Pump Mechanics and Management Basic procedures for initiating pump therapy
Learning Objectives Review frequency of BG testing, target BG goals, recording/communicating with team Discuss schedules and activity Learn how basal insulin adjustments are made Learn how bolus adjustments are made Discuss hypoglycemia management Discuss hyperglycemia management
Learning Objectives (continued) Review DKA Discuss sick day management Discuss exercise management Discuss daily living with the pump Discuss preparation for Live Start
Monitoring Intensive Testing: Before Meals Two hours after meals Bedtime Midnight 3am
Target Blood Glucose Goals Pre-meal: 80 150 2hr Post meal: <160 Bedtime: 100 140 12mn & 3am: 100-140
Schedule and Activity Schedules need to be consistent to establish basal rates. Flexibility comes later Limit strenuous activity the first 5 days of pump start to 1 hour Keep carbs consistent and eat similar foods.
Basal Insulin Changes Start with single basal rate Changes are made based on pre-meal, bedtime, midnight and 3am BG Remember where one basal stops another begins
Adjusting Basal Insulin Basal rate changes begin to show effect on BG in approximately 60-120 minutes Since basal rates can be changed from tenths(.1) to hundreths(.05) of a unit, lead time is needed for an accumulation effect on the blood glucose. Expect changes in dosages frequently at first Realize as children grow the insulin patterns one month may be obsolete the next month. 12am 3am = 0.6 3am 6am = 0.5 6am 12pm = 0.4 12pm = 12am = 0.5
Bolus Insulin Changes Changes in meal bolus based on 2 hr post meal BG value Ratios are changed to achieve target post meal goals Attempt to make basal change first, then fine tune the bolus
Hypoglycemia POSSIBLE CAUSES - Basal is too high - Bolused too much - ICR incorrect - Incorrect carb count - Increased activity or exercise - Target BG too low
Hypoglycemia Management ACTION PLAN BG < 70mg Give 15g simple carb Recheck BG 10-15min If BG > 70 treatment successful If BG < 70, repeat 15g carb If BG < 70 after 2 treatments Suspend pump, continue to treat Resume pump after BG > 70
Correction Bolus Pump name for sliding scale is Correction Bolus or Correction Factor The correction is programmed into the pump and calculates a dose of insulin when BG is above target range Correction bolus amount based as indicated by pump s current BG, Sensitivity, Target BG
Using Correction Feature Correct pre-meal, post meal, and snack using recommended bolus recommended by pump Correct bedtime, midnight and 3am ONLY if BG >250
Insulin on Board or Active Insulin The amount of insulin still working in the body from the previous bolus This feature determines if any of the insulin from the previous correction is still affecting the BG level When you use the correction bolus feature any insulin still active from the previous bolus will be taken into consideration
Hyperglycemia Possible Causes Illness/Stress Missed meal bolus Inaccurate carb count Pump cartridge empty Kinked cannula Air in tubing Redness, irritation at site Pump/Pod malfunction Basal rate too low or programmed incorrectly Pump in Suspend Dead battery Infusion set connection to pump loose
Hyperglycemia Management Negative Trace Ketones BG over 250 check ketones Give correction bolus recommended by PUMP Push carb free fluids Recheck BG in 2hrs If BG has not decreased by insulin sensitivity give correction bolus recommended by pump with SYRINGE Change POD Recheck BG in 2 hrs Contact CMC if BG not decreasing by senstivity.
Hyperglycemia Management Small, Moderate, Large Ketones BG 250 greater check ketones If ketones small, moderate, large GIVE CORRECTION BY SYRINGE Change POD Push carb free fluids Recheck BG in 2 hrs Contact CMC if BG not decreasing
Understanding Advanced Feature Example: BG: 300mg Food: 0 Correction: Current BG: 300 Target BG: 120 Sensitivity Factor: 50 (300 120= 180 /50 = 3.6u) Active Insulin = 3 Estimated Bolus: 0.6
How to Calculate Insulin Needed for Syringe Correction When estimating the correction for high blood glucose with positive ketones, ADD BACK the active insulin (or Insulin On Board) Pump will calculate Correction: Current BG: 300 Target BG: 120 Sensitivity Factor: 50 (300 120= 180 /50 = 3.6u) Active Insulin = 3 Estimated Bolus: 0.6 So then because of the positive ketones, instead of giving 0.6 as the pump recommends, you would give 3.6 units (rounded to 3.5 or 4 units) by syringe or pen for the correction
Remember Symptoms of DKA Elevated BG Ketones Nausea Vomiting Fruity odor to breath Difficulty breathing Medical Emergency
Sick Day Illness may cause an increase in BG due to stress hormone release Test BG and ketones every 2hrs while ill A TBR (temporary basal rate) set in 2-4hr increments may be needed An increase of 10-50% may be necessary Follow high blood glucose protocol during sick days
Plan Ahead for Sick Days Supplies to have on hand: ketostix syringes Humalog/Novolog extra PODS sick day fluids: diet/regular drinks, popsicles and jello; chicken broth Emetrol
Exercise Pump allows you to adjust basal rate using a TBR Use a TBR for vigorous exercise Generally do not remove your pump for exercise greater than one-hour Test BG before and after exercise Pre-carb prior to exercise Decrease meal bolus by one unit if exercise occurring within 2 hours of meal Insulin reduction learned with experience
Exercise Without Disconnecting Pump/POD Check blood glucose before exercise If BG 100 180 give 15 carb Use TBR for activity of 1 hour or more: - reduce basal rate by 50% - set TBR 30 min - 1 hour prior to exercise and the duration of the exercise TBR may need to be extended for delayed hypoglycemia
Disconnecting POD for exercise Pods are designed for one time use Give basal insulin by bolus before you disconnect Pod Calculate bolus by reducing the hourly basal by 50% Repeat this bolus for each hour you are disconnected by syringe Replace Pod after activity
Daily Living with pump cont. Attach PDM to belt or waistband Hot tubs/saunas: Remove pod before entering the hot tub/sauna. Heat can make proteins like insulin harden. Hot tub can lower BG so check BG carefully afterward Remove Pod for x-rays, MRI, CT scans Have emergency supplies available when away from home Contact CMC if you must discontinue pump for short period
Recording and Faxing Blood glucose logs will need to be emailed or faxed every day for the first week We will decrease faxing or email to 3 times per week,then 2 times per week, then once a week Record accurately and completely Review log Email Diabetes_Educators@childrens.com Fax 214-456-5963
Homework Wear POD Practice filling POD with saline Practice setting multiple basal rates and cancelling Practice bolus with all meals Practice setting TBR Remove POD on Sat. Reinsert new POD with saline Organize Emergency Kit Begin intensive BG testing excluding 12mn/3am this weekend REMEMBER TO TAKE ALL INSULIN SHOTS
Preparing for Live Start Lantus Regimen Sunday night: -DO NOT TAKE LANTUS At BEDTIME - Use sliding scale at bedtime if high -Check blood glucose every 3 hrs - Use sliding scale to cover BG during night Monday morning: - Take normal Humalog/Novolog dose - Eat breakfast
Additional Instructions - Appt Time: 9am - Bring lunch for child - Bring BG logs - Bring pump and supplies - BRING INSULIN - List of needed supplies - Emergency kits