Pump Basics for the School Nurse. Children's Endocrinology Center of Dallas

Transcription

1 Pump Basics for the School Nurse Children's Endocrinology Center of Dallas

2 Pump Basics Covers: A general overview of the insulin pump Refer to the manufacturer s website for the specific features of each pump: see below The student s management plan may differ from the general overview provided: refer to the Diabetes Management and Treatment Plan for the student s specific plan

3 Agenda: Pump Topics Glucose monitoring schedule Bolus insulin: the Insulin to carbohydrate ratio (ICR) Basal insulin theory Correction insulin/insulin sensitivity Hypoglycemia management Hyperglycemia management/sick days Skin care and site rotation Exercise Life with the pump Online resources

4 Blood Glucose Monitoring and Pattern Management Routine testing is before each meal and bed time Additional checks may be requested, such as at the initiation of pumping Intensive testing provides information to make basal and/or bolus changes to improve blood glucose Intensive test schedule is: prior to meals, 2 hours PP, HS, 12mn and 3 am The glucose log or downloaded data from the pump is useful to evaluate glucose trends over 3-5 days, and to identify potential dosage changes

5 Typical Target Blood Glucose Goals Pre-meal: hr Post meal: <160 Bedtime: mn & 3am: Hypoglycemia < 70mg The younger child or child with hypoglycemia unaware may have more liberal goals

6 The pump: 3 modes of insulin delivery # 1: Basal rate background insulin that is delivered constantly. Identified as units per hour When one basal rate ends, another begins. Pump clock begins at 12 mn Pump Time / units delivered per hour 12mn 1.0 u/hr 8am 4pm u/hr u/hr u/hr u/hr 3 11

7 Adjusting Basal Insulin Basal rate changes begin to show effect on glucose in approximately minutes: lead time is needed to see the effect Basal rates can be changed from tenths(.1) to hundredths (.025) of a unit Why change basal rates? With growth, the basal insulin profile will be outgrown With a change in activity (i.e.: beginning routine soccer practice) the basal may need to be adjusted To evaluate basal changes: test every 2 hours ( without eating) for 4-6 hours. Glucose should not vary by more than 30 mg. If glucose increases, more basal insulin may be required. Make a 10% change in the basal rate 1-2 hours prior to the problem time identified

8 Evaluating the New basal rate Observe the blood glucose log for 4-5 days to evaluate the basal change for safety (avoiding hypoglycemia) and efficacy (glucose values in better range) Re-evaluating the basal rate via every 2 hour testing may be helpful also

9 The pump: 3 modes of insulin delivery # 2: the Bolus dose: dosage is manually administered based on CHO amount chosen for the meal 2 meal bolus strategies are used: Either a fixed dose and fixed amount of CHO OR an Insulin to CHO ratio which allows flexibility with meal plan

10 Insulin to Carbohydrate Ratios A guide for determining how much insulin is needed to help the body process, or metabolize the carbohydrate in a meal or snack 1 unit of fast acting insulin per number of carbohydrate grams Example: 1 unit rapid insulin to 15 grams CHO The ratio is 1 unit: 15 grams A meal of 60 grams requires 4 units insulin 60 grams /15 = 4 Ratios are very individual and can vary from meal to meal

11 Calculating the ICR Ratio To calculate a meal dose: Total grams of carbohydrate to be eaten for the meal divided by the ratio factor Example: 1:10 ratio Meal amount = 50 grams Divide 50 by 10 = 5 units (1:10 ratio)

12 Making the Adjustment Changing the ratio: Adjust only 10-20% at a time Example: Starting with 1:10 ratio, either adjust to 1:8 or 1:12 If the post-meal blood glucose level is too: High Lower the ratio (1:8) Low Raise the ratio (1:12)

13 Evaluate the change Test 2 hours after the meal The glucose should be 50 mg/dl above or below your starting glucose Premeal glucose= 80 mg The new ratio is used 2 hour post prandial glucose= 128 mg The ratio appears to be accurate

14 The pump: 3 modes of insulin delivery # 3: the correction factor You must program the following into the pump to create the correction program The target (usually 100 to 130): when glucose is above this value, the pump begins to suggest additional correction insulin Insulin sensitivity (states that 1 unit lowers glucose by this amount, usually 50 to 100): the pump uses this value to calculate additional insulin recommendations when high Insulin on Board ( written as hours of insulin action: usually 4 hours): the duration of insulin action

15 The pump: 3 modes of insulin delivery #3 Correction Factor (insulin sensitivity) Use the correction factor to provide additional insulin to correct when glucose is high Use the Correction bolus for high blood glucose at premeal, post meal, and bedtime snack test times Smart Pump Feature: The Active insulin / insulin on board feature reminds you to give a lower dosage if insulin was recently administered and is still active Smart pump feature: A higher overnight target and/or lower sensitivity may help to prevent overcorrection (hypoglycemia) during the night hours The correction factor/insulin sensitivity helps to identify a possible dosage, but the pump user must manually administer the bolus

16 Review: Pump features in the smart pump ICR (insulin to CHO ratio): allows the pump to calculate the meal dosage after the CHO amount is entered Target glucose: the glucose value above which, the pump begins suggesting correction insulin Multiple targets may be set, based on the time of day/night Correction factor (or insulin sensitivity): 1 unit of insulin will usually lower the glucose by this amount Multiple Sensitivity factors may be set: one for daytime and a more conservative value for overnight

17 Pump features to help your smart pump Temporary basal rate: a feature that allows a lower or higher basal rate by a percentage for a specific time frame Use prior to exercise to help avoid hypoglycemia Use during a sick day event to provide an increased amount of background insulin Insulin on board (or active insulin): a safety feature that reminds you how long insulin lasts in the body and prevents stacking of insulin

18 Hypoglycemia Management POSSIBLE CAUSES Too much insulin - Basal rate is too high - Bolus dosage too high - ICR incorrect - Incorrect CHO count Increased activity or exercise Target glucose is set too low ACTION PLAN Glucose less than 70mg, and student is alert Give 15g oral CHO Recheck glucose 10-15min If glucose > 70mg treatment successful If glucose < 70mg, repeat 15g CHO If glucose < 70mg after 2 treatments Suspend pump, continue to treat Resume pump after glucose > 70mg Administer glucagon if child is unconscious, or seizing and unable to eat

19 Hypoglycemia: why not disconnect the pump? Why don t you disconnect/suspend the pump when the child is low? The insulin infusing now is not active for 1 to 1.5 hours: disconnecting/suspending the pump now will not help treat a low glucose occurring now If hypoglycemia is resistant to treatment with oral CHO: consider disconnecting the pump, recognizing that it must be reconnected to prevent ketones

20 Hyperglycemia Possible Causes Illness/Stress Missed meal bolus Inaccurate CHO counting Insulin cartridge is empty Kinked cannula/infusion tubing Air in tubing Redness, irritation, infection at catheter site Pump malfunction Basal rate is too low or programmed incorrectly Pump is in Suspend Dead battery Loose connection from tubing to insulin cartridge

21 Pump: Hyperglycemia Management ACTION PLAN: NEGATIVE KETONES Glucose =/> 250: check ketones If ketones neg or trace Give correction bolus by PUMP Encourage CHO free fluids Recheck glucose in 2hrs If glucose has not decreased by the insulin sensitivity factor, give correction by SQ injection Change infusion set and reservoir Recheck glucose in 2 hrs Contact CMC if glucose is not decreasing by sensitivity, or ketones increase ACTION PLAN: POSITIVE KETONES Glucose =/> 250 mg: check ketones If ketones are small, moderate, large Give correction bolus by SQ injection Do not decrease dose for insulin on board Encourage CHO free fluids Change reservoir and infusion set Recheck glucose in 2hrs Contact CMC if glucose is not decreasing by sensitivity, or ketones increase

22 Ketone management Ketones are a concern when using the pump ketones may indicate an interruption in insulin delivery, and can lead to DKA To supplement insulin when ketones are present Give the total correction bolus suggested by the pump, not the decreased amount Do not consider Insulin on Board / active insulin when estimating correction for high blood glucose with Ketones (sm,mod,lg) ie: If ketones are present, the last insulin dose may NOT have been injected

23 Remember Symptoms of DKA High glucose Ketones Nausea Vomiting Fruity odor to breath Difficulty breathing DKA is a Medical Emergency

24 Sick Day Reminders Illness may cause an increase in glucose due to stress hormone release Test glucose and ketones every 2 hrs while ill A TBR (temporary basal rate) may need to be set in 2-4 hr increments to help control glucose An increase of 10-50% may be appropriate Follow high blood glucose protocol during sick days Test for ketones during illness even if glucose < 250

25 Parent supply list for Sick Days Supplies to have on hand: Ketostix Expire 6 months after opening the vial Store in vial with lid tightly closed Foil wrapped packaging is available: expire per manufacturer s expiration date Rapid acting insulin/insulin pen/syringe Extra infusion sets/reservoirs/battery Sick day fluids: diet/regular drinks, popsicles and jello; chicken broth Emetrol, Zofran for nausea, vomiting

26 Skin Care/ site rotation Pump sites should be changed every 3 days to avoid infection and insure best absorption of insulin Good hand washing and site cleaning will help to avoid infections and allow pump tape to adhere Several products are available to help the pump tape adhere Rotation of pump insertion sites will help to avoid hypertrophy of the tissue Sites include hips, abdomen, mid back, lateral abdomen Some Omnipod pumpers may use the arms and thighs

27 Exercise Guidelines for Disconnecting the Pump When pump is disconnected, a small amount of basal insulin is needed while off the pump The basal insulin is given by bolus as the pump is disconnected How much? Reduce the hourly basal by 30-50% and give as a bolus as the pump is disconnected Repeat this bolus for each hour disconnected If glucose is 100 to 180mg, 15 grams CHO are recommended to prevent a low with the exercise May use pen or syringe to deliver the hourly basal if desired Specific guidelines are learned with experience

28 Exercise Without Disconnecting the pump Check glucose before exercise If glucose is mg: 15 grams oral CHO are recommended Use TBR (temporary basal rate) for activity with a duration of 1 hour or more: - reduce basal rate by 30-50% - set TBR 1 hour prior to exercise and for the duration of the exercise TBR may need to be extended to prevent delayed hypoglycemia

29 Life with the Pump Change pump insertion site every 2-3 days Amount of insulin needed in the reservoir: Total daily dose x 3 days Add 25 units to prime ( if using a tube pump) Add additional 25 units for fudge factor Change infusion set/reservoir during the day: not at bedtime. Delivery problems may be unnoticed if the pump site is changed at bedtime: ketones! Keep written basal/bolus dosages in event of pump malfunction

30 More Life with the Pump Showers and bathing: disconnect the pump, leave pump in run mode. The Omnipod pump may be worn in the bath. Hot tubs/saunas: Disconnect before entering, if pump allows. Heat can make proteins like insulin harden. The heat from the Hot tub can lower glucose so monitor glucose carefully after tubbing Remove pump for x-rays, MRI, CT scans Have emergency supplies available when away from home Contact CMC if disconnecting pump for an extended period of time and a change to SQ insulin is desired Contact both CMC and the pump manufacturer for pump malfunctions: the manufacturer will usually overnight a new pump, but SQ insulin injections are required to prevent ketones

31 On line Pump Resources Medtronic Insulin pump chool.html Omnipod insulin pump by Insulet Animas Insulin pump