Continuous Subcutaneous Insulin Infusion (CSII) pump therapy

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1 Continuous Subcutaneous Insulin Infusion (CSII) pump therapy GHPI1267_04_15 Department: Diabetes team Review due: April BETTER FOR YOU BETTER FOR YOU 1

2 Introduction This booklet has been compiled by the Insulin Pump Therapy Team to standardise the information given to patients on Continuous Subcutaneous Insulin Infusion (CSII) pump therapy in Gloucestershire. Contents Page 4 Page 5 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 18 Page 19 Page 21 Information for CSII pump therapy First days of using an insulin pump Hypoglycaemia management Potential causes of hypoglycaemia Hyperglycaemia guidelines Potential causes of hyperglycaemia Managing sick days Converting back to basal bolus insulin Insulin pumps and hospital Travelling with your pump Pump daily diary Testing basal rates Fasting basal rate chart 2

3 Information for CSII Pump Therapy patients Insulin pump therapy is used in patients with type 1 diabetes who are unable to reach target haemoglobin (HbA1c) levels with multiple daily injections resulting in the person having disabling hypoglycaemia or HbA1c levels have remained elevated above 64mmol/l or 8.5% with multiple daily injections despite the person and or their carer carefully trying to manage their diabetes. NICE 2008 National Clinical Excellence. Insulin pump therapy only uses rapid insulin with a quick on set. Therefore, if there is a problem with the delivery of insulin, the blood glucose level will rise very rapidly, which is why it is important for you to monitor your blood glucose for a minimum of 4 to 8 times across the day/night. Frequent testing of the blood glucose will allow the early detection of significant changes in the blood glucose control allowing a quick response to administer a correction dose to reduce blood glucose to target level. Diabetes Ketoacidosis (DKA) may occur if your blood glucose level rises to 13.9mmols/L or above and is not treated. DKA is a serious medical condition caused by very little or no insulin in the body. A lack of insulin in the body means the glucose remains in the blood stream and cannot enter the cells to provide energy. The body responds by producing more glucose and eventually the breaking down of body fat to produce energy. This results in the formation of ketones and acid. DKA requires urgent hospital treatment and if not treated properly it can be life threatening. 3

4 We strongly advise that you and your family or carers read this booklet and keep it in an accessible place for reference when required. Clinic appointment Three months after commencing insulin pump therapy, you will be sent an appointment with the diabetes consultant. This appointment will give you the opportunity to discuss if pump therapy has been successful and whether you have benefitted from using an insulin pump. Should the diabetes control show no improvement, pump therapy may be discontinued. However, this situation will be reviewed at each clinic visit. During your consultation, your fasting basal charts will be reviewed. The data will be downloaded from your blood glucose meter and pump to provide information to help optimise your diabetes control. You will be able to fast for periods of time and test blood glucose two hourly to determine if basal insulin requires adjustment. You will be invited to attend the Pump Diabetes Nurse and Dietician Clinic if you require further support. You will also have the opportunity to attend an insulin pump refresher group to update your knowledge on pump management. First days using an insulin pump During the first few days of insulin pump therapy, your blood glucose levels may be erratic and take time to settle. This is due to a different method of delivery of basal insulin and any remaining basal insulin from your last basal injection. 4

5 The aim of pump therapy is to keep blood glucose between 4 to 7 mmol/l and also depends on the individual. If you have no hypoglycaemia awareness you may be given a different range. For the first 48 hours, you should test capillary (fingerprick) blood glucose every 2 hours. You may need to continue testing blood glucose 2 hourly if levels vary. Once blood glucose levels are stable, you will be required to test in the same way 6 to 8 times a day prior to food, at bedtime, before and after exercise and before driving. For ongoing care you must: Change your metal cannula every day Change your Teflon cannula every 2 to 3 days Test your blood glucose 2 hours after inserting a new cannula. Try not to make these changes at bedtime Do not remove your old cannula until the new cannula is in place and secure Change the cartridge/reservoir and tubing every 3 to 6 days (depending on pump manufacturer instructions enclosed with cartridges). Always keep a supply of insulin, syringes/pens in case of emergency, i.e. for correction bolus by syringe/pen or reverting back to insulin injections. Check the insulin expiry dates regularly. 20 5

6 The Diabetes Pump Therapy Team Tel: Monday to Friday, 9:00am to 4:00pm For technical advice please call the pump company helpline: Roche (Disetronic) 24 hour helpline Medtronic Animas on Once you have your basal rates correct, then you need to check if your carbohydrate ratio is correct. Test your blood glucose before and two hours after your meal. Should your blood glucose rise more than 2.8mmol 2 hours after your meal, then you should consider reducing your carbohydrate ratio with that meal. 6 19

7 Testing basal rates One of the key advantages of insulin pump therapy is the ability to tailor basal rates in ways not possible with insulin injections. You should test your basal rates by fasting with every season change, or every 3 months and prior to your hospital appointment. Test the basal rate during the night first. Once you have the correct overnight basal rate set, you can move on to testing the basal rates in the first part of the day. Test basal rates in sections of the day rather than test for whole day. Remember; optimising your basal rates is key to optimising your pump. Aim is to keep all blood glucose levels 4 to 7 or 5 to 8 mmol/l Test blood glucose 2 hourly during fast Choose a time when your blood glucose is within target prior to testing fasting basal rates but not at the expense of a correction dose. Should you require to give a correction dose, check blood glucose after 1 hour if within target commence fasting Try not to eat a meal high in fat prior to fasting as this will have an extended effect on your blood glucose No alcohol should be consumed in the previous 24 hours Not premenstrual Increase or decrease basal rates 2 hours prior to the blood glucose out of target by Hypoglycaemia management Hypoglycaemia (hypo) is when your blood glucose level is less than 4 mmol/l. Is the blood glucose below 4mmol/L? If the blood glucose is below Independently able 4mmol/L? Assistance required to treat hypo Treat the hypo with 15 grams of quick acting carbohydrate, eg: 4-5 glucose tablets Tube of glucogel 90ml lucozade 150ml orange juice/lemonade Test blood glucose test in 15 minutes If blood glucose remains below 4mmol/L take another 15 grams quick acting glucose. Repeat blood glucose test after a further 15 minutes. If blood glucose remains below 4 mmol/l repeat fast acting carbohydrate If the hypo is a result of alcohol or exercise have a carbohydrate snack with no bolus of rapid insulin. Advice for carer. If the patient is drowsy or unconscious Lie patient on their side in recovery position Administer Glucagen if it is available and you are competent Do not operate the insulin pump, unless you have education in programming the pump Dial 999 When patient awake and alert provide a carbohydrate snack but no insulin bolus 7

8 Potential causes of hypoglycaemia An increase in physical activity Alcohol Priming a new infusion set whilst it is still attached to the body Infusing insulin through damaged sites e.g. areas of lipohypertrophy. Lipohypertrophy is overused injection/ cannula sites causing the area beneath the injection site to become lumpy and may affect the absorption of insulin Basal rates are set too high Failure to cancel or reduce a set temporary basal rate on certain pumps Errors in handling the pump Miscalculation of a bolus Giving over 6 units in one bolus dose (it is recommended to split the dose if over 6 units are required) due to increased sensitivity to insulin Over correction of a high blood glucose Slow digestion of food Stress Menstrual cycle Incorrect carbohydrate or correction ratio Incorrect % decrease in health event on Roche Combo pump/insight pump. 8 17

9 Other travel information If you are travelling to a country with high temperatures: You may be more susceptible to hypo s, due to the absorption of the insulin Consider making adjustments to your basal rates depending on your blood glucose levels Direct exposure from the heat to the pump may affect the efficiency of the insulin and may require the cartridge and tubing to be changed more frequently Dehydration and hyperglycaemia (high blood glucose) levels can lead to ketoacidosis On arrival at your destination, change the pump time to local time, your basal rates will automatically change Never change the battery or insulin cartridge on the beach as sand may enter the cartridge chamber and affect the movement of the piston rod. Hyperglycaemia Guidelines Is the blood glucose above 13.9mmol/L? Correction bolus given and blood glucose not reducing. Check blood glucose and ketones one hourly Blood ketones < 0.6mmol/L Correction bolus by insulin pump Re check blood glucose in one hour If blood glucose reducing continue to monitor until blood glucose in target Blood ketones > 0.6mmol/L Correction dose via insulin pen/syringe Change cannula, cannula site, cartridge and insulin Check pump, perform pump self test if applicable, trouble shoot from prompt list If blood glucose has not decreased after 1 to 2 hours after first correction dose change cannula, cannula site, cartridge and insulin Continue to check blood glucose until within target range Monitor blood glucose and ketones one hourly, continue with correction dose via pen or syringe until blood glucose in target and blood ketones below 0.6mmol/L Drink glass of water every half hour 16 If blood glucose continues to rise, blood ketones > 1.5mmol/L, nausea, vomiting, difficulty in breathing or struggling to cope. Attend A&E 9

10 Potential causes of hyperglycaemia Increased insulin requirements Illness or infection Physical activity reduced Stress Hormonal changes e.g. menstrual cycle Medication e.g. steroids Inflammation at infusion site Insufficient insulin delivery Miscalculation or forgot to administer insulin bolus dose Excessive amount of carbohydrates following hypoglycaemia Rebound from hypoglycaemia Basal rates set too low Too long a period off the pump Pump not functioning/ pump in stop mode/ incorrect operation of the pump/battery has run down Insulin is not effective e. g. insulin has expired, been in use for more than a month, near the end of the vial, crystallised, cloudy or been exposed to extreme temperatures. 10 Blood ketone strips Hypo treatment Blood glucose meter. Pack your insulin and pump supplies in your hand luggage. The temperature in the hold could freeze your insulin and cause it to become inactive. Take double your insulin consumables to cover the holiday. You may have to store your diabetes equipment in a secure area of the aircraft depending on the flight company regulations. Metal detectors will not harm your pump and will not normally activate security alarms. It is advisable to notify the airport security that you are wearing an insulin pump. Insulin pumps and blood glucose meters that are active must not go through X-ray unless the batteries are removed. If you have to have a body scan, disconnect the pump from body and remove pump batteries. If your pump is operated by blue tooth, the blue tooth function must be switched off during the flight and you will need to operate the pump manually. If you use an insulin pump with a sensor, disconnect the transmitter and store on the charger. Check your blood glucose manually. Reconnect the transmitter after the flight, remembering that there will be a 2 hour initialization period and a calibration will be required. Check tubing and insulin cartridge for air bubbles frequently. Atmospheric pressure from altitude may adversely affect insulin delivery from the pump and cause the formation of air bubbles. If this occurs then you will need to prime our infusion line. 15

11 If you are unable to manage your pump independently, then it will be necessary to treat your diabetes with conventional therapy i.e. subcutaneous injections or I.V. insulin and dextrose infusion Do not remove the pump until either sliding scale insulin and intravenous fluids or insulin administered by pen or syringe is established. Investigations Certain examinations can interfere with the operation of the insulin pump for example the Magnetic Resonance Imaging (MRI scan), X-ray and Computer Tomography (CT scan). You must remove the insulin pump, transmitter and sensor if applicable and store safely outside the room. Should you not remove the pump it may affect the warranty of your insulin pump. If your procedure lasts longer than 1 hour, you will be need to have either sliding scale insulin commenced or a bolus dose of rapid insulin. Traveling by air with your insulin pump Requirements: Identification Pump travel letter Latest prescription Pump folder Contact numbers Pump equipment Insulin pens, needles, basal and rapid insulin 14 Infusion Set Infusion set blocked, kinked or the cannula has become dislodged Infusion set empty or not primed Infusion set leaking at connection between tubing and cannula Air or blood in the tubing Infusing insulin through an area of hypertrophy (tough, thickened skin) Empty cartridge/reservoir Cannula has bent or has slipped out of your skin. Managing sick days When you are unwell, there is a rise in blood glucose levels due to the body s response to illness. Blood glucose levels rise even though you may not be eating and drinking normally as the body releases stored glucose from the muscles and the liver. Therefore, you may require extra insulin during this time to keep your blood glucose levels within target and prevent ketoacidosis. In addition to the following advice for the treatment for hyperglycaemia, you will need to use the Temporary Basal Rate Increase Function and increased health event (Combo/Insight pump only) on your pump. 11

12 Suggested temporary basal rate increases: Minor illness e.g. cold increase the basal rate by 25% to 50% Severe illness or infection increase the basal rate by 50% to 100% Consider increasing the bolus dose for food by 50% or use health event (Combo/Insight pump) Only use the temporary basal rate increase for a maximum of 12 hours Test blood glucose 2 hourly whilst using the temporary basal rate function Please refer to hyperglycaemia flow chart on page 8. Converting back to basal bolus therapy In certain circumstances it may be necessary for you to go back to your previous regime of four injections a day (basal bolus). To make the change back to basal bolus therapy, you should: Calculate your total daily dose of insulin over the last 6 days (i.e. basal and bolus) Divide this total by 6 to give you an average daily pump dose of insulin To calculate the amount of long acting insulin, divide the total daily dose by 2 and then add 10%.The amount of fast acting insulin you will require is your normal bolus dose as judged by your normal carbohydrate: insulin ratio. 12 For example: Total dose of insulin given over 6 days = 180 units Divide 180 by 6 = 30 units Divide 30 by 2 = 15 units Add 10% ( ) = 16.5 units Therefore, 16 units of long acting insulin would be given for background/basal insulin and bolus as per carbohydrate ratio for meals with fast acting insulin. It is advisable to take the basal insulin in the morning. Converting back to insulin pump therapy When restarting insulin pump therapy, there will be active basal insulin present, therefore you will be required to test blood glucose 2 hourly initially. A temporary basal reduction may be required in the first 24 hours. Insulin pumps and hospitals For any hospital admission it is essential that the medical and nursing staff are aware that you are using an insulin pump. It is therefore important that you carry some form of identification that you have diabetes and are using an insulin pump with you at all times e.g. medic alert disc, pump identification card. You may be able to continue using your pump during your hospital stay if this is agreeable with the medical team Remember to take all the necessary equipment for your insulin pump with you as this will not be available on a hospital ward 13

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