Robert M. Bernstein, MD, FACE Regional Endocrinology Associates, PC 1533 Saint Francis Drive Santa Fe, NM Cell: (505)

Transcription

1 Robert M. Bernstein, MD, FACE Regional Endocrinology Associates, PC 1533 Saint Francis Drive Santa Fe, NM Cell: (505) URL :

2 Santa Fe, NM, population 75,000. Two Board Certified Endocrinologists, one CDE/RN, single specialty practice in Diabetes and Endocrinology since Our pump experience: 182 pump starts over the past 12 years, now averaging 1 2 new patients/month. The great majority of problems we have encountered are due to patient error.

3 Case 1: 27 year old woman, T1 DM since age 14, nine weeks post partum, healthy baby. Began pump four years ago in another city, seen irregularly in our office, and we had not seen her for the past 17 months. Two weeks after baby was born, patient was admitted to an outlying hospital with DKA, no apparent infection or other precipitating event. Pump discontinued, treated per standard protocol, released on injections, glargine and lispro.

4 When we checked pump, it was not working, no display, completely inoperable. Patient said she did not get any alarms. Manufacturer replaced pump at no charge, and patient resumed pump therapy. Five weeks later, again admitted DKA. Pump again not working. Patient was referred to us to solve this problem.

5 Pump damage Cracking, with subsequent immersion in water. Heat exposure, e.g. hot tub or sauna. Major impact.

6 Poor candidate: Not committed or interested Rebellious and/or incapable

7 Case 2: 44 year old woman, T1 DM since age 19, very intelligent, meticulous control, pump user for seven years. Felt well upon awakening, glucose 282mg/dl, and glucose continued to rise, despite two insulin boluses. No alarms. Patient stopped by office, unscheduled, at 1:00 PM to report glucose above 400 mg/dl.

8 Infusion set problems: Failure to securely reconnect tubing to infusion set, after disconnecting (shower, sex). Subcutaneous catheter dislodged. (Pump will continue to push insulin, but patient may not notice insulin leak, especially if on low dose, or asleep.) Partial blockage of tubing due to kinking. If insulin is being delivered, no alarm, even though patient is receiving insufficient insulin.

9 Above problems are avoided and/or solved by frequent glucose testing and adherence to Hyperglycemia Protocol.

10 Hyperglycemia Protocol If glucose is above 250 mg/dl, give bolus and recheck glucose again in two hours. If still above 250 mg/dl, give another bolus and recheck again in two hours. After two boluses, if glucose is not below 250 mg/dl, subcutaneous injection and change infusion set. (If glucose is rising after first bolus, patient may choose subcutaneous injection insulin and change set at that time, rather than waiting.)

11 Case 3: 64 year old educator, intelligent. Husband is a mechanical engineer, likes to fix things. Diabetes 22 years, generally good control, no diabetic complications, pump user for four years. Patient was getting frequent "no delivery" alarms, elevated glucoses, and was therefore frequently changing infusion sets, and running out of supplies because of these frequent changes.

12 Reusing equipment: Reusing reservoir. Topping off reservoir, rather than discarding old reservoir. Using same infusion set more than three days.

13

14 Case 4: 43 year old woman, intelligent, pump user for seven years, diabetes 32 years, no complications, previous consistent good control. Began playing softball, softball practice at lunchtime most days. After beginning softball practice, began having difficulty with hyperglycemia on the last day before changing infusion set.

15 Excess heat, causing degradation of insulin (sun exposure, hot tub, sauna)

16 72 year old man, active, in apparently very good health. Type I diabetes since age 28, inadequate control, HgbA1c consistently above 9% despite a single injection of long acting insulin and two injections of short acting insulin, and two finger stick glucoses daily. A friend recommended patient change to pump therapy. Patient was very cooperative, seemed to understand mechanics of pump, and began pump therapy. Glucoses did not improve.

17 I thought the pump would take care of everything. Not testing sugars and/or giving boluses. Inadequate education of patient.

18

19 Poor candidate: not committed/interested, rebellious, incapable, medications, ageing, reading ability ( I don t have my glasses with me today. )

20 Importance of Healthcare Personnel RN, CDE, or someone well versed in insulin pumps and diabetes care, and able to take time with each patient. Many people with Type I diabetes and using a pump already are excellent in this position.

21 Pump damage Cracking, with subsequent immersion in water. Heat exposure, e.g. hot tub or sauna. Infusion set problems: Failure to securely reconnect tubing to infusion set, after disconnecting (shower, sex). (Pump will continue to push insulin, but especially if patient is on low dose, or asleep, he/she may not notice insulin leak.) Subcutaneous catheter dislodged. Partial blockage of tubing due to kinking. If insulin is being delivered, no alarm, even though patient is receiving insufficient insulin.

22 Reusing equipment: a.reusing reservoir. b. Topping off reservoir, rather than discarding old reservoir. c. Using same infusion set more than three days. Excess heat, causing degradation of insulin. Failure to rotate infusion sites. Disregarding alarms. ( if patient is also wearing CGMS, may receive multiple alarms during the day.)

23 Not testing sugars and/or giving boluses ( I thought the pump would take care of everything. ) Over riding bolus wizard, usually under dosing, less frequently overdosing. Guessing, instead of counting carbohydrates. Forgetting to activate ( ACT on screen) bolus.

24 Poor candidate: not committed/interested, rebellious, incapable, medications, ageing, reading ability ( I don t have my glasses with me today. ) Proper assessment by healthcare team, education, follow up, and time with the patient.