1.11 INSULIN INFUSION PUMP MANAGEMENT INPATIENT

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Irma McLaughlin
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1 WOMEN AND NEWBORN HEALTH SERVICE CLINICAL GUIDELINES SECTION A: GUIDELINES RELEVANT TO OBSTETRICS AND GYNAECOLOGY 1 STANDARD PROTOCOLS 1.11 INSULIN INFUSION PUMP MANAGEMENT - INPATIENT Authrised by: OGCCU / Diabetes Service 1.11 Insulin Infusin Pump Management - Inpatient 1.11 INSULIN INFUSION PUMP MANAGEMENT INPATIENT AIM T enable individuals whse diabetes is being treated in the utpatient setting with a cntinuus subcutaneus insulin infusin (CSII) can cntinue t be managed safely with their insulin pump during their hspitalisatin. BACKGROUND An insulin pump is a cmplex electrnically-cntrlled device fr the cntinuus subcutaneus infusin f insulin t patients with type 1 diabetes mellitus. Its advantage ver multiple daily insulin injectins is that patients can deliver mre physilgical amunts f insulin between meals and at meal times. There are many insulin pumps nw available and all insulin pumps have different management prgrams. It is highly unlikely that nn-specialised medical r nursing staff will knw the exact details f hw t prgram and perate each device and even highly specialised staff within Diabetes/Endcrine Units may nt have this knwledge unless they wrk in clinics where patients using these devices are seen regularly. Hwever, the basic principles f insulin administratin using CSII with an insulin pump is nt dissimilar t the principles invlved in a basal blus multiple injectin insulin regimen. This invlves maintaining cnstant backgrund insulin administratin (basal insulin therapy) with bluses f insulin administered when fd is cnsumed (blus therapy). KEY POINTS 1. Hspital staff shuld assume, unless therwise advised, that the nly persn wh can manage the pump during their hspitalisatin is the patient. 2. Any changes in insulin administratin will need t be made by the patient wh must be cmpetent in managing the pump and physically and mentally able t accept and institute these recmmendatins. COMPETENCY Any patient wh is admitted t hspital using an insulin pump must be assessed fr their cmpetency t use their device. If they can demnstrate their physical and mental cmpetency t manage the device, the patient shuld be allwed t cntinue n their insulin pump. On admissin t hspital, either t a ward r Emergency Department, the patient must demnstrate t the satisfactin f the assessing health prfessinal that they have the ability t use the management prgram f the device and understand hw t mdify the prgram All guidelines shuld be read in cnjunctin with the Disclaimer at the beginning f this manual Page 1 f 5

The resurce persn may be able t advise r rectify any issues r cncerns, allwing the patient t cntinue n their insulin pump.

2 The diabetes educatr r diabetes resurce persn fr the hspital shuld be ntified upn admissin f a patient with an insulin pump. An urgent cnsultatin shuld be btained if there is a cncern abut cmpetency f the patient t cntinue n pump therapy. The resurce persn may be able t advise r rectify any issues r cncerns, allwing the patient t cntinue n their insulin pump. If the patient is nt prficient with their pump, the physician n call shuld be ntified and may institute alternative therapy. CONTRAINDICATIONS The use f the CSII is cntra-indicated in situatins where the patient s safety may be cmprmised by the physical illness r mental state f the patient. Cntra-indicatins fr CSII using an insulin pump are:- Patients with an impaired level f cnsciusness. Labur and birth is nt an abslute cntraindicatin t the use f an insulin pump, and may be used as determined by the physician. Patients with critical illness requiring intensive care. Patients with majr psychiatric disturbance. Diabetic ketacidsis. Patients refusing r unwilling t participate in self care. Lack f infusin sets, spare batteries and ther equipment required t maintain patient n CSII therapy. Any ther medical circumstance deemed unsuitable by the supervising medical fficer. Any discntinuatin f pump therapy shuld be preceded by a discussin with the diabetes physician, diabetes educatr r diabetes resurce persn. DOCUMENTATION Befre a patient cntinues n CSII as an in-patient, the fllwing criteria must be dcumented. It must be clearly written in the medical recrd and n the bld glucse mnitring frm that the patient is n an insulin pump. The brand name and mdel f the pump must be written in the medical recrd. The type f insulin used in the insulin pump must be identified and recrded in the bld glucse mnitring frm. The current basal and blus insulin dses must be dcumented in the medical recrd. That cmpetency has been assessed and deemed satisfactry, as per abve sectin. The patient agrees t ntify the medical staff f any changes they make t their insulin pump All guidelines shuld be read in cnjunctin with the Disclaimer at the beginning f this manual Page 2 f 5

3 CONSULTATIONS The fllwing health prfessinals shuld be cnsulted. Diabetes Physician. Diabetes Educatr r diabetes resurce persn trained in insulin pump management. Dietitian. INSULIN ADJUSTMENT Changes t the patient s insulin therapy may be made at anytime by the patient prvided the change is ntified t the medical staff, as stated abve. Any change t the insulin regimen recmmended by the medical staff will be dcumented in the medical recrd and cnfirmed by the patient at the time f implementatin, as stated abve. BLOOD GLUCOSE MONITORING Patients n an insulin pump shuld perfrm a minimum f 4 bld glucse tests per day. A minimum f 4 tests per day may be perfrmed in patients with satisfactry cntrl. In patients with less satisfactry cntrl, 6 tests per day shuld be perfrmed An vernight test (e.g. 02:00) may be necessary. Additinal bld glucse levels may be undertaken at any time by the patient. Additinal tests may be perfrmed at the request f the medical fficer r nursing / midwifery staff when clinically indicated. The number f tests perfrmed each day can nly be reduced n the rders f the medical fficer and can NEVER be reduced t less than 4 tests per day. DEVICE MANAGEMENT The patient is respnsible fr ensuring the crrect peratin f the insulin pump. The patient will rtate the infusin set cnsistent with the recmmendatins fr the device. This will be every three days, unless ther dcumentatin is prvided. The patient will make the adjustments t the insulin pump s prgram. The patient will be respnsible fr all blus dse administratin. The insulin pump may need t be discntinued temprarily during a number f circumstances during hspitalisatin. In this situatin, discntinuatin f the insulin pump fr mre than 30 minutes may result in significant hyperglycaemia. Such circumstances where the insulin pump needs t be temprarily discnnected includes:- Any radilgical investigatin (pump must be remved) 2011 All guidelines shuld be read in cnjunctin with the Disclaimer at the beginning f this manual Page 3 f 5

4 CT Scan (pump must be remved) MRI scan (pump must be remved, including metal cannula) Physitherapy (depending n the therapy) Hydrtherapy (if pump is nt water-prf) Patients whse insulin pump needs t be discntinued fr lnger than 30 minutes may need t be cnsidered fr an injectin f subcutaneus insulin, e.g. subcutaneus sluble insulin (Actrapid, Humulin R, Humalg, Nvrapid r Apidra) t cver their shrt term requirements. Patients needing t be regularly discnnected frm their insulin pump shuld be cnsidered fr basal/blus subcutaneus insulin injectin therapy. OPERATIONS AND PROCEDURES The use f the CSII in perating theatres, prcedure rms etc is nt cntraindicated. Its use must be cnsidered carefully in cnsultatin between the anaesthetist, surgen, physician, diabetes educatr and patient. Ptentially the insulin pump, by delivering stable and cnsistent insulin administratin ver hurs can prvide excellent peri-perative bld glucse cntrl. In the basal infusin mde nly, it can be cnsidered equivalent t a very lng acting insulin. As with all patients with diabetes underging surgery, patients wh are uncnscius need t be mnitred carefully during and after their surgical prcedure. Their bld glucse shuld be measured frequently while their cnscius state is impaired. PATIENTS CONTINUING ON CSII PERI-OPERATIVELY. The patient must cnsent t cntinuing n the insulin pump therapy peri-peratively. CSII and IV insulin shuld nt run at the same time. The infusin site must be placed away frm the peratin site with cnsideratin als given t where a diathermy pad may be placed. Ensure the insertin cannula is plastic, nt metal. If the pump is t be used during surgery, the patient must replace metal cannulas with plastic insertin cannulas befre any surgical prcedures that may invlve diathermy. An identificatin tag must be attached t the patient that states that the patient is using an insulin pump. This shuld be sited in a readily visible psitin apprpriate t the prcedure t be undertaken. The anaesthetist must have access t the insulin pump during surgery t enable it t be turned ff r discnnected if necessary. The patients BGLs must be mnitred every hur peri-peratively until they have satisfactrily regained cnsciusness and the patient is capable f making decisins regarding managing their insulin pump. In the event f the bld glucse levels increasing t an unsatisfactry level peri-peratively, the diabetes physician n-call shuld be ntified and switching t an IV insulin infusin shuld be cnsidered. In the event f the BGL levels falling belw 4mml/L peri-peratively, the insulin pump must be turned and / r discnnected. Once euglycaemia is restred, CSII may be recmmenced, either at a lwer insulin infusin rate (if the medical staff are able t prgramme the device) r at a higher IV glucse infusin rate t prevent further episdes f hypglycaemia All guidelines shuld be read in cnjunctin with the Disclaimer at the beginning f this manual Page 4 f 5

5 Alternatively, the insulin pump may remain ff and an IV insulin infusin cmmenced t cntrl the patients BGLs. The use f CSII in majr prcedures shuld nly be cnsidered in rare circumstances due t the strng pssibility that an adjustment t the patients insulin therapy will be required during the prlnged peri-perative perid. Discntinuatin f the insulin pump and cmmencement f IV insulin therapy is recmmended in this situatin. PATIENTS NOT CONTINUING ON CSII PERI-OPERATIVELY. Patients whse insulin pump is discntinued prir t surgery will require an intravenus insulin infusin. Discntinuatin f the insulin pump even fr shrt perids f time with n alternative surce f insulin may result in the rapid develpment f hyperglycaemia and the patient shuld be carefully mnitred. The CSII can be recmmenced when (a) the patient has regained full cnsciusness and (b) it is cnsidered medically apprpriate. REFERENCE Centre fr Healthcare Imprvement. Inpatient Guidelines: Insulin Infusin Pump Management Queensland Health All guidelines shuld be read in cnjunctin with the Disclaimer at the beginning f this manual Page 5 f 5

Commissioning Policy: South Warwickshire CCG (SWCCG)

Commissioning Policy: South Warwickshire CCG (SWCCG) Cmmissining Plicy: Suth Warwickshire CCG (SWCCG) Treatment Indicatin Criteria FreeStyle Libre Flash Cntinuus Glucse Mnitring System Type I Diabetes Prir apprval must be requested frm the Individual Funding