk of DKA Interruption of the flow of insulin symptoms of DKA in 4 hours DKA is ALWAYS preventable Correct all BG above target If BG is still high 1½ 2 hrs after correction, give insulin by pen or syringe and change infusion set. Do not use pump! Check for ketones if >15 mmol/l or with nausea or vomiting If ketones +, give correction bolus 1.5 (50% ) by pen or syringe Basal patterns Predictable or regular change in routine Standard basal pattern fine: tuned first Shift work, camp, weekdays vs. weekends, vacation, menstrual cycles, predictable exercise (e.g. a ski day)

9 Temporary basal rate (TBR) Temporary or to the standard basal rate for short-term change from normal routine Set as a percent of the normal basal rate (e.g. +50% or 50%) Activity, illness, unpredictable work schedule, travel Can be used to test out new basal rates TBR to avoid hypoglycemia Activity and the pump risk of delayed lows No one-size-fits-all formula Observe for individual response BG before, during and after activity Strenuous activity requires more adjustments than moderate activity Activity >45 min needs insulin Options for managing activity Extra carbs without bolus Decrease insulin food bolus TBR corrections Pump off max 1½ hrs Combination works best Other not-so-obvious activities Sexercise Shopping Work Housework Yardwork Vacation Pump initiation: The big day! Must be a typical week Pump is primed with insulin and inserted Calculate and give food bolus for breakfast and correction bolus, if needed Review education/answer questions Discuss pattern management Discuss monitoring and follow up Temporary pump removal guidelines Baseline A1C

10 When to check blood sugar? Initial follow-up Fasting Before and after meals Within 2 hours of a correction or site change Before, during, after activity Bedtime 3 AM First day: follow-up call after school/work or evening. Instructions given in case of lows Daily phone follow-up for the first week Communicate by /carelink for a few weeks Basal rates, I/C ratio, and ISF adjusted collaboratively Family eventually expected to do ongoing routine adjustments Who you gonna call?? For technical issues, or issues regarding consumables, call the 24-hr # found on the back of the pump For therapy management questions, call health care professional Troubleshooting I general things: is the time set right (AM/PM, time zones)? are the bolus calculator parameters set right? is patient priming the tubing/cannula? is the insulin bad/cooked? is the tubing hooked up to the site, cracks in tubing? is patient testing and entering BG? how old is the site? check the basal review: what is the total daily basal insulin? Troubleshooting II EDU Website check total daily doses: are they reasonable for the kid s size? are they much more than the total from basals? are they 50/50 basal/bolus? how variable are they from day to day? check the bolus history: missing boluses? extra boluses? is patient using bolus calculator? is insulin in whole units, carbs multiples of 10?

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